General Internal Medicine - Canary in the coal mine

Dear Members,
 
Today we launched the third topic in our Acute Care Concerns advocacy series. I held a news conference this morning with Section of Internal Medicine President Dr. Troy Pederson to comment on the current situation and solutions that are needed. As I wrote this letter, I heard that Edmonton Zone internal medicine had been completely overrun with no capacity for new patients. This is happening as we are heading into the Labor Day weekend with respiratory virus season just around the corner. The need is urgent.
 
General internal medicine (GIM) physicians have a unique role – in both hospital and community settings – caring for the most complex patients with overlapping, multiple health issues of all kinds. In many ways, they are the last line of defense for complex inpatient care.
 
Our internal medicine colleagues are working at an unsustainable rate and are constantly being asked to do more, with less. They’ve told me they can’t keep up much longer. I do believe that if GIM goes down, acute care will collapse. This may strike some as hyperbole, but as so many other services have been disrupted and impacted, safe and timely hospital care for Albertans is truly at risk. We will face hospitals full of patients with no one to manage and coordinate their multiple, complex medical needs. This is not only inefficient and wasteful, it is unsafe. Internal medicine patients – so often the elderly, frail and vulnerable – deserve better.
 
Why are things so bad right now? The skill set and omnipresence of internal medicine is a strength: They can handle a broad range of shifting needs. That flexibility, though, is also a liability in these times. When there are gaps in the acute care team, our GIM colleagues end up doing many things to patch the care together. They are doing this because they can, not because they should.  For example (and this is just one of many), admission administration and other record keeping and management tasks that were once performed by non-physician team members now fall on already overworked GIM physicians.
 
Additional pressure builds as we are lose more hospital-based subspecialist physicians. These subspecialists are understandably responding to the untenable pressures on acute care and withdrawing from aspects of hospital service, and particularly from after-hours care. They are not to blame for the crisis in internal medicine. Every colleague needs to do what’s best in order to stay well and functioning. For GIM physicians, though, there really is no one to whom patients can be passed if they step back to try and stay well themselves. We need to fix this.

Like so many parts of health care, it’s not a case of: Pay more, get more work. Internal medicine colleagues in general could not do work more than they are already doing. But we can make their work go further. We can build up the teams that support them and their patients. We can get better organized and catalog, understand and manage a full staff of health care teams so that they too are working most effectively. It’s inexcusable in this day and age to not know from day-to-day what support staff will be in hospital, what teams will be in place to help physicians provide care and to be asked to do the work of other professions simply because the government has not invested proactively and appropriately.
 
A word about teams and how much we need them. We see it in family and rural medicine. I see it every day in the ER and around my hospitals. Teams keep us going when we would otherwise fall down. I will leave you with Dr. Pederson’s thoughts on this topic.
 
"The output of the system is still really good one patient at a time, but I think we could deliver a system that is equally effective, more efficient, and creates a culture where physicians and non-physicians can start to work as teams again and value each other. That is what I feel is eroding. I love my hospital, but I just find more unhappy people than I ever have before that I work with. We are that canary in the coal mine and we are doing something wrong and we need to get back to this health care team that feels supported and feels like they are doing important work."
 
Well said.
 
Finally, we continue to press for action on the AMA’s Acute Care Stabilization Proposal but we’ve still not seen a response from government. Our proposal will not solve all the problems in the system but it will go a long way to address many of the issues we are facing, including after-hours availability and aligning patient care with payment models and incentives that will help stabilize acute care so that Alberta can once again be competitive in terms of physician retention and recruitment
 
Regards,

Paul Parks
President, Alberta Medical Association