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In case one, we found bilateral subdural haematomas. Surgical opinion was that patient was high risk, had a poor quality of life and would not benefit from evacuating the chronic lesions. However, systematic risk assessment and perioperative medical management by our physicians enabled both surgeon and family to proceed with the operative approach. Patient regained alertness, ate and walked again.
Case two was diagnosed with Adult Still’s disease.
Case three? Polymyalgia rheumatica.
And case four? Uncontrolled thyrotoxicosis and not gastroenteritis.
Patients such as these belong to the X-files of the Department of Internal Medicine, or rather, cases solved. While highly focused subspecialist practitioners contribute by excluding diagnoses related to specific fields (“I don’t know what you have but it’s not from your heart”) and offer latest therapies to defined disease entities, (eg helicobacter pylori, hepatitis B), the above types of cases require slant of mind and approach which is recently being resurrected, namely, the skills of a general physician or internist.
From bizarre diagnoses like mercury poisoning, to rare viruses and bacteria to autoimmune disease, malignancies, stress reactions, from stone fish envenomisation to deconditioning to common garden pathologies, a wide variety of culprits are uncovered that try to lay claims on human health…
This is because our starting point is not a few specialised diagnoses or solutions. Rather, our forte is systematic
assessment and tailoring therapy to the situation, with targeted referral to appropriate colleagues if required after a
firm diagnosis is made.
 How Internal Medicine Got Reinvented and What’s Different Now
Up to a decade and a half ago, there existed strong general medical departments powered by astute and experienced master clinicians up-to-date and confident with managing all organ-systems and pathologies.
However, the push to subspecialisation led to the redundancy and near extinction of this breed.
Patients too, have been instrumental in the creation of the demand of this type of practice, in the pattern they consumed health care services, continually seeking out the highest level specialist for each and every symptom.
However, the total patient experience in many cases has on the contrary become compromised because:
1. Many patients have non-specific and atypical presentations. When their condition cannot immediately be classified, it becomes a mystery where their port of call should first be. These diagnostic dilemmas often do a tour of duty in multiple subspecialty clinics who exclude what they do not have but would not be designed to pinpoint what they actually do have. Non-recognition and blindness of things outside the specialty is a very real problem indeed, as “the knowing eye sees”.
2. Post diagnosis, many patients ended up seeing half a dozen doctors – one for each problem, quite exhausting and often counterproductive for typically elderly subjects who may be confused by conflicting inputs from different
specialties. It became quite clear that the bulk of patients serviced do not actually need cutting edge care but good comprehensive holistic management of the total person by a single skilled physician.
Patients too, have realised that they could no longer keep up making a tour of duty with many pit-stops at various high level specialties designed for the best care. Hence, a reverse trend is now observed where many patients prefer one skilled practitioner to handle most of their medical issues in a professional and costeffectively way in a “single stop”.
Therefore, even as she was disbanded some 15 years ago, her relevance was realised… Internal medicine is now a standalone subspecialty undertaken at advanced level with its own training programme stressing on diagnostic, screening and integrative medicine, alongside other subspecialties such as cardiology, nephrology etc.
Definition and Relevance of Internal Medicine Reinvented Internal medicine has become an accreditated standalone field with its own subspecialty training programme leading to separate accreditation. But what is exactly is internal medicine, and how is its practice defined, given the comprehensive selection of subspecialities available? How does a generalist physician position himself and remain relevant in a sea of extremely qualified subspecialists? These are some burning questions often facing a young resident deciding on his future career path as an internist.
Defined in a nutshell, Internal Medicine involves the practice of diagnostic, integrative, coordinative and holistic medicine within a hospital setting. Rather than a disease or organ-defined specialty, it is essentially a Methodology and a Philosophy that is based on the desire to offer holistic comprehensive knowledge and care. Since the human body is a sum of its cooperating parts all connected and synergised together, internists find focusing on one narrow area somewhat fragmented and counterintuitive. Extremely interested in all aspects of the human physiology, those with an internist mindset find it unsatisfying and insufficiently stimulating to restrict study by means of blinkers to only on one organ or area. The practice of internal medicine is very similar to the primary care physician in the community, except it is hospital based and deals with more complex cases, hence a new term
coined and sometimes used: the Hospitalist.
Today’s internist, though practicing in a hospital, also endeavours to solve and manage most patients in an ambulatory, outpatient, but tertiary hospital setting, hence the practice is somewhat differentiated from the heavy inpatient focus of yesterday’s internist or the primary care physician practicing and maintaining health in the community.
As for relevance, the need is huge for good internists, especially with the burgeoning elderly multipathology patients filling up hospitals. These patients often do not need cutting edge technomedicine, but thrive and improve on an astute medical analysis coupled with a holistic approach to their problems and needs.
Hence, almost as soon as the general medicine units were disbanded at Singapore General Hospital (SGH), a new department was set up due to sheer need, as it was found that about 30% of patients could not be easily classified. Currently, among medical inpatients currently in SGH, about 30% are managed by the Internal Medicine and the other 70% by 12 subspecialties.
New Internal Medicine Specialty Training Programme and Practice
What constitutes the training and practice of Internal Medicine?
Firstly, Internal Medicine training involves Diagnostic Method. The skills of the general internist do not revolve around a particular organ, diagnostic group or procedure, but the age old skills of careful and comprehensive history taking, spending bedside airtime listening carefully to the patient (since there are no procedures we do, this is our “procedure”) and multisystem physical examination, coupled with in-depth knowledge of state-of-the-art diagnostic tools.
Secondly, training and practice involves the strenous responsibility of keeping abreast of latest developments and drugs across all fields, so that we may not only recognise diseases but orchestrate and harness the skills and services of our subspecialty colleagues in the most efficient way. While impossible to know everything in all fields, today’s general internist must keep abreast to sufficient detail. An internal medicine advanced trainee is required to do registrar postings in multiple subspecialty areas before exiting as a qualified internist.
Thirdly, Internal Medicine today is heavily committed to integrative care, and the practitioner must be able to collate different pathologies and manage patients as a whole without fragmentation of care. This is especially true of the elderly patients.
Fourthly, an internist typically does have an area of special interest to research in and develop further, either in an established specialty or a niche area not covered by the mainstream specialties. Some internists would prefer double accredition eg rheumatology, geriatrics, gastroenterology, while others may choose to focus on a specific clinical or paraclinical service eg clinical nutrition, bone health, hypertension, medical ethics etc.
A specific area to mention dealt with by our internists is hypertension. Difficult and uncontrolled hypertension generally gets referred to our department for investigation by primary care doctors across the island, since secondary causes span a variety of diagnostic possibilities from vascular, renal to endocrine pathologies, familiar to our broad based practice. End organ damage at multiple sites are looked for by us, and control of the difficult hypertensive by multiple drugs involve knowledge of physiology and current medical guidelines which our trainees are obliged to know.
Integrative Medicine and Medical Maintenance Today’s patient, often elderly with comorbidities, faces another challenge after the stress of the diagnostic stage… that of continued medical maintenance. Many have issues in several organ systems and many end up seeing multiple subspecialists who may not get a chance to communicate with each other in space and time. Especially for common generic ailments like chronic heart, renal and metabolic conditions, one port of call may actually improve outcome, coordination and reduce cost. Many patients have problems in multiple organ systems and would prefer consolidated care by one clinic and one internist with an overview, rather than the exhausting and costly practice of regularly seeing 5 or 6 practitioners. The internist would be able to at any point harness the expertise of his colleagues effectively should an additional opinion or procedure be required, overall giving more cost effectiveness, better patient experience and outcome.
Under an internist care, they would however still be required to see highly focused subspecialists for interval follow up of specific issues, albeit less frequently eg cancer follow-up, diabetic retinopathy, post angioplasty review.
Our integrative services is heavily subscribed in the area of total diabetic management which involves not just endocrinological blood sugar control, but macro/microvascular surveillance, medical management of coronary, cerebrovascular and peripheral vascular disease, diabetic bladder disease, coronary co-morbidities such as hypertension and hyperlipidaemia, renoprotection, eye care, mobility etc. This is similar to demands made to the primary care physician given Singapore’s huge diabetic burden. Cases seen by our department are typically those with poor control, severe metabolic derangements and established end organ damage often requiring procedures.
Another clinical area constituting a big part of our practice is the care of the elderly patients with many comorbidities such as prostate issues, osteoporosis, IHD, cardiac failure, hyperlipidaemia, hypertension, diabetes etc. This area of our medical maintenance work overlaps and is often identical to that of a geriatrician. Generally those with more acute issues get channelled to our department as the port of first call.
Which Patients to Refer?
If a patient presentation does not lend itself to an obvious diagnosis and where management plans involve multiple systems, a complete assessment by one of our internists might be considered. While it is true that we do not turn away any patient and virtually all groups of patients can be handled by us at least in their initial stages, the following are some guidelines that delineate the boundaries of the work that we do:
Which Patient Will Benefit from Internal Medicine Consultation
1. Diagnostic dilemmas and unclear presentations.
2. Patients with multiple pathologies who need integration of care.
3. Patients who need coordination of referrals where many services are required.
Subspecialty skills are often more effectively optimised when cases are prefocussed, predigested and prediagnosed. Working within the hospital community, we are better positioned to forward-refer, orchestrate and match the services skills of subspecialty colleagues to patient needs, where it is unclear whom patients need to be referred to.
Which Patients Don’t Need Us
1. Stable patients with clear plans are best managed by a good primary care physician. For this group, their integrative care and maintenance are most effective when they are close at hand, accessible and barrier free, ie within the community and not within a hospital setting.
Upon diagnosis and stabilisation, we actively discourage such patients from making the hospital take over their primary care, as waiting for appointment day, transportation challenges for the mobility-impaired, higher cost, can all result in a poorer outcome and assessment delays.
2. Where there is a clear indication for subspecialty intervention eg typical angina, epilepsy. In these patients, an interim assessment by us will be redundant and add to cost and delay.
In any case we are just a call away if discussion is needed for a suitable manner to triage and direct these patients.
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