1. Internal Medicine in Europe Daniel SERENI EUROPEAN FEDERATION OF INTERNAL MEDICINE Brussels 5 May 2007

2. Internal Medicine in Europe

30 000 to 40 000 Internists

Diversity of Internal Medicine in Europe

Challenges to Internal Medicine

Need for Internal Medicine in Europe

3. How Long Is Training In Internal Medicine?

3 years: Latvia

4,5 years: Israel

5 years: most countries

6 years: Netherlands, Finland, Czech Rep.

6-7 years: UK

7 years: Denmark, Slovakia, Germany, Malta.

4. Countries With Mandatory CommonTrunk For Sub-specialists.How Long?

Exists in ALL COUNTRIES EXCEPT: Spain, Italy, France

and Portugal.

DURATION (in years).

• 2:Greece, Slovakia, Slovenia, UK, Malta.

• 3 :Belgium, Switzerland, Finland, Czech Rep,

• Israel,Latvia

• 4 :Netherlands

• 4,5 : Denmark

• 5 :Sweden, Turkey, Poland

• 6 :Germany.

• Recommended in Estonia and Israel

5.

YES

Greece, Spain, Netherlands, Latvia, Switzerland, Sweden, Finland, Poland, Czech Rep, Estonia, Slovakia, UK Portugal and Israel

NO

Italy, France, Belgium, Denmark, Turkey, Slovenia, Germany, Malta

Countries Where Teaching Diagnostic Techniques forInternists are Defined 6. Percentage of Internists Working In Hospitals

Over 80% of Internists in most countries work primarily in hospitals

Except:

• Germany 45 %

• Czech Rep 25%

• Greece 20%

• Switzerland 20%

• Latvia 15%

7. Medicine In Europe Is Characterised By Diversity

Healthcare systems may be

• • state driven : UK, NL, Sweden

• • state and private : Fr, It, Sp, Germany, CH, Pl

% of GNP spent for healthcare varies from

120 000 internists

• Including hospitalists

• Mostly out -practice

• Clear messages to the public

• • doctors for adults

• • caring for the whole patient

• • Longer training than family physiciansorGPs

• Annals of Internal medicine

Australia

New Zealand

16. Internal Medicine in Europe

Diversity of Internal Medicine in Europe

Challenges to Internal Medicine

Need for Internal Medicine in Europe

17.

Context

technology

medical progress

competing fields

dismantling of IM departments in hospitals

limitation of resources

fashion and glamour: young doctors decreasinglyattracted to IM

Also

Weakness of identity as a scientific discipline

Will of indepen den c yof former derivate specialities: cardiology

Threats on Internal Medicine 18. Who threatens Internal Medicine?

Doctors lobbies

• General practitioners

• Specialists

• there is only one pie to share

Health care providers

• Tend to focus on GPs for out - practice and on medico-technologic-subspecialties in hospitals

• • what is new is more attractive

Patients

• They have a poor knowledge of whatinternal medicine andinternists are.

19.

Do the broad scope of Internal Medicine and the variety of its practices mean that Internists can take care of all patients?

In primary care?

In hospitals ?

As specialists only ?

With or without a sub-specialisation ?

Lack of visibility

Competition

CHOICE

Need for adefinition of IM adapted to local situation 20. Medical practice

General medicine / family medicine

• All ages

• Prevention

• Frequent hea l th problems

• Home care

Sub - specialists

• Use of specific medical technology

• Narrow fields of pr a ctice

General internists

• Specialists in diagnosis

• Rare and systemic disease s

• Integrated care , associatedmorbidities

21. Practice of Internal Medicine in France, a survey in 2002

90 % in hospitals

About half have a subspecialty: infectious diseases, gastro-enterology, diabetes, geriatrics, nephrology, vascular disea s es, etc

Most frequent diagnosisforinpatients

• Infections17% , vasculardiseaes 10% , h ea matologic disord er s8.5% , cancers 8% , systemicdiseases 7.5% , gastro-enterology7% , cardiology6%

Out-patients

• Mostly referred by GPs or other specialists

• Asking for diagnostic or therapeutic advise

22. Diversity of competence and knowledge Level of excellence subspecialists GPs internal medicine internal medicine 23. Internal Medicine in Europe

Diversity of Internal Medicine in Europe

Challenges to Internal Medicine

Need for Internal Medicine in Europe

24.

Government

to control expenses

to regulate manpower

to obtain cost effectiveness political debates

Society

equitable access to care

quality of care

doctors competency

• ethical and professional Issue

Health care is a challenging political issue 25.

undifferentiated situations

combinations of diseases

general and systemic diseases

new fields in medicine

the internist has received a long and adequate training enabling him/her to take care of such patients

Internal medicine as an answer to the needs of the patients 26. Role of Internists in Medical Training

Faculty teaching

• Se me iology

• General diseases

• All major general text books refer to InternalM e dicine

Practical training

• Studen t s

• Interns, residents

27. New fields for Internists

Hospitalists( USA)

• 12 000

• Links with emergency care

• Care of inpatients ( 85% of them are internists)

acute geriatr ics

Internists in the Emergency Room

Medico- social aspects

Hospital primary care

Palliative care

Integrated care

Emergence of new sub-specialties

28. Internists And Research

Mainly at University Hospitals

Oriented towardsparticular fields of I.M.

Difficulties related to: time, money and support

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..

Need for a europan clinical research network in IM

29. Internal Medicine in Europe: Strengths

Historical role in patients care

Most internists hospital-based

Remains the basis of student training

ProvidesCommon Trunkfor sub-speciality training in most countries

Training programme for IM fairly uniform

Internists opinion leaders

Active IM societies

30. 31. Lobbying for Internal Medicine

Internal Medicine is adapted to the present situation because of its capacity to solve complex and combined medical problems .

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

A majority of patients and primarily the elderly need an integrated care : in complex situations, Internists are the only doctors dedicated to the task.

Internists can deliver a cost effective medical care thanks totheir 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.

32. Lobbying for Internal Medicine

Training ofStudents must remain based on a common trunk in Internal Medicine

Residents should get a minimum training in IM medicine before subspecialisation

In a health care system based on GPsgate keepers, Internists are necessary as consultants and responsible for coordination of patients care

Internists in other countries may be in charge of primary care

Whatever the organisation of the primary care, Hospitals need Internal Medicine Departments or Services

Internal Medicine is an Indispensable Specialty