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General internal medicine in Australia and New Zealand -- a renaissance

A new society challenges potentially excessive subspecialisation

MJA 1998; 168: 104-105  

            

 

Last year in Auckland the Internal Medicine Society of Australia and New Zealand (IMSANZ) arose from the merger of the Australian Society of Consultant Physicians in General Medicine and the Internal Medicine Society of New Zealand. The new society, with 400 Australian and 100 New Zealand members, is now the regional voice of consultative general medicine. Its birth coincides with the renaissance of this discipline in Canada, the United States and Europe. Hospitals, health care managers and funders are reconsidering the likely benefits to both quality and efficiency of health care when medical services are provided by a team in which the "breadth" skills of generalists complement the "depth" skills of subspecialists.1

 

Outcomes of care

Who achieves better outcomes -- general or subspecialty physicians? There are two relevant Australian studies, both in tertiary hospitals. One was not completed because of lack of enthusiasm by busy clinicians and doubts about the value of consensus evaluation following case note audit.2 The second, a randomised study, showed no differences between general medical and specialist geriatric care in acutely ill patients older than 70.3

Although comparisons with the US are problematic because "general" in the US includes primary care as well as consultative general medicine, US subspecialists have better outcomes for the care of rheumatoid disease and myocardial infarction,1 while for hypertension and non-insulin-dependent diabetes outcomes for generalists and specialists are similar.4 However, specialists consume more resources.5

 

Health care costs

In the US, swelling numbers of physician subspecialists reportedly increase health care costs, unmatched by proportional outcome benefits.6 Excessive subspecialisation may lead to economic blow-out, especially in the uncapped, fee-for-service private sector. With "managed care" to contain costs, there is a resurgence of training and career opportunities for generalists.7,8

 

Is there too much subspecialisation in Australia and New Zealand?

In Australian capital cities, subspecialisation, especially in procedural subspecialties, may be excessive. Of 2611 Australian consultant physicians in adult medicine in 1995, only 399 described themselves as "general", compared with 371 cardiologists and 286 gastroenterologists.9 In State capitals in the period 1988-1995 physician numbers (excluding paediatricians) increased from 1729 to 2146, while general physician numbers dropped from 412 to 281.9 In 1996, of 552 Australian advanced trainees of the Royal Australasian College of Physicians (excluding those in paediatrics), only 42 (8%) were in general medicine, with 84 in cardiology and 51 in gastroenterology. However, in New Zealand, 25% of the trainees were generalists. Despite the subspecialisation in Australia's biggest cities, there are shortages of consultant physicians in country areas. Up to 50 additional consultant physicians are needed in provincial and rural Queensland alone.10 Most would need to be generalists.

 

Why do tertiary hospitals need general medical units?

Tertiary practice, now dominated by technology and procedures, is becoming organisationally and financially based on discrete episodes of care involving single diagnoses. In this climate, the general medical unit may be seen by some as unnecessary; three teaching hospitals in Sydney as well as the Canberra Hospital, ACT, now have no such units.

Compartmentalisation of care by medical specialty means that significant comorbidities and patient concerns unrelated to the particular specialty are easily overlooked, misdiagnosed or inappropriately managed. Gains in efficiency through greater throughput of patients with similar problems may be offset by more consultations and unnecessary investigation. Further, the continuity of care is disrupted. Generalists, with skills in managing undifferentiated problems and conditions that cross subspecialty barriers and an awareness of both the psychosocial and the biological aspects of illness, offer "whole person" patient care and can act as advocates for the patient.11

While many subspecialists practise in a similar way, general units are needed to provide training positions and role models for both basic and advanced training in general medicine. The generalists' integrated view of patients is an absolute requirement for undergraduate and early postgraduate education in a setting where illness is not arbitrarily framed by such overlapping criteria as age (e.g., geriatrics), organ system (e.g., cardiology), pathological process (e.g., oncology), aetiology (e.g., infectious disease) and treatment goal (e.g., palliative care).

 

New agenda for general internal medicine

General internal medicine has the breadth and the capacity to embrace new challenges. Generalists can continue to learn from experienced subspecialists and can acquire both the knowledge and procedural skills that might be necessary in particular city or rural, hospital or office settings. They can also lead the way, as in North America,12 in clinical epidemiology and decision-making, ethics, clinical informatics, health technology assessment, clinical audit, and health service research. General physicians can act with other colleagues (e.g., in general practice, surgery, emergency medicine, psychiatry, geriatrics) to help integrate medical care and provide an overview of medical management that may be lost with exclusive specialty care.13

Barriers to the realisation of this new agenda include negative perceptions of generalists by some influential subspecialists in hospitals, by professional societies and by patient support groups; difficulties faced by general trainees in competing for coveted subspecialty training positions;14 and competition among institutional units for limited resources under casemix funding. Lack of confidence and leadership among generalists themselves may set up internal barriers.

While the need for subspecialisation in consultative physician practice is recognised and supported, it seems the pendulum has swung too far. Our health care systems stand to benefit from a more vigorous contribution by well-trained and committed general physicians. For a winning team, we need outstanding players -- some with specialised talents and others who are versatile.1

Ian A Scott
Director
General Medicine Princess Alexandra Hospital, Brisbane, QLD

Peter B Greenberg
Director
General Medical Services North Western Health Care Network, Melbourne, VIC

  1. Nash DB, Nash IS. Building the best team. Ann Intern Med 1997; 127: 72-73.
  2. Douglas RM, Blood A. Evaluation and peer review of the role of specialist and general medical units in a teaching hospital. Aust N Z J Med 1978; 8: 337-343.
  3. Harris RD, Henschke PJ, Popplewell PY, et al. A randomised study of outcomes in a defined group of ill elderly patients managed in a geriatric assessment unit or a general medical unit. Aust N Z J Med 1991; 21: 230-234.
  4. Greenfield S, Rogers W, Mangotich M, et al. Outcomes of patients with hypertension and non-insulin-dependent diabetes mellitus treated by different systems and specialties. Results from the medical outcomes study. JAMA 1995; 274: 1436-1444.
  5. Welch WP, Miller ME, Welch HG, et al. Geographic variation in expenditures for physician services in the United States. N Engl J Med 1993; 328: 621-627.
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  9. Dent O. The Royal Australasian College of Physicians Clinical Workforce in Internal Medicine and Paediatrics in Australia 1988 and 1995. Fellowship Affairs 1989; 8: 9-20, and 1997; 16: 17-30.
  10. Hadfield C. Rural manpower in Queensland -- a start to tackling the problem? IMSANZ Newsletter June 1997: 6-7.
  11. Guidelines for members and advanced trainees in general medicine, 1997. Sydney: Internal Medicine Society of Australia and New Zealand, 1997.
  12. Greenbeck MR. Educating physicians for the 21st century. Acad Med 1995; 70: 179-185.
  13. Ward JD. The hospital general physician in the 1990s. J R Coll Physicians Lond 1996; 30: 209-210.
  14. Smith BJ, Darzins P, Heller RF. RACP Survey of advanced trainees' job aspirations: the fate of those who pass the clinical exam of the RACP. Fellowship Affairs 1993; 12: 31-33.

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