The Ulster Medical Journal meets the Vancouver Group

but the largest hospitals there are just not enough consultants available. Finally if we go down the highly subspecialist path general skills will atrophy and the role of the generalist will be handed to specialists in accident and emergency medicine. Once lost the position will not easily be regained. The alternative is to redevelop the physician generalist/specialist, as a practitioner possessing general skills for managing acutely ill patients, whilst conducting a special interest based mostly in an ambulatory care setting. Those physicians willing to take on this challenging task must continue to be identified as having trained in and as continuing to practise acute medicine. It has been encouraging to see some subspecialist groupings, notably those in geriatric medicine, rejoining this tradition. Acute medical workloads require to be better defined and valued. That this activity will take place in fewer beds will have one blessing-no longer will "admit medical" be acceptable for patients whose only fault is to be elderly or have relatively ill defined problems. Though one is best not to trust specialties which change their name, the term general medicine must go. It has a vague and woolly feel and is too easily confused with general practice. Internal Medicine is more distinctive and is internationally recognised. Physicians can usefully raise their profile by developing admission units and areas concentrating resources and technology. The physician generalist/specialist of the future need not fear the growth of internists based in primary care though he will reasonably argue that entry to such practice will require properly supervised training and recognised professional qualification. He will also point out that a team of generalist/specialists will remain uniquely well placed to teach medical students for whom the prospect of the sum of hospital based subspecialist teaching or the mileage allowance book to reach widely spread general practice based teaching are the bleak alternatives. Finally and perhaps ironically the future physician generalist/specialist, far from being an anachronism, is likely, once accurate costing of alternatives becomes available, to continue to be a vital cog in the hospital service of the future which labours to combine accessibility, effectiveness, efficiency and flexibility with some degree of common sense. The casualty departments, the general practitioners unable to have their sick patients admitted and the medical disasters waiting to happen because of treatment delays, will eventually result in an outbreak of wisdom leading to the formulation of contracts which adequately take …