Things I learned in Canada

Dear Dr Crestor
Your comments above appreciated. Below is an editorial in the making: does this make sense south of the border?
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Editorial CSIM Journal

Image and Identity: the Internist’s lodestone

A senior colleague of mine gave me an historical perspective on the role of the internal medicine ’specialist.

“You know, when I trained, at the Montreal General, there was little one could do by way of diagnostic studies. We could take x-rays, and look at blood, urine, and tissue. But there was no ultrasound, or CT or fancy angiography. One lady I remember was deeply jaundiced. We had her in hospital for 3 weeks. She went for her laparotomy to confirm pancreatic cancer. When doctors were stumped, they sought out the advice of a diagnostician, someone with a lot of experience, who kept up with the literature, and who could shed light on a complex problem. An internist. Now, the the practice of Medicine has changed. We diagnose people antemortem, hence the fall in number of PMs. We have most of the answers for most of the diagnostic problems. Just as radiology has changed, therapeutics have changed. At a time when my boss recommended antiserum for pneumococcal sepsis, the young bucks said this sulpha drug worked like a damn.

And what about home visits? We used to make these but not now. The role of the visiting specialist was to tell the family that this was a very serious disease, that we couldn’t do much by way of therapy, and to expect the worst in a given period of time. The family were accepting, and could then prepare for the worst with some degree of certainty. That is what they needed at that time”.

If Internal Medicine has changed, should we change with it? When Olser, in an address to the American Association of Physicians in 1895, called for training of “able young men…. in internal medicine as a specialty”, he created a name that confused the layman and the practitioner alike. How could a generalist be a specialist too?

As the volume of knowledge grew, and the capacity for internists to know everything and do everything receded, subspecialist departments expanded in number and in power. Procedural skills took precedence over cognitive skills, leading to a shortfall in recognition and reward. Internists do many procedures, but none are unique to GIM, nor well paid.

GIM has changed. From a mother-like core-discipline encompassing all of the subspecialties, GIM now focuses on the care of patients with multisystem problems, on multiple drugs. Patients with diabetes and hypertension, with shortness of breath and chest pain, with atrial fibrillation and stroke. We treat medical complications of pregnancy and the degenerative diseases of ageing. GIMS have a strong sense of responsibility for those who have social problems, or ethical issues. Ours is a discipline embracing teaching, research, administration and healthcare planning.

Residents attending the GIM workshops in Toronto last November had interesting feedback for us. “I can get 2 fellowships in 5 years of training, so why just settle for just GIM?”. “I can make more money with a better lifestyle by choosing a subspecialty”. Clearly, residents perception of GIM is influenced by the image of the overworked, undervalued and underpaid tertiary centre generalist, taking over patients the ‘subspecialists have finished with’, fighting to get patients placed when beds are at a premium, managing complex problems that may need attention at unsocial hours. An afternoon devoted to discussing the broad tapestry of GIM did little to change these residents’ minds.

The name ‘internist’ is confusing. We are not interns. In general, we do not do internal examinations (unless indicated). Most of the diseases we treat have internal manifestations, but why define them by location in the first place? I believe it is time for GIM to redefine itself, so that both students of Medicine, patients, politicians, and our fellow physicians can better comprehend the breadth and scope of what we do.

What term best describes the 21st century generalist? In the US, where internists have a more primary care role, “Doctors for Adults” is a term promoted by ACP. In Canada, where a consultant role is still prevalent, “Specialists in Complex Adult Medicine” may be more appropriate.

If image and identity are to be our downfall, in times of exploding demand and withering recruitment, let’s find out what the market understands, and invest in a PR strategy that will help all of us appreciate our true worth. Stop talking about a name change and enact one. Sell generalism as well as the partialists do their domain. Recruitment often follows income, and it is time cognitive skills were adequately rewarded. We need GIM to flourish, not just for our own benefit, but for the functional survival of our surgeons, anesthetists, GPs, healthcare planners – and patients – alike.

Hector M Baillie MD
Specialist in Complex Adult Medicine
Secretary, CSIM