Let's hear it for the medical registrar

Editor – In the December 2011 issue of Clinical Medicine, you mentioned in your own editorial, ‘Lets hear it for the medical registrar’ (Clin Med December 2011 pp515–516), the issue of involvement in the acute take and the role of the generalist in hospital general internal medicine. In the same issue, Goddard and colleagues reported a national survey of medical registrars' experience and attitudes to their future careers – in particular, the reluctance of nearly half of them to continue active involvement in the acute take on becoming consultants.¹ Here too, the issue of generalism versus specialism was raised. I believe that this needs further reflection and exploration before we rush headlong to the creation of ‘hospitalists’ (in other words, re-creation of general physicians), for a number of reasons.

• 1We already have what is probably the most extensive training in general internal medicine of any health system: two years at CMT level, rotating through several specialties, followed by five or six years higher specialty training, with GiM dual accreditation throughout for many CCST holders. Are we proposing even longer or more rigorous training in General Internal Medicine? Will ‘hospitalists’ be any better trained in GiM than current dually accredited consultants?
• 2With the expansion of acute medicine as a specialty, as well as a growing focus on medical admission units with very intensive ‘front door’ involvement of illness (albeit often alongside various long-term co-morbidities)?
• 3The majority of acutely admitted adult patients are older – often among the oldest of old, and often with multiple long-term conditions, frailty and complex co-morbidity. For instance, 1 in 4 adult beds is occupied by someone with dementia.² Geriatric medicine – the largest GiM specialty of the Royal College of Physicians – deals well with these patients and there is an excellent evidence base for the effectiveness of comprehensive geriatric assessment³ (the skill that geriatricians offer) as well as for the care of individual syndromes related to old age such as delirium, falls, or incontinence. So either we need more geriatricians or we need to ensure that all general physicians have competencies in care of frail older people with multiple co-morbidity.
• 4In the scenario described in the articles to which I refer, of an acute receiving physician who cares for a big portion of acutely admitted GiM patients, calling on specialty consultants could lead to an unfulfilling role of notional responsibility, where one's name may be above the bed, but, in reality, one is waiting daily for specialty advice from another team before a decision can be made. Such ‘remote control’ management can be frustrating and might be an unattractive prospect – in its extreme form turning the generalist into an ‘intern’ for the visiting specialist.
• 5Provocative though this may sound, I can't help wondering whether doctors paid by and trained at length by the NHS should take pride in looking after the patients who come through the door, rather than those whom they might find more intellectually stimulating or rewarding to look after.

The business of acute hospital medicine in the twenty-first century is not all high-tech, cutting-edge or curative, but the management of (generally older) patients with (generally multiple) commonplace long term conditions, often a degree of physical disability, cognitive impairment or social vulnerability and often needing a multidisciplinary approach which deals not merely with disease, but bio-psycho-social factors, rehabilitation and maintenance. If physicians working in adult medicine don't feel confident or willing to look after such patients or, worse still, label them as ‘social’ or ‘acopia’,⁴ we need to tackle this in training, in job planning and in appraisal and management. Our values, priorities and skills need to catch up with this reality. Something has gone wrong if nearly half the doctors who have chosen to train extensively and expensively in general internal medicine conclude that they don't then want to practice it.