Specialist Geriatrician

Research

Research  includes both specific research units and in research activities involved in day to day work.

Research settings include universities, academic medical units, general geriatric medicine units, and private practice.

Research includes basic sciences, clinical research, clinical trials, and quality improvement activities directed at improving the health of older people and the efficiency of health services for older people

• Management roles in academic units, hospital units, or health services
• Promotion of healthy ageing and health improvement for older people
• Promotion of the dignity of the older patient
• Improving attitudes toward ageing by the general community, governments, and the health care system
• The mix of work undertaken by geriatricians varies according to the needs of the local area and the interests of the geriatrician. It may be different in different states and between rural, remote, and metropolitan areas.

General Physician

The Definition of a General Physician

General physicians are specialty physicians with expertise in the diagnosis and management of complex, chronic and multisystem disorders in adult patients. They undertake a comprehensive assessment of a patient’s problems and needs, both biomedical and psychosocial, and provide and coordinate patient care with the assistance of multidisciplinary teams to optimise health outcomes. General physicians have a breadth of expertise which enables them to deal with undifferentiated and ambiguous presentations and to diagnose and manage illnesses affecting more than one organ system. The work of a general physician is not limited by patient age, diagnostic category, stage of disease, treatment intent, or clinical setting. The practice of general physicians extends across acute hospital and ambulatory settings

and involves interactions with other specialists from a variety of disciplines, as well as primary care providers and allied health professionals. General physicians adopt a scientific, evidence-based approach to the patient as a whole person, notwithstanding an interest and some level of training in another specialty. This approach includes detailed knowledge of the pathophysiology, diagnostics and therapeutics of a broad range of diseases.

This breadth and depth of knowledge and experience make general physicians ideally suited to providing high quality consultant services across a spectrum of health and illness. These capacities place general physicians in an important and responsible position as clinicians, teachers and researchers, particularly where clinical problems affect multiple organ systems, involve issues which do not fall within the domains of single organ-system subspecialties, and where integration of multidisciplinary expertise may be required.

The Attributes of a General Physician

General physicians possess several unique attributes which differentiate them from other medical specialists:

• Expert diagnosticians: general physicians have the ability to assess and diagnose clinical problems in their entirety. Diagnostic formulations comprise not only specific medical diagnoses but a broader axis of functional and psychosocial problems and comorbidity burden which may impact on prognosis and clinical management. In the case of undifferentiated presentations, general physicians have the ability to consider the many possible causes (which may involve multiple organ systems), identify those most likely to be responsible, and synthesise a multidimensional diagnostic formulation. In arriving at a complete diagnosis, general physicians are selective and rational in their use of diagnostic tests based on knowledge of test performance and avoid ordering an array of investigations which are very unlikely to contribute to clinical decision making.
• Expert providers of integrated care: general physicians have the ability to devise management plans in which choice of therapies and other clinical interventions are based on an integrated consideration of evidence of therapeutic effectiveness, interactions with comorbidities and other therapies, functional status and life expectancy, patient values and preferences, and the broader social and environmental context in which care is provided. Clinical care is tailored to meet the therapeutic goals of prevention, cure or palliation, taking into account the patient’s needs and priorities which may change over time. General physicians are skilled in providing longitudinal care of patients over many years, ensuring optimal management of acute exacerbations of chronic disease as well as optimal disease control and secondary prevention. A general physician has integrative skills whereby multiple potential determinants of health outcomes that span clinical, functional and psychosocial domains are considered simultaneously in devising management plans.
• Expert problem solvers: general physicians have the ability to take charge of difficult and complex clinical presentations, sort and prioritise goals of management, and take decisive action in resolving problems using a flexible and broad-minded way of thinking. General physicians are skilled in reconciling short term management of acute illness (including exacerbations of chronic diseases), with the potential for longer term prevention and rehabilitation. In situations where patient care has been splintered by conflicts of opinion and advice from different providers, general physicians act to broker workable solutions and forward looking management plans to the benefit of patients and the whole care team.
• Expert patient advocates: general physicians have the ability to see the whole patient, including the social background and the belief systems that mould his/her thoughts, actions and attitudes to illness and intended management. General physicians individualise their advice and recommendations in accordance with patient values and preferences and the wishes of their families and carers. They are particularly mindful of the need to avoid or simplify complicated or invasive investigation and treatment regimens which offer only marginal benefit at the expense of placing patients at risk of harm, or imposing unnecessary burden and costs. This is particularly pertinent to patients with advanced disease and poor prognosis in whom the priority for end-of-life is maximising quality of life and symptom palliation.
• Expert communicators and negotiators: general physicians have the ability to elicit and accommodate a diversity of views and opinions in relation to patient care and then negotiate an agreed way forward on the part of all stakeholders. As a team leader and conciliator with well developed interpersonal skills, the general physician is able to assert leadership, resolve conflicts, and achieve collective agreement and action in the care patients receive.
• Expert innovators and system leaders: general physicians have the ability to see the big picture of health care systems, how they work and how they can be changed for the betterment of patient care. Their informed common sense perception of ‘real world’ medicine – devoid of conflicts of interest – and their familiarity with the principles of evidence-based medicine enables general physicians to be discerning in assessment and use of new and yet unproven technologies. In an era when a drive towards optimising quality and safety of care is juxtaposed with a diminishing availability of healthcare resources, general physicians possess the capacity to balance net benefit with opportunity cost in choosing models of care and clinical technologies that are best suited for maximising health at the level of both individuals and populations. General physicians are ideally suited to play leadership roles in the clinical governance structures of area health services, institutions and departments.
• Expert teachers and mentors: general physicians, by virtue of their broad experience and expertise, have the ability to separate out and impart the essential knowledge, attitudes and skills that medical students, young doctors and other health professionals need to acquire if they are to adequately cope with the challenges of modern healthcare. While single organ system specialists can provide deeper content knowledge in specific domains of care, the general physician can show how this knowledge needs to be integrated, prioritised and contextualised in the grand scheme of things for each and every patient.
• Advanced Training in General Medicine is designed to develop these attributes. A basic physician trainee does not possess the required level of knowledge, skill, or experience to be recognised as a general physician who demonstrates the above attributes and is able to practice independently as a consultant. Prolonged immersion in a diversified general medicine training program associated with exposure to experienced general physicians as role models is required in nurturing these important general physician skills

The Value and Importance of a General Physicians

More people are living longer with complex, chronic and multisystem problems for which management of acute relapses and complications as well as secondary prevention are the key care objectives. For patients who may experience a variety of disease trajectories through their lifetime, there is an increasing need for coordinated, effective and patient centred care overseen by a single, ‘whole patient’ specialist. Increasing subspecialisation results in more health care providers and potentially increases both the direct and indirect costs of health care without necessarily improving patient outcomes. General physicians working alongside other specialists will provide the best care, through combining ‘breadth’ with ‘depth’.

General physicians ensure the delivery of efficient, cost-effective and safe care for the community and contribute to workforce development as leaders in medical education and health policy. General physicians provide the backbone of rural physician practice and occupy key roles and positions in larger regional centres, outer metropolitan hospitals and tertiary centres. The increasing demand for acute hospital beds requires hospitalisations to be more efficient as well as providing better and safer care. General physicians now work alongside emergency physicians in many hospitals as acute care physicians to fast track and coordinate care from the outset.

General physicians are also able to provide the necessary support to primary care providers in general practice and other ambulatory settings following discharge and over the longer term. A major differentiating feature between general physicians and general practitioners is the specialised diagnostic and management expertise of the general physician. Put simply, general practitioners may refer patients to consultant general physicians when there are diagnostic issues, or acute or complex management needs, beyond the capability of the general practitioner to provide.

General physicians, by virtue of their ability to adapt to changing needs, have occupied niche areas in medicine which benefit from physicians who possess a broad perspective and expertise. These areas include perioperative medicine, obstetric medicine, acute stroke medicine, palliative care, clinical pharmacology, clinical informatics, and quality and safety systems.

General physicians provide a considerable portion of specialist tuition for medical students, junior doctors, physician trainees, and other health professionals in hospitals and universities. They are also taking up increasing numbers of roles and positions in academic research, with particular focus on health services research, clinical epidemiology, quality and safety improvement, and clinical education.

Challenges for General Physicians

A career as a specialist in general medicine is not for the faint hearted. General physicians must demonstrate an ability to stay abreast of important advances in clinical medicine across a broad domain of specialties. They must exhibit openness and flexibility in attitude and thinking, which allows them to respond in an adaptive way to new challenges and priorities. They need to be cognisant of, and sensitive to, evolving societal, workplace, legislative and technological developments. Finally, they must be able to recognise circumstances which necessitate the seeking of assistance from other specialists and health professionals in providing optimal patient care. The major challenge for general medicine is to provide the best, safest and most efficient patient care in all settings.

The challenges for the specialty as a whole are the need for more doctors to join its ranks and for the public and the medical profession more generally to be fully aware and respectful of the important roles of general physicians in health care delivery. The specialty needs to be valued in order to grow and make greater contributions to the healthcare system. The status of general physicians in some quarters has been diminished by negative but erroneous perceptions of role and relevance in a medical marketplace dominated by superspecialisation. Access to Advanced Training posts, particularly in some tertiary hospitals, has been limited and the opportunities for adequate training exposures in other specialties have been constrained.

(For further information on the role and future of general medicine within Australasia refer to the IMSANZ-RACP joint policy document “Restoring the Balance: An action plan for ensuring the equitable delivery of consultant services in general medicine in Australia and New Zealand 2005-2008” found at http://www.imsanz.org.au/resources/documents/IMSANZRestoringtheBalanceFeb06_000.pdf)

Notwithstanding these challenges, the ability of general physicians to deal with the challenges inherent in caring

for a broad patient population with a wide scope of problems, and the capacity to engage with changes in medical technology, models of care and the wider social and political milieu provide considerable personal and professional satisfaction. This sense of achievement is heightened further when general physicians involve themselves in the design and operationalisation of better systems of care and in the education and training of the next generation of health professionals. The increasing adoption of dual training offers a means for acquiring skills as both a general physician and a physician in another specialty which further enhances career flexibility, intellectual interest and future employability.