David Oliver: Valuing the medical take

Last month Richard Smith, former editor of The BMJ, wrote an opinion piece1 praising The Ministry of Bodies,2 a book by the Irish gastroenterologist Seamus O’Mahony about his experience as a hospital doctor and his wider observations on the state of medicine. O’Mahony describes himself as a “medical apostate,” admitting that he wasn’t temperamentally suited to much of the work but still devoted a long career to it.

What drew my eye and my ire in Smith’s review was O’Mahony’s description of adult general internal acute medicine and geriatrics, often referred to as “the medical take.” He conceived this as low status, unglamorous, and unrewarding work that most doctors tried to escape if they could. He was also scathing about the perceived worth of expert generalist disciplines, or “icians” as he called them, compared with “ologists” who focused on specific organ systems or procedures.

I am an acute geriatrician and internal medicine physician who works closely with other “icians” in emergency, acute, stroke, palliative, and intensive care, so this view rankles with me and causes an equally personal reaction. Many of us actively chose and embrace this kind of work, both in acute hospitals and in looking after unselected acute patients on wards—another aspect of the job that O’Mahony seems to disparage.

From surveys of junior doctors about their career choices, we know that anxiety about spending several years as a medical registrar has been a factor in putting people off applying to the big internal medicine specialties.34 This stems not just from concern over the workload, unsocial hours, and level of responsibility, but from a certain reverence about the breadth of expertise required. So, “ologies” can seem more attractive if they allow for more outpatient and procedural work, less ward based and take based medicine, or more specialisation and potentially greater work-life balance.

Other commentators have observed a tacit hierarchy of glamour, status, and prestige in hospital medicine,56 just as O’Mahony describes, which values individualism over multidisciplinary teamwork; younger over older patients; curative intervention over the management of multiple comorbidities and frailty; the new, rare, and cutting edge over managing or palliating more common conditions well; and academic centres and roles over service delivery.

The medical take is hard work. But it is also vital work that has to be done well if general hospitals are to function. Get it wrong and the flow through the hospital admission goes badly wrong, and all patients lose out. Get it right and quality of care improves. It’s also arguably more, not less, intellectually challenging to be a competent generalist managing people with varied presentations and multiple conditions who don’t fit neatly into one organ based or intervention based specialty than to deal with a much smaller range of conditions within one “ology”. It’s something to be celebrated and valued, not demeaned and avoided.

A public hospital is there for the public, and a doctor’s work should be defined by patient and community needs, not the neater work that we doctors might feel more worthy of our status or more intellectually rewarding. And surely there should be more, not less, prestige in retaining broad based skills and being able to cope with most presentations rather than just a narrow focus?

Badly organised systems, leading to the post-take rounds across multiple wards described by O’Mahony, are in the gift of us, as doctors, to help solve. We can take ownership and leadership of solutions to improve care pathways. Doing just this has been a big part of the remit of acute internal medicine, geriatric medicine, and emergency medicine. We are not passive victims but highly paid senior professionals with agency.

If systems are badly organised or the work is seen as chaotic, unrewarding, or futile, much of the blame falls on those doctors who undervalue such work and do too little to embrace or support it. Cynicism can be contagious.