The Royal College of Physicians’ Future Hospital Commission report highlighted the importance of general internal medicine (GIM) in the delivery of holistic person-centred care and the Shape of Training report unequivocally recommended that dual training for physicians (GIM alongside a medical specialty) should be standard for trainees in England.
Advances in medical science and technology have driven subspecialisation in medicine and revolutionised the care and clinical outcomes of acutely ill patients in certain specialist areas, for example cardiac ischaemia and stroke. However, increased longevity and prevalence of long-term conditions mean that the majority of medical inpatients with longer lengths of stay (>48 hours) are older, with complex acute illness superimposed on at least one chronic disease. Such patients are now the predominant recipients of hospital-based medical care; their medical problems extend beyond the expertise of physicians trained in single organ-based specialties – physicians with a broad range of competencies (generalists) are key to their effective treatment.
After a period of decline in provision of GIM services, there has recently been a modest expansion. Of the six largest medical specialties (cardiology, respiratory medicine, geriatric medicine, gastroenterology, endocrinology and diabetes, and renal medicine), the proportion of physicians maintaining a commitment to the acute medical take increased from 54.1% in 2010 to 64.1% in 2014.
The changing fortunes and recognition of GIM are reflected in an emerging debate about the name for this area of physician practice. In an NHS where specialist medical care is delivered increasingly in the community there is concern that the term ‘general’ may lead to confusion with general practitioner-delivered care. Furthermore, reasons attributed to GIM’s unpopularity include the lack of specialist ‘prestige’ and the breadth of medical knowledge required. Increasing service requirements and out-of-hours care compound the issue. In this context ‘general’ may understate the medical skills required to manage unselected comorbid patients expertly and so ‘specialty of internal medicine’ has been proposed. However, the registrable specialty in Europe is general internal medicine and this is the term used throughout this review.
The Postgraduate Medical Education and Training Order of Council 2010 (opens PDF 77KB), sets out the categories of registered doctors who are eligible for inclusion in the specialist register. In this document, GIM is included as a specialty that requires a minimum training period of 5 years.
Skills and duties of GIM physicians
General internal medicine (GIM) physicians have skills in the diagnosis and management of unselected medical patients to whom they bring a holistic approach and a commitment to continuing inpatient care. They are skilled in the management of diagnostic uncertainty, risk and safety in the setting of both acute and chronic illness. Patients treated by GIM physicians include the full range of emergency admissions with acute medical problems, ranging from young fit people with severe acute illnesses, to frail older people with multiple disorders.
The GIM curriculum defines the competencies needed for the award of a certificate of completion of training (CCT) in general internal medicine, which allows participation on the acute medical take, and provision of advice on the investigation and management of inpatients and outpatients with acute and chronic medical problems. The duties of GIM physicians extend from the emergency department, ambulatory emergency care (AEC) and acute medical unit (AMU) through to continuing care of inpatients and outpatient service provision. GIM physicians staff the acute medical on-call rota, and provide ‘on the floor’ early consultant review duties on the AMU with acute physician colleagues. In addition to providing care for medical inpatients they usually consult on patients elsewhere in the hospital, for example through ‘buddy’ links with designated surgical wards and obstetric wards. Patients admitted to surgical wards are also older and multimorbid, with a growing need for complex holistic peri-operative care. GIM physicians are well placed to provide this with anaesthetists and physicians in geriatric medicine.
Patients admitted to the acute medical unit (AMU), who are not triaged to early specialist care but need hospitalisation are usually transferred to another ward within 24 hours of admission. The aim is usually to transfer the patient to a specialist ward suited to their needs. However, the patient may be transferred to the first available hospital bed where there is diagnostic uncertainty, if the patient’s illness does not fit the criteria for specialty care, if a specialty bed is not available or if service pressures dictate. In these circumstances GIM physicians offer safe, high-quality, continuing care by managing these patients alongside specialty patients, by facilitating admission to general medical wards staffed by GIM physicians or by managing patients in other hospital wards.
The ways in which GIM is practised vary according to hospital size, staffing and the nature and depth of specialist services provided. Smaller hospitals rely on consultant physicians, irrespective of their specialty, to participate routinely in the acute medical take, have duties on the AMU and provide continuing care to GIM inpatients. In large hospitals acute physicians commonly manage the AMU (in working hours) and the initial care of unselected medical patients (up to 48 hours). In tertiary centres in particular, the provision of specialist services and related consultant services (eg stroke, myocardial ischaemia, gastrointestinal haemorrhage) mean that a reduced range and proportion of specialty consultants undertake GIM duties and contribute to the acute take.
Contrasting generalism and specialism
A recognised consequence of the increasing number of older patients with multiple long-term conditions taken with the significant focus on specialisation, is that patients may be referred from one specialist to another, with no one physician taking overall responsibility for their care. GIM physicians have the skills and approach to address this by providing continuing holistic care, while at the same time ensuring that the patient benefits from specialist input by requesting as necessary. An important aspect here is the ‘set point’ between GIM and specialist care, with agreement that specialist physicians avoid requesting GIM colleagues to take over the management of patients that the specialist is competent to look after. Effective person-centred pathways should minimise inpatient transfer between physicians. Dual-trained physicians should be ready, willing and supported to manage specialty and GIM aspects of care in the patients on their wards. The key therefore, to providing high-quality care to medical patients, is ensuring both continuity of consultant physician care and recognising the balance between specialist and GIM physician care delivery. This balance is likely to be found in different ways according to local circumstances, with differences between smaller rural and district general hospitals compared to larger hospitals dictated by the evolving needs of patients requiring hospital-based acute medical services locally.
GIM physicians have duties in a wide variety of clinical settings and coordinate care for their patients across the full range of specialties, disciplines and geographical locations. In addition, they bring to their GIM practice their specialty expertise and associated generic aspects of physician-delivered care including leadership and professional networks. Having duties as a generalist – managing diagnostic uncertainty in acutely ill complex patients – as well as a specialist, means that GIM physicians have a unique perspective on whole systems care, safety, and the priorities for delivering quality improvement and improved patient outcomes.
The GIM physician of the future
NHS England set out the direction of travel for improvement of services in the Five Year Forward View. A number of new care models are described, with the recognition that different models will suit different types of services in different locations. However, there is an overriding emphasis on flexibility and adaptability according to patient need. Although the recent trend towards a more specialised workforce was noted, it was recognised that the growing numbers of patients with multiple conditions would benefit from a more holistic clinical approach.
The strong support given for new models of medical care together with the RCP Future Hospital Commission report, the Health Education England Shape of Training review and the new internal medicine curriculum place the GIM physician of the future at the epicentre of patient care, both in hospital and community settings working alongside specialist consultants and GPs. In particular, the flexibility and expertise provided by GIM physicians in the assessment and management of patients with unselected medical problems in any hospital setting chimes with the aspirations of the Five Year Forward View and the Future Hospital Commission. Furthermore, the next decade will see considerable growth of GIM physicians working in ambulatory emergency care both in and out of hours and this activity is likely to supersede patient review in conventional GIM outpatient settings.