General internal medicine encompasses the care of the general medical needs of both inpatients and outpatients as well as the management of acute medical problems. The practice of general internal medicine enables the physician to care for the patient who may have a number of co-morbidities and is not limited to one medical specialty.
The roles in which consultant physicians practice general internal medicine varies with each specialty, for example acute physicians play a far greater role in the acute setting whereas other specialties may more commonly use their general medical skills when caring for inpatients or outpatients, suggesting that the role of general internal medicine for physicians is not universal but rather varies depending on the specialty and skills of the consultant physician and the setting in which they are working.
For more information on the training pathway, see the Joint Royal College of Physicians Training Board. You cannot apply directly to GIM at ST3 level - to gain access to training it is necessary to apply for another medical specialty alongside which GIM training is undertaken. Learn more about the recruitment and interview process through ST3 Recuitment.
General medicine is at a crossroads. The number of hospital admissions continues to increase year on year whilst numbers of beds diminish. Yet whilst this pressure on beds demands a faster throughput, the in-patient population is becoming older with more co-morbidity. Thus the physician workforce must be appropriate to the needs of these patients. However, the political drive is to train more general practitioners, so the physician workforce that is currently in place or in training is unlikely to increase significantly.
Two thirds of medical registrars dual-certify in General (Internal) Medicine (GIM) as well as their specialty and two thirds of consultants say they practise GIM. However no trainees are sole certifying in GIM and people’s perception of GIM varies according to specialty, how they work, and indeed where they work. Smaller hospitals, where there are insufficient specialists or acute physicians to support a specialty take, continue to rely on a ‘physician on-take’ model. GIM has a bit of an identity crisis.
The creation of acute medicine as a specialty has been a great success; however the workforce is still insufficient to support on-going GIM care outside of acute medical units in most hospitals. The creation of acute medicine has also allowed other specialties to develop in their own right but has had the unintended consequence of some specialties in many hospitals dropping out of GIM rotas.
Several recent documents call for more ‘generalism’ and training to support the changing patient needs, including both the Shape of Training report and the RCP’s Future Hospital Commission. How this will actually be implemented remains unclear and the conflict between generalism and specialism threatens to become a destructive one. Specialty management of many conditions improves outcomes, and ‘specialty take’ models in large hospitals work well. Generalism must not allow the improvements in care gained over the past decade to be lost. GIM is seen by some to be less important than a specialty, yet to be a true generalist a huge knowledge of many specialties is required.
The other conflict is between service and training. Many trainees and consultants think of GIM as ‘the acute take’, overlooking that most in-patients and out-patients have multiple medical problems and need physicians with GIM skills and knowledge. The service needs of many hospitals overtake training needs and this has a negative effect on how GIM is perceived by both doctors in training and established consultants.
Putting all of this together, the need for doctors who are well trained in GIM is unarguable but there are conflicts and issues in how this is best achieved. GIM is no longer a specialty in its own right but if it was it would be the hardest to do well. All physicians need to be trained in GIM but everyone needs to be clear what is meant by GIM as it applies to their patients. Patients should be the focus of debates about GIM, not historic or doctor-centred arguments.
The RCP strongly supports the notion of GIM and that all patients have GIM needs – not just those admitted acutely. Using the phrase Internal Medicine (as used in the US for many years) may help get away from the generalism/specialism debate.
The Shape of Training review brings many threats to hospital medicine, but it does provide us with an opportunity to put Internal Medicine back at the core of all that physicians do. G(I)M is dead. Long live (G)IM.
Dr Andrew Goddard, RCP registrar, August 2015