Internal bickering over internal subspecialty

Equal parts controversy and confusion are behind the Royal College of Physicians and Surgeons of Canada’s delay on deciding whether to formally recognize general internal medicine (GIM) as a subspecialty of internal medicine, and thereby green light the accreditation of an optional two-year postgraduate training program.

Heated opposition to the change, fueled by widespread misunderstanding of what it will accomplish, as well as conflicts with the vested interests of existing subspecialty groups, prompted the college’s committee on specialties to defer a verdict to the fall in order to give proponents from the Canadian Society of Internal Medicine time to defuse the latest fireworks in their 30-year war to attain GIM accreditation.

“There’s a lot of support for the proposal, and I think the way it’s formulated makes a lot of sense,” says Dr. Ken Harris, education director for the royal college. “But there’s a hurdle in presenting the proposal in a clear and concise way so that everyone fully understands what’s on the table, and in defining the difference between a specialist in internal medicine and a sub-specialist in general internal medicine.”

Currently, medical students train four years in a college-accredited internal medicine program to become eligible for certification as specialists in internal medicine (the diagnosis and treatment of internal organs), or internists. Many students only complete the first three years of the internal medicine program before moving onto a two-year subspecialty program, such as those offered for cardiology. Students who “double count” the first year of their subspecialty training are also eligible to become internists, in addition to subspecialists in their chosen field.

The Canadian Society of Internal Medicine is proposing to create a new GIM subspecialty in which students receive more-detailed instruction in skills related to high-risk obstetrics, complex perioperative care and caring for patients with multisystem disease.

Essentially, such students could also “double count” their fourth year, take an extra fifth year of training and become subspecialists, as well as internists.

“Many people who complete the four-year program find that, when they begin their practice as internists, they end up needing skills that there just wasn’t the time to address sufficiently during training,” says Dr. Brian O’Brien, who as chair of the college’s specialty committee in internal medicine has advocated the creation of a GIM subspecialty.

Medical student groups are opposed to the change, as they suspect the Canadian Society of Internal Medicine is engineering a mandatory extension of training for all internists.

“Our position is the college should just keep internal medicine training under four years and those who want to undergo further training can just go ahead and do that, rather than mandating everybody to take five years,” says Dr. Tyler Johnston, president of the Canadian Federation of Medical Students. “That’s a year of deferred income in an era where we’re already experiencing very high medical student debt, and we’re not sure what the evidence is that adding a year will make us better internists.”

The Canadian Association of Internes and Residents echoed that concern in a recent position paper, stating that mandatory extension of training for internists would “delay entry to practice for all.”

But O’Brien says the creation of a GIM subspecialty would simply give students another option, rather than force them into an extra year of training. “There’s absolutely no interference. This isn’t a huge change we’re proposing. It’s a matter of providing an opportunity for students who do want and need the additional skills,” he says.

Other subspecialty groups also appear opposed to accreditation for GIM, apparently out of fear that it may prove more attractive to students than their field, or simply result in more mouths to feed from the subspecialist pie.

As Dr. Finlay McAlister, president of the Canadian Society of Internal Medicine, notes, “the pie’s only so big, and any time you offer a new college-accredited subspecialty program, it’s going to draw trainees away from other specialties. It’s probably not politically correct to say that but I suspect that may play a role in some of the decision making.”

In the event a GIM subspecialty is accredited, medical schools would have the option of offering it, as with all sub-specialties. But if it is formally recognized, the training would become subject to national standards.

Eight of Canada’s 17 medical schools already offer additional training in internal medicine in the form of an optional fifth year, but because that training isn’t accredited, there’s no national evaluation or quality standards for those programs.

“We want to have official recognition for those students that are spending the extra time and money to do the extra training, because currently they aren’t getting anything to show for it,” says McAlister.

O’Brien, meanwhile, is hopeful that evidence of the value of a GIM subspecialty will accrue from the successful five-year programs running in Quebec, Alberta, Saskatchewan and British Columbia.

McAlister says that accreditation would also protect those existing programs from the vagaries of fair-weather funding. “Right now the provinces that have these programs are willing to fund the unaccredited fifth year because they see training internists as a priority, but the provincial funding climates could change and not having college accreditation is a liability,” he says.

The Canadian Society for Internal Medicine’s most recent bid for GIM accreditation has already advanced further than a string of similar applications over the past three decades. “We’ve been at this for about 30 years,” says O’Brien. “There had to be consensus among internists that this was necessary. We had to understand what the community needed and there needed to be some pilot models to show us how well this is going to work.”

The issue will resurface before the royal college’s committee on specialties in the fall. If it passes muster, it will move on to its education committee for further evaluation, and ultimately, to executive council for final approval.