10th college of physicians lecture: the challenges of reinventing medical generalism in the 21st century.

Presidents, Fellows, Members, distinguished guests I am honoured to be invited by the Singapore College of Physicians to give this 10th College of Physicians lecture titled: “The Challenges of Reinventing Medical Generalism in the 21st Century”. One of the major challenges which we face in General Internal Medicine is re-inventing medical generalism. We are forced to do this now and in the years to come, because of important changes in the demographics of our patient population and the way patients present, as we age, to acute medical units. I think we can agree the cornerstones of good health care: • The right thing for the patient—we must be more patient-focused not only in terms of the standards of care that we give but also in terms of the organisational aspects of care delivery. • Effectiveness—with the demands on systems in which whatever healthcare system you work in, be it insured, partially-insured, not reimbursed or a United Kingdom (UK) state system, we must strive to be effective and effi cient at all times. • Standardisation—I think equally we need standardisation across all domains of healthcare and standardisation of practice needs to be evidence based and guideline driven. • Sustainability is key. How are we going to continue to look after the frail elderly patients of the future?We need a named consultant with continuing responsibility for the patient, a safe decision-maker in charge of every patient. • At the same time we need to maximise the input of all the members of the team and our specialist colleagues, to make sure there is provision of holistic care at the right level. As a profession, we come at this from different perspectives but our priorities must be patient expectation, patient experience and the expectations of the family and carers. Coverage of these issues by the medical media is often disproportionate and emphasises that patients allegedly demand specialist care. If I take my own specialty of cardiology and give you the case of a young man who presents in atrial fi brillation, an uncontrolled ventricular rate, in heart failure with a family history of sudden death in the context of probable cardiomyopathy—a constellation of problems which will not just involve me as a general cardiologist, but one which demands the input from an imaging cardiologist, a rhythm cardiologist, maybe an ablation cardiologist, a device cardiologist and in all probability a cardiac geneticist. Pure specialism is in fact already a thing of the past and has given way to “microspecialisation”. Secondary care medicine is now challenged by the need to co-ordinate care to the extent and to the level that is appropriate for many elderly patients presenting with many comorbidities. We must ask ourselves if microspecialisation for the relative few is set to expand at the expense of holistic care for the many. I want to show you fi gures for a weekend in May: 16 patients on a UK medical ward with an average age of what you would expect, around 80—if you look at the “specialism” problems with which they presented, they number 16 with a mean number of 6 comorbidities per patient. To complicate the nature of the problem we often see potentially life-threatening illnesses occurring together, commonly acute heart failure in the context of worsening renal function. Numerous clinical cases demonstrate the potential dangers of polypharmacy with drug combinations worsening renal function and in turn adversely affecting renal clearance of many common therapeutic agents. Analgesics and anti-infl ammatory drugs frequently lead to problems in the elderly patients admitted to hospitals