The Role Of A General Internal Medicine Doctor:
The medical needs of the population are changing. The increasing number of elderly patients as well as the growing number of comorbidities calls for doctors in training to acquire a spectrum of medical knowledge appropriate to patient needs.
The 2013 Shape of Training report1 has led to major reforms to the postgraduate training of medical doctors. Over the coming years there will be a move away from early specialisation and instead an emphasis on the importance of internal medicine in acute medical services.
The reformed internal medicine training programme recognises the importance of generic professional capabilities and how evolving patient needs requires internal medicine back at the core of a physician’s role.
Doctors working in general internal medicine (GIM) are responsible for diagnosing and treating a wide spectrum of clinical problems, ranging from the acute severely ill young person to elderly patients with multiple complex comorbidities(2).
As part of the acute medical care workforce, GIM doctors have expertise in diagnostic reasoning, determining treatment plans for patients acutely attending hospital and referring to the appropriate specialist opinion.
However, illness does not always necessarily fall into the remit of a specific specialty especially as the ageing population have complex medical problems involving multiple symptoms. This is when patients are also cared for under the umbrella of general internal medicine, managing inpatients and outpatients with co-morbidities.
As well as having competent communication and diagnostic skills, GIM doctors must be proficient at the practical interventional skills such as aspiration of fluid from the chest and abdomen, inserting chest drains and performing lumbar puncture(3).
A Typical Week:
GIM is largely a hospital inpatient specialty, working with patients on the medical wards and providing continuation of care until discharge. As part of the role, GIM doctors are also responsible for the acute treatment of unwell patients, working in the acute medical unit (AMU) and medical admissions unit (MAU), reviewing newly admitted patients and being in charge of their acute care before admission to a medical ward.
A broad knowledge base is required to be able to treat the spectrum of clinical problems that could enter the hospital doors. While this responsibility is extremely rewarding, the nature of the work requires the ability to treat a cardiac arrest one minute and a sepsis the next, making it a high stress environment.
The EU Working Time Directive limits the working week to 48 hours4. On-call is routinely part of the rota for GIM doctors, both registrars and consultants, and with a wealth of general medical knowledge, doctors are responsible for the acute medical care of patients across the hospital.
The Route To Becoming A General Internal Medicine Doctor:
For any career journey as a doctor you first need to have completed a medical degree followed by the two-year foundation programme. Following this, trainees must apply for core training to start a career in GIM.
There are two possible core training pathways2:
Completion of either of these as well as passing the MRCP(UK) meets the minimum specifications for application to ST4 higher specialty medical training.
The curriculum for both programmes has been under recent revision. As of August 2019, the IMT programme has replaced Core Medical Training (CMT). The new three-year curriculum, composed of IMY1, IMY2 and IMY3, includes mandatory training in geriatric medicine, critical care, and outpatients.
Its focus on chronic disease management and comorbidity aims to prepare doctors for the growing demands in these areas and is specifically angled towards a career in general internal medicine(5).
The ACCS-AM training programme has also been revised and will replace the current ACCS-AM curriculum in August 2021, when the duration of the programme will be extended to four years. What remains the same is the first two years, rotating through specialty placements in Emergency Medicine, Internal Medicine, Anaesthetics, and Intensive Care Medicine.
In the third and fourth year of study, trainees will join the latter 2 years of the IMT programme (IMY2 and IMY3), rendering them eligible for recruitment into ST4 higher medical specialty training(6).
The overarching message is that trainees must complete IMY3 to be able to enter higher medical specialty training, irrespective of their previous core training7. In the IMY3 year, trainees ‘step up’ to the medical registrar role and are entrusted to manage the acute take of patients with indirect supervision.
Currently, competition for IMT and ACCS training remains reasonable, with 2229 applications for 1563 posts across the UK in 20198. However, with the developing programme changes and the growing demand for doctors in medicine means that competition ratios may fluctuate in years to come.
Wait, are we all going to be general internal medicine consultants?
To be a consultant of a specialty is to have a certificate of completion of training (CCT) in that specialty.
The ongoing revisions in the medical training pathway are part of the movement to create more generalists. Alongside the new core medical training, specialist medical training in GIM has also been altered. The new curriculum known as Internal Medicine Stage 2, will be implemented in August 2022.
As part of this change, all trainees in group 1 higher medical specialties (see text box below) will receive additional training in GIM9. This means that nearly all trainees following the GIM curriculum to CCT will be doing so in parallel with training in another medical specialty, and vice versa ultimately most medical specialty trainees will also be training in GIM. National recruitment into Stage 2 training will be done through application to the medical specialty, with competition ratios dependent on this factor.
The dual programme will focus on the medical specialty of choice and include an indicative 12 months of further internal medicine training leading to a dual CCT in a group 1 specialty plus internal medicine.
This specialty training will take a minimum of 4 years altogether depending on the medical specialty of choice. A compulsory component of assessment for CCT are Specialty Certificate Examinations (SCEs) or Knowledge-Based Assessments (KBA) which will complement workplace-based assessments to ensure specialists have sufficient knowledge of their specialty to practice safely and competently as consultants(10).
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020 the salary bands range from £77,779 to £109,849. Salaries can be further enhanced with NHS excellence awards.
For more information on doctor's salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
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Shape of training review [Internet]. Gmc-uk.org. 2013 [cited 10 November 2020]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/shape-of-training-review
General Internal Medicine (GIM) [Internet]. JRCPTB. 2020 [cited 10 November 2020]. Available from: https://www.jrcptb.org.uk/specialties/general-internal-medicine-gim
General internal medicine [Internet]. Health Careers. 2020 [cited 10 November 2020]. Available from: https://www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/general-internal-medicine
Doctors and the European Working Time Directive [Internet]. The British Medical Association is the trade union and professional body for doctors in the UK. 2020 [cited 10 November 2020]. Available from: https://www.bma.org.uk/pay-and-contracts/working-hours/european-working-time-directive-ewtd/doctors-and-the-european-working-time-directive
Internal Medicine [Internet]. JRCPTB. 2020 [cited 10 November 2020]. Available from: https://www.jrcptb.org.uk/internal-medicine
Acute care common stem (medicine) [Internet]. JRCPTB. 2020 [cited 10 November 2020]. Available from: https://www.jrcptb.org.uk/specialties/core-medical-training-and-acute-care-common-stem-medicine
Overview | IMT Recruitment - Full, comprehensive guidance on applying to IMT posts in UK ACCS-AM and CMT training programmes [Internet]. Imtrecruitment.org.uk. 2020 [cited 10 November 2020]. Available from: https://www.imtrecruitment.org.uk/imy3/overview
Specialty training competition ratios 2019 - https://specialtytraining.hee.nhs.uk/Competition-Ratios
Shape of Training and the physician training model [Internet]. JRCPTB. 2020 [cited 10 November 2020]. Available from: https://www.jrcptb.org.uk/imt
MRCP(UK) examinations | MRCPUK [Internet]. Mrcpuk.org. 2020 [cited 10 November 2020]. Available from: https://www.mrcpuk.org/mrcpuk-examinations