Single accreditation for GIM

Written Dr Bharathy Kumaravel

Tomorrow’s doctors need to appreciate that health is beyond just diagnosis and treatment of specific conditions. An ageing population is more likely to have multiple morbidities (long-term conditions). For instance, it is common for an 80-year-old patient to present with diabetes, hypertension, COPD, and depression.  The challenges of multimorbidity are that patients present with complex self-care needs; care is provided by several teams often in isolation, resulting in fragmented care and an increased use of resources- including emergency healthcare. 

Socioeconomic deprivation can add a further layer of complexity while providing health and well-being care for someone with multi-morbidity. Doctors need to consider the role  of social determinants of health while providing care for their patients. 

Advances in healthcare have helped in the management of individual long-term conditions, thereby adding years to our lives. However, to improve the quality of life in later years, doctors need Generalism skills to deal with multiple long-term conditions. General practitioners, diabetologists and geriatricians already appreciate this challenge and work in teams to provide holistic patient care. We need to change the way we train future doctors.  

We need a shift away from the current model to integrating Generalism into all specialities, not just a few. Medical education has traditionally been designed around individual specialities (such as medicine, surgery, obstetrics and gynaecology, cardiology, and ophthalmology). It focuses on training future doctors on the pathology, diagnosis, and treatment of individual health conditions. 

We need to integrate Generalism training into medical education - so that future doctors can: 

- provide person centred care 

- appreciate population health

- advocate for social justice

- tackle health inequalities

- provide sustainable healthcare and 

- deal with complex multimorbidity

NHS England is piloting the introduction of Generalism into various levels of health education.  In Midlands, we are piloting introducing it in IMT.  Work is still in progress; however, it is reassuring to learn that the new curriculum is offering the training and immersive experiences needed for Generalism. Our Enhance IMT trainees have started demonstrating leadership skills- advocating, and influencing across boundaries. 

We are taking a critical approach to inquiry with key stakeholders- trainees, faculty, administrators, general practitioners, hospital consultants, community trusts, public health colleagues and the voluntary sector to co-create the curriculum. We recently held a stakeholder engagement event to learn about their perceptions and take their views on board while reviewing our programme.

Written by Dr Elizabeth Estabrook

The UK is an outlier in its approach to the care of medical patients that are hospitalised. Almost all Western health systems have a “Generalist” who manages the day to day care of patients on the ward. Having trained in Internal Medicine in the USA, I completed an Internal Medicine Residency program and become what they call a “Hospitalist”. Over the last 25 years this has been the fastest growing specialty in the USA. Patients admitted with a medical condition are primarily managed the Internal Medicine Hospitalist and specialist input is sought on a case by case basis. This can include anything from acute myocardial infarction, decompensated cirrhosis, to complex lung disease. This model has been shown to be highly effective in improving patient care and reducing length of stay. Of course there is variation in how this model is delivered depending on local resources and specialist care is needed in many cases. However, specialist opinion, diagnostics and interventions are sought in conjunction with the Hospitalist who aims to provide a holistic approach to their care, especially when some patients will need multiple specialties involved in their care. The Internal Medicine physician is a highly respected position for those who wish to be the “diagnosticians” of the hospital. Their opinion is sought in order to evaluate complex and undiagnosed patients and in addition, in many hospitals, actively involved in the day to day management of post-operative patients with complex co-morbidities or complications.

In creating the General Internal Medicine run-through training, NHS England have given the UK an opportunity to develop a similar model. This is not as revolutionary as some might think - we are actually familiar with this model in General Paediatrics and Elderly Care Medicine which already employ a very similar model. For those aged 18-80 a Generalist model has the potential to revolutionise the way we practice hospital medicine. As a recognised specialty that prides itself in diagnosing complex and interesting presentations, as well as the holistic care of patients with complex multi-morbid disease that are hospitalised, it is time that it is recognised as an essential component to NHS care. This model can allow for a rewarding and flexible career for those interested in hospital medicine, whilst having the potential to allow other specialists to have more time to focus on their clinic and procedural lists. As waiting times and demand increase, the Generalist has the potential to improve outcomes both in and outside the hospital.

At University Hospitals Plymouth NHS Trust we are delighted to be a part of the second phase of Health Education England’s pilot programme for standalone General Internal Medicine training. The catchment population of Derriford Hospital is characterised by diversity (rural and urban populations) with a wide variance in health and life expectancy.  

Our department was set up 4 years ago and it prides itself in providing continuity of care to complex patients that do not clearly fit the admission criteria for other subspecialty wards. The creation of the pilot programme for GIM training comes at a time when there is high demand for delivering complex and comprehensive care to patients with multiple comorbidities in changing healthcare environments. 

General Internal Medicine trainees will have to develop a strong base of generalist skills with confidence across different disciplines. Due to the complex multimorbidity of GIM patients, trainees will learn how to coordinate care when input from multiple specialties and teams are needed.  

Trainees will have to develop an understanding of their local community and develop skills that allow them to understand population needs and optimal use of resources. At UHP we have therefore linked with the Plymouth Institute of Health and Care Research (PIHR) at the University of Plymouth in order to allow trainees to carry out a supervised project that evaluates novel ways of improving the quality of care delivered to the most vulnerable people in our community.    

We have also linked with Peninsula Medical School and trainees will find opportunities to regularly teach Medical students and Physician Associate students. The department also hosts junior doctors who play a major role in helping the department carry out its day to day work. From time to time we hold social events such as our recent International Luncheon (pictured).  

At UHP we are very excited to help train the generalists of the future and we know that local populations will benefit tremendously from Health Education England’s initiative. We will be receiving our first trainee in August 2023 and we are hoping to help them master not only diagnosis, management and evidence based medicine but to also help them gain a deep understanding of holistic person-centred care.  

West Midlands Residential Medical Registrar Training Course

Being a Medical Registrar is one of the most important and rewarding roles within hospital medicine. It is however physically and mentally challenging. In recognition of the challenges faced by our higher specialty trainees when taking up this role, The School of Medicine for the West Midlands commissioned Shrewsbury & Telford Hospital NHS Trust to deliver a 3-day residential course specifically designed to cover a wide range of clinical skills and non-clinical skills in a fun and interactive way. The course was codesigned with 202 (West Midlands) Field Hospital (Army Reserve) personnel who help us build in human factors training focusing on leadership and team building.

16 ST4s from our stand alone GIM programme across England joined us, alongside some local IMT3s for three days in May. The delegates attended to various day time training events returning in the evenings for a team dinner and evening training and social events.

The Course was split over three days,

Day One-Medical Registrar Clinical Simulation

Day Two-Human Factors

Day Three-Hospital Clinical Simulation Exercise

The first two days focused on clinical and human factor training leading to the final day exercise where all these skills were tested in a safe and supportive environment. The course was a great success and enjoyed by both the trainers and the delegates. The written feedback from the delegates was very positive! Below are some examples.

"It was the best simulation course I have ever attended".

"100% I will surely recommend to my colleagues".

"Focus on teamwork, leadership and followership is rarely spoken about in the rest of training. Very dynamic and engaging".

The Shrewsbury and Telford team look forward to delivering in again this year.