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Giles, Ted J. « The Canadian Society of Internal Medicine » Medical Specialty Societies of Canada Affiliates of the Royal College of Physicians and Surgeons of Canada. Ed. T.P. Morley, FRCSC. Toronto: The Boston Mills Press, 1991.
Article reprinted with the permission of Associated Medical Services, Inc.

Though the discipline of internal medicine can look back upon an illustrious history spanning most of the present century, the present Canadian Society of Internal Medicine remains less than a decade old. Why were the societies representing two of the largest and longest established specialties, internal medicine and general surgery, so long delayed in making an appearance on the Canadian scene?

For many years following its establishment, the Royal College was viewed by most internists and surgeons as the body with the legally constituted mandate to maintain and promote their professional interests. Certainly in terms of training, qualifications and standards of practice that view was quite understandable. But in addition, Canadian internists and surgeons have had a long tradition of active membership and participation in the affairs of the American College of Physicians and the American College of Surgeons. The large and well-organized annual and sectional meetings of these organizations, along with those of the Royal College, provided the fulfillment of their needs for continuing education as well as the opportunity for involvement in emerging problems or changes affecting their disciplines. For those engaged in academic teaching and research and those with special clinical interests, other organizations existed, both Canadian and American, which were specifically oriented to their particular interests. It is hardly surprising, therefore, that there was little clamor or perceived need on the part of these two disciplines to set up yet another society.

THE FIRST CSIM

The first, though ultimately unsuccessful, attempt to form an organization that could speak with a unified national voice on behalf of Canadian internists had its origins at a founding meeting held in 1958. The meeting had been organized by a committee headed by the late Brock Fahrni of Vancouver, with the assistance of Victor Hertzman, also of Vancouver, and Garfield Kelly of Kingston.

There is no record of the number of internists who may have participated in this founding meeting. From what follows, however, it can be concluded that a decision was taken to establish an organization that could function as the voice of internists from all parts of the country and that the organization should take the form of a federation of already existing or proposed provincial or regional societies.

Minutes of « the second annual meeting of the Canadian Society of Internal Medicine » record that it was held at the Georgia Hotel, Vancouver, on 24 January 1959, with 23 internists in attendance. The meeting was again chaired by Dr. Fahrni, who, at the conclusion of the meeting, was elected the Society’s first president. Other officers elected were V.O. Hertzman as secretary and Garfield Kelly as treasurer.

By adopting the minutes of the previous meeting, the proposal that the Society be structured as a federation of provincial societies was confirmed. The obtaining of necessary funds to carry on the work of the Society was left to the executive, but it was suggested it might assess member societies on some equitable basis (presumably membership numbers).

Some indication of the ambitions of the society may be judged from the fact that the establishment of a journal devoted to internal medicine, comparable to the Canadian Journal of Surgery, was discussed. The idea was set aside as premature, though the then Editor of the Canadian Medical Association Journal gave assurances that the proceedings of the Society could be published in the CMAJ.

Strangely, no further meeting of the Society took place until January, 1963, at the time of the Royal College meeting in Edmonton. In the interim, Hugh Arnold of Lethbridge had succeeded Fahrni, and as president he chaired the meeting. The minutes record the expressions of disappointment at the slow pace of development of the Society and some divergence of opinion as to the advisability of proceeding further with the whole idea. However, a motion to continue the effort was approved and the meeting then went on to review the proposed « Constitutional Bylaws », presumably drafted by the executive. With a few minor amendments, the document was formally approved. One significant amendment, though not subsequently adhered to, was that the annual meetings of the Society should be held at the same time and place as Royal College meetings rather than those of the CMA.

The objects of the Society as set out in the constitution were:

• to create a national federation of Canadian Provincial or Regional Societies of qualified Internists for the coordination of their efforts in furthering the practice of Internal Medicine;
• to study the scientific, economic, and social aspects of medicine at a national level in order to secure and maintain the best patient care and the highest standard of practice in Internal Medicine;
• to encourage the development of strong Provincial and Regional Societies of Internal Medicine.

What the minutes purport to have been the most interesting part of the meeting was a discussion of what the activities and functions of the society should be and on the role and functions of internists. Widespread confusion was noted in the public mind surrounding the word « Internist », the precise status and role, and the relationship to general practitioners. Activities of the American Society of Internal Medicine in educating both the profession and the public in these matters was cited as one of the steps the society could undertake. This led to the adoption of a motion to send a representative to the next meeting of the American Society in Denver and to report back to the Council.

A second proposal, though not put to the vote, was that it would be useful for the Society to gain, possibly through a questionnaire survey, a national picture of the roles and functions of Canadian internists.

A further lapse of three years occurred before the next formal meeting of the Society, again at the time of the CMA annual meeting in Edmonton on 13 June 1966. It took the form of a dinner meeting chaired by Dr. Arnold, and featured an address by Mr. B.E. « Woody » Freamo, then Director of the CMA’s Division of Medical Economics, on « The Future Outlook for Canadian Internists, both Professionally and Economically ».

The minutes summarized Mr. Freamo’s observations which included:

• There is an oversupply of internists in Canada at the present time and most internists were functioning as high grade general practitioners rather than as consultants.
• Internists as a group must reconsider their professional roles and functions, make a decision regarding them and then stick by that decision.
• The disparity between incomes of various groups could be attributed to the importance placed by patients and the profession on technical ability and the insignificance of considered opinion and that « opinion » should be held in much higher esteem than technical « know-how’.
• If the production of internists could be related to medical needs and if their postgraduate training were used to maximum effect, then internists would not only function as true consultants but would inevitably have their consultant status reflected in an elevation of income.

The meeting then went on to review the detailed questionnaire prepared by Robert Hatfield of Calgary. As had been agreed at the previous meeting, its purpose was to obtain information on the practice profiles of internists including, among other things, the numbers of new referred and non-referred patients seen weekly in their offices, average hours worked per week and the source and amount of their practice income etc. The meeting concluded that much of the information asked for could be obtained from existing sources or through statistical sampling methods, and that a shortened version should be prepared with emphasis on the economic aspects of the practice of internal medicine.

The meeting ended with the election of George Gray of Lethbridge as President, Dr. Arnold having indicated his wish to step down. However, recognizing the need for the Society to be more broadly based, the members present agreed that a president-elect from Ontario should be nominated to succeed Dr. Gray at the next annual meeting.

The final chapter in what, from the beginning, had been a precarious existence for the Society, occurred at the 1967 meeting in Quebec City. A dinner meeting had been planned to which a hundred internists had given advance notice of their intention to attend. A mere handful actually turned up.

In a letter to the treasurer settling some outstanding financial matters, Dr. Gray commented that the Quebec meeting had been « a complete and utter flop and raised into question the whole status of the Society ». He suggested that the executive should meet to decide on its future. The treasurer responded that if the Society was dead then he agreed that it should be made official.

Some thirteen years later, in 1980, in response to repeated concerns of the bank regarding the prolonged inactive status of the Society’s trust account, the remaining balance of $805.92 was turned over to the Alberta Society of Specialists in Internal Medicine on the grounds that it had been the defunct Society’s principal driving force and major contributor.

It is not difficult to identify the principle reasons for the failure. Foremost was the decision that there should be a federation of provincial societies but active societies existed only in British Columbia and Alberta, and in a fairly nebulous planning stage in Saskatchewan and Nova Scotia. Thus, without any effective avenue through which to communicate with other internists, particularly those in Ontario and Quebec, many internists across the country were unaware of the existence of the Society, much less the purposes for which it had been formed.

Undoubtedly the sporadic frequency of its meetings had made it difficult to sustain progress or momentum in either the development of the Society or in the activities it had hoped to undertake. The added fact that its meetings were held exclusively in the West, and, with but one exception, in association with the Canadian Medical Association rather than the Royal College, undoubtedly limited attendance by internists, not many of whom attended CMA meetings. The impression was perhaps also conveyed, initially at least, that the concerns of the Society were mainly economic and political rather than the preservation and enhancement of the education and training of internists.

CSIM TODAY

The present Canadian Society of Internal Medicine originated with a meeting convened by Alan Gilbert of Edmonton at the time of the Royal College annual meeting in Calgary in September, 1983. The purpose of the meeting was to assess whether internists from across the country might now be interested in forming an organization that could speak on their behalf. Dr. Gilbert was well-known and a highly respected internist and medical educator who had been active in the affairs of the Royal College for many years, including eight years as councilor. He was familiar with the first attempt to form such an organization, and knowledgeable regarding the contemporary trend toward sub specialization which was already eroding the identity and role of the parent discipline.

More than one hundred internists, representing all parts of the country, quickly indicated support of the need for such an organization. A seventeen member organizing committee, chaired by Gilbert was charged to explore whatever steps might be necessary to bring the organization into being, and to report back at the next Royal College meeting.

By the time the next meeting, in 1984, came round the committee had not only recruited more than four hundred charter members, but was also able to present for ratification a draft application for incorporation complete with constitution and bylaws; in addition, it had organized the first scientific program of three symposia and the Medicine North America Lectureship by Professor Paul Beeson on « The Future of General Internal Medicine ». The meeting approved the constitution and bylaws and the organizing committee was installed as an interim council headed by Dr. Gilbert who became the Society’s first president. Letters patent of incrporaotion were granted by the Minister of Consumer and Corporate Affairs, Canada, on 19 October 1984.

That such rapid progress was due not only to the dedicated work of the organizing committee but also to the widespread alarm at the effect of subspecialty fragmentation on the integrity of the parent discipline.

From the outset, the new society enjoyed the full blessing and support of the Royal College which had long regretted its inability to obtain the views and advice of the large body of community practitio­ners of internal medicine. In keeping with the privilege accorded to all other specialty groups, the Society was immediately invited to put-forward nominees for the specialty committee in internal medicine. At the same time, a request from the Society that it be granted the status of an affiliate society and a seat on the CMA General Council was promptly granted.

Constitution

One feature of the constitution, perhaps unique among specialty societies, was a proviso that one-half of the councilors and members of its important standing committee on education (from each of the four geographic regions) must be members « who do not hold aca­demic teaching appointments ». Thus community practitioners repre­senting the « grass roots » of the membership were assured an equal voice with those engaged in academic medicine.

Objects

The objects of the Society are:

• to promote the educational and scientific advancement of the broad discipline of internal medicine;
• to study and to comment appropriately upon the impact of educa­tional and scientific advances and of changing social and economic developments as they relate to the maintenance of high standards of patient care among its members;
• to collaborate with other national and/or regional organizations having responsibilities or mutual interests related to the attainment of the Society’s objectives.

The Focus: Internal Medicine or General Internal Medicine?

The terms « internal medicine » used in the name of the Society and « the broad discipline of internal medicine » used in section 1 of its Objects, has- become the subject of a largely semantic debate: some members held that the term « general internal medicine » might have reflected more accurately the Society’s principle focus. That sentiment was strongly rejected by the Society. It asserted that those entitled to identify themselves as internists on the basis of certification in internal medicine must, first and foremost, be competent « generalists » regardless of what added training or limitation of professional activity they may subsequently pursue. Though opinions vary as to the nature and length of training necessary to attain that objective, the Royal College and the Association of Professors of Medicine share the Society’s attitude.

This perception, as the principal focus of the Society, may have been a factor in the subsequent withdrawal of some members whose professional activities were almost exclusively limited to a subspecialty, and who therefore concluded that the Society had little to offer them.

Recognizing that its strength and credibility would depend much upon the size of its constituency and a stable source of funding, the Society made membership recruitment an urgent priority. Next in importance was the definition of its objectives in more specific terms and the planning of ways in which they might best be pursued.

Recruitment

With a view to adding significantly to the four hundred founding members, letters announcing the formation of the Society and its objectives were sent over the signature of the President to all holders of the certificate in internal medicine from the Royal College and La Corporation Professionnelle des Medecins de Quebec. This was followed up by personal approach by members of the interim council to potential members within their respective regions. As a result, by mid-1985 membership had grown to 730, and by the end of 1986 had reached a peak of around 850.

It must be acknowledged that this rapid growth in membership was attributable in part to the Society’s endorsement of an innovative educational videotape series entitled MEDSAT, which it was then permitted to offer to members of the Society at a significantly reduced price. It is certain that some joined the Society to take advantage of this attractive benefit. The Society suffered considerable embarrassment when the US producer of the series was forced to stop production because of the failure of its US market. Fortunately the withdrawal of the tapes was not reflected in a significant number of resignations.

What Do Internists Do?

While early councils of the Society were familiar with the adverse impact that sub specialization was having on the practice of internal medicine in its broadest sense, and on the traditional role played by internists in medical education at all levels, they recognized that any action aimed at alleviating these problems must be based on detailed and accurate information on what internists wanted and what they were actually doing; the size of communities they served, how adequately their training had prepared them for what they were doing, how their training might have been improved and their views on existing and future manpower needs as well as the type of internist required. Though councils recognized that a questionnaire survey within its own membership would reflect the views of a relatively small percentage of the total number certified in internal medicine, they felt it would be sufficiently large as to yield statistically valid information.

The Department of Clinical Epidemiology and Biostatistics at McMaster Medical School assisted in the design of the questionnaire and carried out a computerized analysis of the responses. The survey, conducted during the spring and summer of 1986, achieved a sixty-five percent response. The following are some of the interesting points revealed by the survey:

• of the 456 respondents only 29 percent practiced general internal medicine in the broadest sense; 52 percent practiced internal medicine but devoted more than half of their time to a subspecialty; only 18 percent confined themselves to a subspecialty;
• of those who devoted a major portion or all of their time to a subspecialty, only 49.5 percent (44 percent of generalists and 57 percent of sub specialists) were certified in the subspecialty;
• 41 percent of respondents believed there was a shortage of internists in their community; 47 percent indicated present numbers were adequate and 7 percent suggested there was a surplus;
• the estimate of needs over the next five years for the country as a whole were: for general internists, 390 (38%); for general internists with a subspecialty interest, 292 (29%); and exclusive sub specialists 342 (33%);
• most felt that their training for their type of practice had been adequate or reasonably so;
• a majority felt the minimum training period for internal medicine should be 4 years, though a smaller but significant number indicated 5 years.

One of the most revealing findings was the large number of those who were practicing general internal medicine with a subspecialty interest compared to the future need for this type of internist. Obviously, such findings have had to be taken into consideration in any recommendations that the Society may wish to propose with respect to the training requirements for general internal medicine.

Two papers presenting more detailed results of the survey, one dealing with manpower and the second with the length and content of training, were prepared for publication. Unfortunately, neither was judged to be of sufficiently wide interest to merit acceptance. Nonetheless, information revealed by the questionnaire has provided valuable guidance to the Society’s subsequent deliberations and recommendations.

Professional Activity Validation Study

CSIM’s own survey had not been fully analyzed when the Society, along with all other specialty societies, was invited to collaborate in a jointly sponsored Royal College/CMA peer validation of the professional activities of all physicians enrolled in the CMA Physician Man-power Data Bank. With some 4000 physicians certified in internal medicine, this proved to be a tremendously onerous task for a Society still in its formative stage and not yet able to mobilize the full resources of its membership. Nonetheless, the importance of the study in providing, for the first time, information concerning the distribution of generalists and sub specialists among the large body of certificants in internal medicine was recognized. By collaborating closely with coordinators of the peer review process who represented the various subspecialty societies, the task was brought within manageable limits.

NUMBER AND PERCENTAGE DISTRIBUTION OF CERTIFICANTS IN INTERNAL MEDICINE BY SPECIALTY PRACTISED

Specialty Practiced	Number	% of Total
General Internal Medicine	1177	29.4
Cardiology	687	17.2
Clin.Immunology/Allergy	149	3.7
Endocrinology/Metabolism	254	6.4
Gastroenterology	346	8.7
Geriatric Medicine	115	2.9
Hematology	229	5.7
Infectious Diseases	140	3.5
Medical Oncology	172	4.3
Nephrology	206	5.1
Respiratory Medicine	297	7.4
Rheumatology	225	5.6
TOTAL ALL SPECIALTIES	3997	100.0

The fact that less than thirty percent of the total were classified as general internists was not wholly unexpected and lent strong support to the Society’s concerns over the declining numbers of general inter­nists to provide specialist care to large segments of the Canadian population. These concerns were heightened when an age distribution breakdown of the 1177 general internists revealed that twenty-five percent were over the age of sixty and half of that group was already beyond the normal retirement age of sixty-five.

As part of the study, each specialty group was asked to forecast future requirements based on clearly established evidence of existing shortages. For its part the Society put forward data derived from its own membership survey, supplemented by the ageing factor noted above. The Society further pointed out that the large overlap in func­tion between generalists and sub specialists made it impossible to reach conclusive decisions as to the manpower needs of each.

The reaction of the Society was one of considerable disappoint­ment when the validation committee’s final report indicated that the projected needs put forward by the various subspecialties had, for the most part, been accepted, while those put forward by the Society were rejected on grounds of having been insufficiently precise. Nor did the committee feel it to be within its terms of reference to comment upon the Society’s suggestion of the need for a mechanism to reach a con­sensus on the roles and manpower needs of each of the groups involved. However, the committee did acknowledge that there was an important need for general internists which must be recognized.

The Impact of Sub specialization on Primary Disciplines

In response to growing concerns regarding the continuing prolif­eration of subspecialties and the impact this was having on the pri­mary disciplines, the Society submitted a comprehensive brief to the Royal College in which it drew attention to the ways in which subspecialization had adversely affected the generalist in internal medicine professionally and economically, and the harm it had caused to com­munity service and medical education: Noting also the growing threat to the discipline’s survival, the Society made a number of recommen­dations, the most important of which were:

• certification in internal medicine as a mandatory prerequisite to qualification in a subspecialty be discontinued;
• satisfactory completion of a period of core training in general internal medicine as a basic preparation for all trainees in internal medicine be maintained as a prerequisite to entry into further training in either general internal medicine or a subspecialty thereof;
• completion of such further training beyond « core », as may be prescribed by the specialty concerned, should lead to certification in that specialty;
• the minimum further training beyond « core » leading to certification in internal medicine should be two years in a program organized and supervised by the director of an approved program in internal medicine.

The far-reaching implications of the proposals sparked anxious debate within the College and the membership of the Society. In the academic community strong opposition was registered, particularly by the professors of medicine who pointed out the serious difficulties that acceptance of the proposals would create on the organization of their medical departments and the conduct of residency training pro-grams. Threats to the unity and integrity of the discipline as a whole and fears of further fragmentation of patient care through the creation of a host of independent specialties were cited as the inevitable outcome of the changes proposed. Other concerns were expressed regarding the legal ramifications of who was qualified to do what, as well as on the disposition of hospital privileges. A number of the Society’s own members pointed out the intolerable workloads that would be imposed on general internists in smaller communities and community hospitals if sub specialists were no longer to be considered qualified to share in the care of patients with illnesses falling outside their own more narrow field of competence. Finally, there were critics who said that the proposals seemed motivated more out of self-interest than on any firm evidence that the present system was resulting in any deficiency in the quality of care provided to the public.

The Society readily acknowledged the validity of these criticisms and agreed that more discussions were necessary before any further steps were taken. Accordingly, the proposals were withdrawn on the understanding that the problems presented in the brief would continue to be discussed with a view to finding alternative solutions. One option at present under consideration is a certificate of special competence in general internal medicine based on two years post-core training. Though the terminology seems rather redundant, it at least places general internal medicine on an equal academic plane with the subspecialties. Two years of post-core training can undoubtedly be justified on its own merit. It may, however, founder because of widespread opposition to the prolongation of any residency training programs in the face of the imminent move toward a compulsory two-year prelicensure requirement.

CONCLUSIONS

Through its brief existence, the Society has devoted its efforts to the attainment of its primary goal of preserving and promoting the generalist in internal medicine as a broadly-trained and competent consultant/clinician. In doing so, it has steadfastly rejected the primary care role embraced by the discipline in the United States which is bringing it into growing conflict with the general/family physician.

The Society is convinced that the well-trained generalist in internal medicine is best placed to render high quality consultant/specialist care for most disorders falling within the broad field of internal medicine. Because of a breadth of knowledge and comprehensive approach to clinical problems, the generalist has a unique role to play in the diagnosis and management of complex multi-system disorders.

Moreover, the generalist’s primary reliance on sound knowledge and clinical judgment rather than on costly and frequently unnecessary investigative procedures, results in a highly cost-efficient level of care.

The Society has made significant progress toward the attainment of its goals. It has succeeded in drawing widespread attention to the difficulties which the specialty faces. In recent years, largely upon the urging of the Society, thirteen of sixteen schools have established divisions of general internal medicine within their departments of medicine. This has revitalized the role of the general internist in medical education and has enhanced the image of the discipline which may induce more trainees to consider it as a career.

The Society is optimistic that its efforts to restore the specialist identity of the generalist in internal medicine will succeed, but not at the cost of encroachment on the field of the family medical practitioner.

T.J. Giles