General internal medicine –the bedrock of the Irish medical system

The RCPI review of general internal medicine training is a timely intervention to help address critical needs within our hospitals 

General internal medicine (GIM) is the core business of Irish hospitals, accounting for approximately two-thirds of hospital bed days. The preservation of general medical skills in an era of increased specialisation is critical to maintaining standards of care in Ireland, particularly in managing multimorbidity, frailty, and polypharmacy in our growing, ageing population.

Pressures on GIM manifest across the system as longer waiting times in emergency departments, increased numbers of patients placed in beds not suited to their specific needs, decreased efficiency in the discharge process, increased errors, and greater stress within the workplace.

What is frequently described as an emergency department crisis could more accurately be described as a GIM crisis, hosted in the emergency department.

International standards for internal medicine training have shifted to be more structured 

Training review

The training and skills required by the medical workforce are dynamic and continuously evolving. Unfortunately, research suggests the level of generalist skills in internal medicine is declining. Internationally, GIM communities have struggled with this to a greater or lesser extent, with some regions prioritising the development of internists or hospitalists as a career path. In others, including Ireland, trainees generally complete stage two training in another medical subspecialty.

International standards for internal medicine training have shifted to be more structured. Following consultation with our members, the RCPI is committed to delivering a more structured training programme across basic specialist training (BST) and higher specialist training (HST) to better support physicians in dealing with the ever-growing complexities of general medicine.

A key aim of the RCPI’s Institute of Medicine (IOM), since it was established in 2020, has been to improve the governance and integration of general internal medicine training, and to ensure that training is reviewed, optimised, and benchmarked to international standards, graduating exceptional general physicians of the future.

Since summer 2022, I have been leading this review. We are looking at current structures and practices and assessing these against international training models in the UK, the US, Australia, and the Netherlands. We have established a steering group of GIM experts whose ongoing guidance and expertise continues to guide our direction and focus.

We have consulted extensively with stakeholders, including training directors, trainees, the IOM board and officers, the RCPI council and management, the acute medicine programme, the HSE National Doctors Training and Planning, and the integrated care team in the HSE.

As a result, a number of key themes have been identified, including:

• Establish an internal medicine training programme (Impacts on BST and HST training);

• Integrate cross sub-specialty training;

• Champion internal medicine and prioritise the role of the internal medicine trainer;

• Improve and incentivise the GIM training experience in level 3 hospitals;

• Consider and explore internal medicine as a single specialty training option.

A formal interim report to detail the findings of our review and set out recommendations for an improved training programme in general internal medicine will be delivered mid-2023. Planning to operationalise and implement the recommendations by 2025 is currently underway.

This is a vital piece of work and we are grateful for people’s support with it. Improving our training programmes to meet the needs of the doctors and patients of tomorrow is a core part of the RCPI’s mission. This will enhance the delivery of care in general internal medicine in both the hospital and community that is so critical to the health of our population.

If you would like to provide feedback, please email optimise@rcpi.ie.

References available on request