Diabetes and general medicine: to couple or uncouple?

The ownership of general medicine continues to be a perennial issue within acute trusts. Over the years, there has been a steady progress towards specialism but, as the world has moved on, patients are older and have multiple disease morbidity; the recent clamour has been to move away from single organ disease to, once again, a more generalist approach. General medicine used to be reasonably simple with all specialists being part of the on-call rota, sharing out patients and using their general medicine accreditation. Though perhaps not enjoyed by all, it certainly generated a sense of camaraderie and the job was shared by all, not by a few. The direction started to change when cardiology as a specialism made the case for becoming a specialty in its own right – with doorto-needle targets becoming an important part of trust requirements. Over time, as has been borne out, this move has had its pros and cons. The pros indeed have been for all to see: better cardiovascular outcomes, especially in relation to myocardial infarction outcomes, and better resourced cardiology units across the country. The benefits for patient care have been many. However, the cons have included the break-up of a sense of camaraderie. Suddenly, one specialty was more special than others. Suddenly, the patient with a myocardial infarction or angina had preferential care, and their own specialist rota and carers; this was intrinsically different from, say, someone with a severe asthma attack or diabetic ketoacidosis. Not surprisingly, others started to follow suit. The gastroenterologists made their, not unjustified, case for ‘bleeding rotas’, the need to have hepatologists, and a separate gastroenterology rota. Elderly care physicians ran the risk of being consumed by the sheer volume of patients, with admissions starting to skew and reflect the ageing population; thus they began to set their own tramlines and criteria. The bond between all physicians appeared to have been broken. We all now existed in silos, wrapped in our own specialties – all correct in their own view, yet incorrect when the bigger picture was taken into account. In between all of this, there still existed the need to see and review patients who did not quite fit into any criteria, and the label ‘general medicine’ was used. That left the respiratory physicians and diabetes specialists being given the burden and the concept of being the teams who looked after patients beyond narrow specialism – and this started to grate as time passed by. The question, quite rightly, was raised about the patients of their own specialism – did they not deserve care better than or at least as good as that of a cardiology patient?