Acute medical care in public hospitals may be handled differently in different countries. As general physicians in Singapore are trained to deal with undifferentiated clinical problems and run most of the admitting wards, they are suited to take care of patients with acute medical problems. The exceptions to this rule are made for patients accurately diagnosed with stroke and acute coronary syndrome, who have better clinical outcomes if admitted directly to stroke units and coronary care units respectively. In the diagnostic workup, general physicians are trained to practise probabilistic medicine, and thus to order more focused investigations to rule in or rule out certain diagnoses. The subspecialist is more inclined to exclude possible diagnoses in his or her field. Once there is a clear-cut diagnosis, for primary care, it is up to the patient to decide if his primary doctor should be a generalist or subspecialist. An important role for the general physicians who manage patients with multiple diseases is constant medication review to shorten the list of drugs.
First, the definition of terms is necessary. The general physician in Singapore is on the Specialist Register, on par with the cardiologist, neurologist, and so forth. He or she has undergone 6 years of structured training with advanced training focused on closing the gaps in subspecialty fields, critical thinking, decision making and communication skills in the context of elderly or younger patients with co-morbidities and multiple medications. So this is quite unlike the USA, where after a residency of 3 years and Board Examinations in Internal Medicine, the doctor can become a primary doctor or “hospitalist”. In the UK, most physicians in the NHS hospitals have dual certification, and although trained in both general internal medicine and a subspecialty, they tend to practise mainly in their subspecialty. In Singapore, the general physician, if he has a subspecialty at all, is usually skilled in an as yet unofficially recognised field, e.g., obesity medicine, obstetric medicine, vascular medicine.
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