Partha Kar

Who treats the old lady with multiple pathologies?

“Is there any blood anywhere?” drawled the person at the other end of the phone at 2 in the morning.

“Sorry, what blood?” asked I – a second year SpR at the time – puzzled as to why the consultant physician on call was asking me about blood when I was trying to discuss a case of meningitis.

“I said, is there any blood anywhere?” he repeated with more menace.

“Erm, not really.”

The answer that followed is still imprinted in my mind: “I am a gastroenterologist. Don’t phone me if there is no blood.” The phone slammed down.

I turned around to see a friendly Emergency department consultant. My face must have painted a picture, as she stopped and asked me what had happened. I related the incident. She smiled, gave me some advice, and said: “You know there’s not many generalists left anymore – and, by the way, your consultant is actually a good doctor, he’s just a bit special”.

Fast forward eight years and the NHS is struggling. Reports suggest we need more generalists, and better trained GPs. The ‘olden days’ used to have general medicine clinics, staffed by general physicians – you know, the ones who used to ‘specialise’ in having the bigger picture, the ones who could join the dots, the ones who could come up with the clever diagnosis.

And then specialism happened. We all became specialists in our niches. The cardiologists left general medicine, no longer were they dually accredited. They only looked at the heart. They dealt with heart failure but if it was due to a pulmonary embolism, it now had to be the respiratory physicians’ issue. If by chance, the patient had a minor bleed secondary to the warfarin, they had to be seen by the gastroenterologists; if, heaven forbid, their blood sugars were high, call the diabetologists…

So what the heck happened to us as physicians? I take my hats off to Medical Assessment Unit colleagues who still do and understand general medicine. Unfortunately, they are being reduced to triage doctors due to the incessant pressure of either having to discharge patients or moving them to another speciality. But medicine isn’t that easy – not everyone fits nicely into a category, a pre-defined speciality, do they? The patient sits and watches while physicians argue and debate who they can see, who they cannot…while time ticks by.

If we stand back and accept that we are ALL physicians, then maybe it would be easier. I have no problem with anyone being a super expert but that shouldn’t translate into one forgetting the reason why they got their degree in medicine. For sure, there is specialist training, for sure no one can ‘pop a tube down the throat’ like you do, but does that mean you’ve forgotten how to treat something that doesn’t fit into your chosen niche.

How about the ‘money’ argument? Well, how about this, most physicians have been trained in their speciality AND general medicine. Did they get paid while they were doing their training? Well, of course…and a tuppence for guessing who paid them to be trained in general medicine along with their speciality. Correct, that would be the taxpayer. So in that case, let me ask these questions: when someone ‘not quite in your speciality category’ comes under your remit but has a general medical problem, do you walk away saying “I am special”? Or, do you apologise to that patient for wasting their taxes, which were spent on training YOU to learn about general medicine too?

In super hospitals or big regional training centres, there needs to be super specialists. Don’t get me wrong, I don’t want a cardiothoracic surgeon dabbling in gall bladder surgery, nor the ace pituitary endocrinologist looking at a DVT.

But, for the good old DGH – give me a break. Be a specialist in your outpatient clinic, be a specialist on the wards too, but for God’s sake, don’t say you “don’t do anything else”. It’s dishonest to your own training, and to the public who have paid for your training.

So, who looks after that old lady with multiple pathologies who doesn’t fit into a pre-defined speciality category? The answer should be “all of us”, as physicians do.

As Chuck Palahniuk, author of the novel (and then film) Fight Club, wrote: “We are not special. We are not crap or trash, either. We just are. We just are, and what happens just happens”.

Brush up on your acute and general medicine skills at Hospital Dr’s Acute & General Medicine Conference 2012. Click here to see the speaker programme.

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3 Responses to “Who treats the old lady with multiple pathologies?”

  1. silkrabbit says:

    As a specialist who spent 4 years as a general medical registrar (accidentally, I was trying to do an MD at the time) I have been very grateful for that valuable experience. When I’d finished, I could do General medicine in my sleep (in those days you often did.) When the criteria for referral to an arthritis doctor seems simply to be a raised ESR, or very ill, don’t know what is wrong, must be vasculitis/connective tissue disease, General Medical diagnostic skills are very important. I’d support increased time in General Medicine before Speciality Training. Mine was accidental, but I have been a more confident consultant for it, and the patients have been better served.

  2. OldNick says:

    The answer to your question is, of course, a geriatrician. Looking after old ladies with multiple pathologies is bread and butter to us. Most of us also do lots of acute medicine, so in many hospitals there’s a good chance that the consultant at the other end of the phone at 2.00am will be also be a geriatrician.

  3. Dr Rahul Mukherjee says:

    1. It is absolutely essential to distinguish between Hospitalists and Office Physicians

    2. Preferentially those Office Physicians should be encouraged to practice in hospital who deliver the QIPP (Quality Innovation Productivity Prevention) agenda on Long Term Conditions, i.e.

    a. 25% reduction in LOS
    b. 20% reduction in unscheduled care utilisation
    c. 20% reduction in readmission rates
    (more on http://www.dh.gov.uk)

    All other Office Physicians should be encouraged to work directly in Primary Care. We have got excellent examples of a select group of such Office Physicians in the health service, who have already voluntarily given up some Programmed Activities, enabling the recruitment of high quality Hospitalist colleagues.

    Also, it is high time that training programmes are broadened in such directions as suggested by Temple et al., so that all trainees receive a foundation of exposure to health care management and health services delivery, enabling them to participate as informedcitizens in the systems in which they work and learn and future physicians are better equipped to interpolate themselves in the wider context of the whole health economy.

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