Hospital doctors who are ready to be excellent generalists should be allowed to get out there and practise
Gordon Moore, who died a few months ago, was an Intel executive who is mostly remembered for his ‘law’ that the number of transistors we can fit on a microchip would double about every two years. He predicted this in 1975 and has been more-or-less correct ever since, which is probably more than we can say for most predictions made in the 1970s. It can sometimes feel like this law operates in reverse, though, in medical specialties: The breadth we focus on will approximately halve with every generation.
I loved listening to surgeons who worked mid-century tell stories of doing heart surgery in the morning and an appendix in the afternoon; hearing of GPs delivering babies; and of the general physician dealing with heart attacks, diabetes, Parkinson’s, and just a little tuberculosis on her daily ward round.
While it makes for a good story, obviously this is not the type of medicine we are nostalgic for. Nobody needs an enthusiastic amateur with a scalpel having a go at their aortic valve. But it can sometimes feel like the modern silo of practice would make you claustrophobic. I remember hearing of a university hospital in London where the ANCA-positive vasculitis team just did not feel comfortable dealing with ANCA-negative vasculitis. In major hospitals, often the simplest decisions require an outside consult. Meanwhile, patients spin the plates of 12 different medical appointments for their problems.
At first glance, it might seem like this worldview has reached its apogee in the US. They are the triumphal overlords of hyperspecialisation, with a CT chest-abdomen-pelvis sometimes requiring three different flavours of radiologist to read it and oncologists that may mostly see cancers with just one specific kind of mutation.
But look a little closer and you’ll see it’s not that simple. While academic centres can be niche-heavy, some parts of the hospital, and doctors in the community, are not. Oncology-haematology functions as a single discipline here, which means many graduates from training programmes will set up a practice where they will see every cancer or blood disorder that comes through the door, a prospect which leaves me a little faint. Many general surgeons here are really quite general, dealing with skin cancer and bowel tumours in the same day. And a backbone of the medical system are generalist doctors who are prepared to deal with whatever medical problems the emergency department has to offer: These are the ‘hospitalists’.
Like in Ireland, medical trainees in the US – residents – have a three-year programme, roughly analogous to intern and two house officer years combined. Unlike Ireland, though, those who complete a residency in internal medicine and their board exams can be independent practitioners. They are certified in internal medicine and can work as hospitalists or outpatient general internists (which is somewhat like being a GP). About 20 per cent of residency graduates remain as internists the rest of their career.
As a graduate of the Irish system I may be biased, but I have never been in doubt that the doctors we produce are on par with the US. However, was I ready to practise independently on my final day as an SHO? Perhaps not. One job I think the American training system performs better than ours is a steadily escalating level of responsibility every few months, so that the graduating residents are used to taking on the role as chief decision-maker. In Ireland, our ‘increased level of responsibility’ tends to happen by accident, with lots of anguish, for three hours, on a previously well-behaved medical ward, at 3am; before we return to writing transfer letters.
Is the American model one we should emulate? I am always wary of aping what happens across the Atlantic just because it’s exotic. But I do think their system has some muscular reasoning behind it.
Not every hospital doctor wants to be a specialist: Those who are ready to be excellent generalists should be allowed to get out there and practise. It is probably not controversial to say that most hospital specialties would embrace a discipline that took the lead on general medical on-call. And crucially, from my own experience, SHOs would no longer feel like the orphans of the medical training system, stuck between the more protected early months as an intern and the later life as a protégé under a specialist. Now they would have leaders focused solely on general medicine.
But there are drawbacks too. Our system would need an overhaul to provide the right tempo of graded exposure to responsibility. Those remaining specialties will lose some of the general medical skills they have and become more of a consult service. In a time of difficulties recruiting to many specialties, this will also represent a further drain of potential candidates.
None of this is cause to reject the suggestion out of hand. We stand to gain plenty from a motivated, ambitious corps of hospitalist physicians, and I have no doubt that our patients would too. Maybe in time we will even reverse our own version of Moore’s law a little bit. But let’s leave the brain surgery to the brain surgeons.
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