The future of Internal Medicine in Europe

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The future of Internal Medicine in Europe

  1. 1. Internal Medicine in Europe Daniel SERENI EUROPEAN FEDERATION OF INTERNAL MEDICINE Brussels 5 May 2007
  2. 2. Internal Medicine in Europe <ul><li>30 000 to 40 000 Internists </li></ul><ul><li>Diversity of Internal Medicine in Europe </li></ul><ul><li>Challenges to Internal Medicine </li></ul><ul><li>Need for Internal Medicine in Europe </li></ul>
  3. 3. How Long Is Training In Internal Medicine? <ul><li>3 years: Latvia </li></ul><ul><li>4,5 years: Israel </li></ul><ul><li>5 years: most countries </li></ul><ul><li>6 years: Netherlands, Finland, Czech Rep. </li></ul><ul><li>6-7 years: UK </li></ul><ul><li>7 years: Denmark, Slovakia, Germany, Malta. </li></ul>
  4. 4. Countries With Mandatory Common Trunk For Sub-specialists.How Long? <ul><li>Exists in ALL COUNTRIES EXCEPT: Spain, Italy, France </li></ul><ul><li>and Portugal. </li></ul><ul><li>DURATION (in years). </li></ul><ul><ul><li>2: Greece, Slovakia, Slovenia, UK, Malta. </li></ul></ul><ul><ul><li>3 : Belgium, Switzerland, Finland, Czech Rep, </li></ul></ul><ul><ul><li>Israel, Latvia </li></ul></ul><ul><ul><li>4 : Netherlands </li></ul></ul><ul><ul><li>4,5 : Denmark </li></ul></ul><ul><ul><li>5 : Sweden, Turkey, Poland </li></ul></ul><ul><ul><li>6 : Germany. </li></ul></ul><ul><ul><li>Recommended in Estonia and Israel </li></ul></ul>
  5. 5. <ul><li>YES </li></ul><ul><li>Greece, Spain, Netherlands, Latvia, Switzerland, Sweden, Finland, Poland, Czech Rep, Estonia, Slovakia, UK Portugal and Israel </li></ul><ul><li>NO </li></ul><ul><li>Italy, France, Belgium, Denmark, Turkey, Slovenia, Germany, Malta </li></ul>Countries Where Teaching Diagnostic Techniques for Internists are Defined
  6. 6. Percentage of Internists Working In Hospitals <ul><li>Over 80% of Internists in most countries work primarily in hospitals </li></ul><ul><li>Except: </li></ul><ul><ul><li>Germany 45 % </li></ul></ul><ul><ul><li>Czech Rep 25% </li></ul></ul><ul><ul><li>Greece 20% </li></ul></ul><ul><ul><li>Switzerland 20% </li></ul></ul><ul><ul><li>Latvia 15% </li></ul></ul>
  7. 7. Medicine In Europe Is Characterised By Diversity <ul><li>Healthcare systems may be </li></ul><ul><ul><ul><li>state driven : UK, NL, Sweden </li></ul></ul></ul><ul><ul><ul><li>state and private : Fr, It, Sp, Germany, CH, Pl </li></ul></ul></ul><ul><li>% of GNP spent for healthcare varies from </li></ul><ul><li><5 % to 13% </li></ul><ul><li>Organis a tion of health care </li></ul><ul><li>Medical density in EU varies from <1 50 </li></ul><ul><li>to 578 (Ita) per 100 000 population </li></ul>
  8. 8. 40 000 Internists intermediate Medical density 2500 internists HOSPITALS
  9. 9. High medical density >10 000 Internists office practice/ hosp
  10. 10. High medical density 2 000 Internists Hospitals
  11. 11. Low medical density 3 000 Internists Hospital /office
  12. 12. Elements In Favour Of Harmonisation <ul><li>Professional values and principles do not differ among European doctors </li></ul><ul><li>Harmonisation would focus on main issues </li></ul><ul><ul><ul><li>Duration and quality of training </li></ul></ul></ul><ul><ul><ul><li>Qualification </li></ul></ul></ul><ul><ul><ul><li>Continuing Professional Development (CPD) , Continuing Medical Education (CME) </li></ul></ul></ul><ul><li>Increasing need for doctors in some countries : UK , France, Sweden…: mobility </li></ul>
  13. 13. EFIM - Educational Activities <ul><li>European Congresses </li></ul><ul><ul><li>1997 Maastricht, 1999 Florence, 2001 Edinburgh, 2003 Berlin, 2005 Paris, May 2007 Lisbon , 2008 Rome , </li></ul></ul><ul><ul><li>2009 Istambul , 2010 Copenhagen </li></ul></ul><ul><li>European School of Internal Medicine </li></ul><ul><ul><li>Alicante 1998 – 2005 </li></ul></ul><ul><ul><li>Sintra / Lisbon 2006- 2008 </li></ul></ul><ul><li>European Journal of Internal Medicine </li></ul><ul><ul><li>1989 - present (Pub. Elsevier) </li></ul></ul><ul><li>Course on Clinical Research, Paris </li></ul><ul><li>European Diploma MRCP </li></ul>
  14. 14. Recognition of Qualifications <ul><li>1957 - Treaty of Rome </li></ul><ul><li>1959 - Standing Committee of Doctors (CP) </li></ul><ul><li>1959 - Union of Medical Specialists (UEMS) </li></ul><ul><li>1975 - Advisory Committee on Medical Training (ACMT) </li></ul><ul><li>1991 - UEMS Monospecialty Boards </li></ul><ul><li>2005- Directive on the recognition of professional qualifications </li></ul>
  15. 15. Examples from other continents <ul><li>American College of Physicians </li></ul><ul><ul><li>> 120 000 internists </li></ul></ul><ul><ul><li>Including «  hospitalists » </li></ul></ul><ul><ul><li>Mostly out -practice </li></ul></ul><ul><ul><li>Clear messages to the public </li></ul></ul><ul><ul><ul><li>«  doctors for adults » </li></ul></ul></ul><ul><ul><ul><li>«  caring for the whole patient » </li></ul></ul></ul><ul><ul><ul><li>Longer training than « family physicians » or GPs </li></ul></ul></ul><ul><ul><li>Annals of Internal medicine </li></ul></ul><ul><li>Australia </li></ul><ul><li>New Zealand </li></ul>
  16. 16. Internal Medicine in Europe <ul><li>Diversity of Internal Medicine in Europe </li></ul><ul><li>Challenges to Internal Medicine </li></ul><ul><li>Need for Internal Medicine in Europe </li></ul>
  17. 17. <ul><li>Context </li></ul><ul><li>technology </li></ul><ul><li>medical progress </li></ul><ul><li>competing fields </li></ul><ul><li>dismantling of IM departments in hospitals </li></ul><ul><li>limitation of resources </li></ul><ul><li>fashion and glamour: young doctors decreasingly attracted to IM </li></ul><ul><li>Also </li></ul><ul><li>Weakness of identity as a scientific discipline </li></ul><ul><li>Will of indepen den c y of former derivate specialities: cardiology </li></ul>Threats on Internal Medicine
  18. 18. Who threatens Internal Medicine? <ul><li>Doctors lobbies </li></ul><ul><ul><li>General practitioners </li></ul></ul><ul><ul><li>Specialists </li></ul></ul><ul><ul><li>«  there is only one pie to share » </li></ul></ul><ul><li>Health care providers </li></ul><ul><ul><li>Tend to focus on GPs for out - practice and on medico-technologic- subspecialties in hospitals </li></ul></ul><ul><ul><ul><li>«  what is new is more attractive » </li></ul></ul></ul><ul><li>Patients </li></ul><ul><ul><li>They have a poor knowledge of what internal medicine and internists are. </li></ul></ul>
  19. 19. <ul><li>Do the broad scope of Internal Medicine and the variety of its practices mean that Internists can take care of all patients? </li></ul><ul><li>In primary care? </li></ul><ul><li>In hospitals ? </li></ul><ul><li>As specialists only ? </li></ul><ul><li>With or without a sub-specialisation ? </li></ul><ul><li>Lack of visibility </li></ul><ul><li>Competition </li></ul><ul><li>CHOICE </li></ul>Need for a definition of IM adapted to local situation
  20. 20. Medical practice <ul><li>General medicine / family medicine </li></ul><ul><ul><li>All ages </li></ul></ul><ul><ul><li>Prevention </li></ul></ul><ul><ul><li>Frequent hea l th problems </li></ul></ul><ul><ul><li>Home care </li></ul></ul><ul><li>Sub - specialists </li></ul><ul><ul><li>Use of specific medical technology </li></ul></ul><ul><ul><li>Narrow fields of pr a ctice </li></ul></ul><ul><li>General internists </li></ul><ul><ul><li>Specialists in diagnosis </li></ul></ul><ul><ul><li>Rare and systemic disease s </li></ul></ul><ul><ul><li>Integrated care , associated morbidities </li></ul></ul>
  21. 21. Practice of Internal Medicine in France, a survey in 2002 <ul><li>90 % in hospitals </li></ul><ul><li>About half have a subspecialty: infectious diseases, gastro-enterology, diabetes, geriatrics, nephrology, vascular disea s es, etc… </li></ul><ul><li>Most frequent diagnosis for inpatients </li></ul><ul><ul><li>Infections 17% , vascular diseaes 10% , h ea matologic disord er s 8.5% , cancers 8% , systemic diseases 7.5% , gastro-enterology 7% , cardiology 6% </li></ul></ul><ul><li>Out-patients </li></ul><ul><ul><li>Mostly referred by GPs or other specialists </li></ul></ul><ul><ul><li>Asking for diagnostic or therapeutic advise </li></ul></ul>
  22. 22. Diversity of competence and knowledge Level of excellence subspecialists GPs internal medicine internal medicine
  23. 23. Internal Medicine in Europe <ul><li>Diversity of Internal Medicine in Europe </li></ul><ul><li>Challenges to Internal Medicine </li></ul><ul><li>Need for Internal Medicine in Europe </li></ul>
  24. 24. <ul><li>Government </li></ul><ul><li>to control expenses </li></ul><ul><li>to regulate manpower </li></ul><ul><li>to obtain cost effectiveness political debates </li></ul><ul><li>Society </li></ul><ul><li>equitable access to care </li></ul><ul><li>quality of care </li></ul><ul><li>doctors competency </li></ul><ul><ul><li>ethical and professional Issue </li></ul></ul>Health care is a challenging political issue
  25. 25. <ul><li>undifferentiated situations </li></ul><ul><li>combinations of diseases </li></ul><ul><li>general and systemic diseases </li></ul><ul><li>new fields in medicine </li></ul><ul><li>the internist has received a long and adequate training enabling him/her to take care of such patients </li></ul>Internal medicine as an answer to the needs of the patients
  26. 26. Role of Internists in Medical Training <ul><li>Faculty teaching </li></ul><ul><ul><li>Se me iology </li></ul></ul><ul><ul><li>General diseases </li></ul></ul><ul><ul><li>All major general text books refer to Internal M e dicine </li></ul></ul><ul><li>Practical training </li></ul><ul><ul><li>Studen t s </li></ul></ul><ul><ul><li>Interns, residents </li></ul></ul>
  27. 27. New fields for Internists <ul><li>Hospitalists ( USA) </li></ul><ul><ul><li>12 000 </li></ul></ul><ul><ul><li>Links with emergency care </li></ul></ul><ul><ul><li>Care of inpatients ( 85% of them are internists) </li></ul></ul><ul><li>«  acute geriatr ics  » </li></ul><ul><li>Internists in the Emergency Room </li></ul><ul><li>Medico- social aspects </li></ul><ul><li>Hospital primary care </li></ul><ul><li>Palliative care </li></ul><ul><li>Integrated care </li></ul><ul><li>Emergence of new sub-specialties </li></ul>
  28. 28. Internists And Research <ul><li>Mainly at University Hospitals </li></ul><ul><li>Oriented towards particular fields of I.M. </li></ul><ul><li>Difficulties related to: time, money and support </li></ul><ul><li>Content: clinical epidemiology, clinical pharmacology, clinical assays, multicentre studies, basic patho-physiology, audit of clinical management, vascular diseases, vasculitis, systemic diseases, diabetes and metabolism, geriatrics, etc.. </li></ul><ul><li>Need for a europan clinical research network in IM </li></ul>
  29. 29. Internal Medicine in Europe: Strengths <ul><li>Historical role in patients care </li></ul><ul><li>Most internists hospital-based </li></ul><ul><li>Remains the basis of student training </li></ul><ul><li>Provides Common Trunk for sub-speciality training in most countries </li></ul><ul><li>Training programme for IM fairly uniform </li></ul><ul><li>Internists opinion leaders </li></ul><ul><li>Active IM societies </li></ul>
  30. 31. Lobbying for Internal Medicine <ul><li>Internal Medicine is adapted to the present situation because of its capacity to solve complex and combined medical problems . </li></ul><ul><li>In hospitals, Internists and Internal Medicine Departments or Services are indispensable for the care of a number of patients who do not require specialised medical technology </li></ul><ul><li>A majority of patients and primarily the elderly need an integrated care : in complex situations, Internists are the only doctors dedicated to the task. </li></ul><ul><li>Internists can deliver a cost effective medical care thanks to their ability to develop standards and guideline with an holistic point of view and to integrate quality of care assessment in a wide range of clinical situations. </li></ul>
  31. 32. Lobbying for Internal Medicine <ul><li>Training of Students must remain based on a common trunk in Internal Medicine </li></ul><ul><li>Residents should get a minimum training in IM medicine before subspecialisation </li></ul><ul><li>In a health care system based on GPs “gate keepers”, Internists are necessary as consultants and responsible for coordination of patients care </li></ul><ul><li>Internists in other countries may be in charge of primary care </li></ul><ul><li>Whatever the organisation of the primary care, Hospitals need Internal Medicine Departments or Services </li></ul><ul><li>Internal Medicine is an Indispensable Specialty </li></ul>

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