Partha Kar

General medicine: either all in or all out

It was always the thin end of the wedge. The ‘special’ specialties were given the option of opting out of general medicine.

Anyone worth their salt knew what was coming next – more and more teams put their convincing cases for why they should also be exempted from general medicine.

History would suggest that cardiologists took the first plunge in spite of objections from others and that very day, whatever the reason, the camaraderie amongst physicians ended. One group was deigned to be more special than the others – they would have their own rota,their own service, their own cherry picked patients.

Flip the coin and you see that also made sense for patients with cardiac problems. Up and down the country, many hospitals now have swashbuckling cardiology units. Financially it made even more sense; in a world of PbR where every single catheter gets costed and put on  a spreadsheet, the more stents you put in, the more profitable your unit becomes.

At the same time, the swagger of the cardiologists became more exaggerated. They were now the top dogs in town, and professional camaraderie the victim.

One by one, they all left the ranks of general medicine: rheumatologists, dermatologists, gastroenterologists. Procedure has become king.

I have seen amazing service delivered by rheumatology. Why spread yourself thin when you can do so much better in your specialised area?

It’s a tough one, isn’t it? On one hand, you have the patients who don’t fit into a niche, on the other, you want specialists supporting a 7-day service, helping out in the community, running their services slickly.

We now have an elderly population with multiple problems. Single disease pathology doesn’t exist any more. So, how’s that game of chess looking now?

It has also created a vicious cycle. The ones who pulled out left the others to carry the system of general medicine. The smaller the pool became, the more disgruntled the general medics have become, torn between a desire to do the ‘right thing’ of helping the patient while also having to improve their specialist service.

And no one is exempt from the cherry picking of patients. Acute physicians don’t tend to look after patients more than 24-48 hours; they rarely follow patients through their whole journey. I don’t blame them, they have multiple fronts on which to fight.

Some clever clogs recently said at a meeting they weren’t trained in general medicine, their training was special. The physician in me, who worked through hospitals which didn’t have acute units, cringed.

Elderly medicine doctors are coming to terms with being swamped. Age cut offs, greater than 1 morbidity, etc, they are trying to fight the tide with existing resources. As the cherry pickers leave, they’re trying to not go under.

I have always maintained that we should have a simple rule. Either all in, or all out. All in makes it equitable, all out makes it clear that we have to redefine how unscheduled care works.

I have long held on to the romantic belief that the cherry pickers would be stopped and it has been lovely to see the college develop that view.

For a system to say that a patient with a heart attack or a patient with an alcoholic liver disease is more precious or special than a patient with diabetes in ketosis is simply wrong. For a long time, it has been the issue of ‘he who shouts loudest’ but finally it is time for the noise to stop.

20% of patients in hospital beds have diabetes. They deserve better, much better than the care they’re receiving now. Swathes of areas in the community need better diabetes care, something which the specialists could and should support. Something has to give, doesn’t it?

Medicine is going one of two ways: either all doing general medicine will come back in, and we will share the burden, or hospitals will be run by acute medicine and elderly medicine, hopefully with better resources.

I suspect it will be the latter, but would be delighted to be proven wrong. Until then, we have a responsibility to improve care for people with diabetes and I am more than happy to fight their corner every step of the way at any meeting or forum.

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One Response to “General medicine: either all in or all out”

  1. Malcolm Morrison says:

    I believe the current figure is that over 60% of all beds are occupied by patients who were admitted as ’emergencies’ – and many of them are ‘over 65′.

    Most patients who present as ’emergencies’ do not have a ‘label’ attached stating the diagnosis! So, there need to be ‘generalists’ at ‘the front door’ – if only to sort out to which ‘specialty’ to send them!

    So, ALL ‘specialists’ should have to train as ‘generalists’ before they specialise. They could then take their share of ’emergency duties’. But, of course, WE have created this ‘doctor’s dilemma’! By becoming so ‘clever’, and being able to offer such amazingly effective emergency care for all sorts of ‘specialist’ problems – from trauma to heart attacks and ‘brain attacks’ (strokes), the demand for ‘specialists’ to be available for emergencies has risen enormously (even forgetting the EWTRs!)

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