• Vol. 31 No. 4, 537–541
  • 15 July 2002

General Medicine—Revisited, Rejuvenated, Revitalised and Reemphasised



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Introduction: The swing of the pendulum towards medical subspecialties, which are mainly organ-based, was inevitable. Over 30 years ago, this problem surfaced in the United States (US). The fragmentation of medicine had its advantages and disadvantages. However, as lifespan lengthens and there are more elderly sick with multiorgan dysfunction and failure, the patient is asking for the one doctor who can manage him as a whole patient rather than the ten specialists, each focused on one body part.

Methods: Revisit—A search of the recent literature revealed that changes are underway in the US and the United Kingdom (UK).

Results: Rejuvenate—Diagnosis Related Group (DRG) funding for inpatients based on the length of stay means referrals to specialists (if any) should be concurrent rather than consecutive. This, in turn, means the general physician should assess the whole patient from the outset and be in charge of the management plan. Also, the patient prefers this to being passed from one specialist to another. Revitalised—We are short of doctors in Singapore and if one patient could be properly managed by fewer specialists, then we will need fewer specialists in Singapore. Their role is to manage the more difficult patients, rather than every patient that happens to have a problem within that organ specialty. Internists should be allowed to have a wider training in Singapore, with dual accreditation in general medicine and another medical speciality made available from this year onwards. The duration of this training will be 5 years. Reemphasised—A full chair in general medicine was established at Harvard Medical School in 2000. The UK Royal Colleges of Physicians are revamping their advanced specialty training programme to include more time in general medicine and the Renaissance School of General Medicine may become a reality.

Conclusion: Whole patient medicine is what patients want, not medicine in bits and pieces. The general physician has a vital role to play in meeting this need.

“The irresistible swing towards medical specialisation has brought advantages for patients but arguably this has gone too far.” It is time to review the role of general medicine and general physicians in Singapore; with its own unique system of healthcare where patients can see any specialist and subspecialists without a referral letter; where in public institutions, “market forces” play a significant role in determining the salaries of doctors (including specialists) and where insurance companies and health maintenance organisations do not have major impact in the delivery and financing of health services.

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