The future of general medicine
Editor – Dr John Firth wrote thoughtfully in August's Clinical Medicine1 about the future of general medicine. However, by explicitly not exploring its relationship with acute and geriatric medicine, he has inadvertently missed the most important component of the story.
He acknowledges that the acute care of largely older adults with frailty, multiple comorbidities, dementia and social vulnerability accounts for a large proportion of today's acute medical take and an even bigger proportion of occupied bed days. While he then praises geriatricians and their multidisciplinary team colleagues for being good at discharge planning, I do not believe that this is the only skill we have that general physicians fall short on, nor that we have access to some magic set of supports that other physicians cannot access. In reality, any general physician can become fairly skilled and knowledgeable in the area of post-acute rehabilitation, discharge and community services if they choose to. But too often, they regard it as an unworthy ‘social’ endeavour and someone else's job, and label older patients as having ‘acopia’ or ‘social admissions’, or being ‘bed blockers’.2
Geriatricians add value to patient care in a variety of other ways by being skilled diagnosticians in the care of frail older people (such as the ‘older woman who has had a funny turn’ he describes). In addition, if as Dr Firth claims, the assessment of such patients is often more challenging and complex than single diseases in younger adults, it does make me wonder why generalism should be seen, as he claims as being less prestigious.
Comprehensive geriatric assessment delivers a range of benefits to patients.3 Ensuring older people are seen at the front door of hospitals by geriatricians, as well as a relentless focus on discharge planning, can deliver big efficiencies and improved outcomes.4 It is geriatricians who have led the way in developing the evidence base for previously neglected syndromes, such as falls or delirium, and in care of inpatients with comorbid dementia. We are also generally dually accredited in general internal medicine (GiM) and deliver more of it than most other specialities.
And despite Firth's claims of low status or popularity, we are the biggest GiM speciality in the Royal College of Physicians with the highest number of trainees.
A big proportion of the acute take in less frail patients can be handled by outpatient clinics or with discharge within 48 hours if patients are admitted. Most patients who remain are then either mainstream geriatric medicine or fit more or less into one of the main organ specialities, without that much unclassified general medicine left. So the relationship between geriatrics and acute medicine is not a sideshow – it is key.
Finally, I must express disappointment that Firth feels that those doing general and geriatric medicine are regarded as ‘second rate’ and of lower status than those focusing on single organs or diseases. This is not a situation we can allow to continue.
As NHS doctors, we are trained and paid by the taxpayer. As such we have a duty to embrace the care of the patients who actually come through the door (generally older and medically complex) not those we might find more glamorous. Looking after these patients should be seen as a vital role to be proud of and one which is ‘core business’ for those of us working in general hospitals. Even tertiary referral centres like Addenbrookes Hospital (Cambridge, UK) are still the district general hospital for their local community.
I have to ask, who is giving out the message that expert generalism is a poor relation? I feel our medical schools have a big responsibility with values and curriculae not focusing nearly enough on the care of older people and those with multimorbidity.5 Postgraduate training often reinforces this. I do not think that the Royal College of Physicians’ scheme to make more doctors do medical registrar on calls will make people who are not interested in general medicine or geriatrics any more interested, nor that creating a ‘chief of medicine’ post, as set out in the Future Hospitals Commission Report, will shift values. We really need to send out the message that care of the unselected medical take and non-elective inpatient work is the key to solving the problems hospitals face, and therefore the most important job of all.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2014 Royal College of Physicians
References
- 1.↵
- Firth J
- 2.↵
- Oliver D
- 3.↵
- Ellis G,
- Whitehead MA,
- Langhorne P,
- et al.
- 4.↵
- Silvester K,
- Mohammad M,
- Harriman P,
- Girolami A,
- Downes T
- 5.↵
- Oakley R,
- Pattinson J,
- Goldberg S,
- et al.
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