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Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision?

Published:December 22, 2021DOI:https://doi.org/10.1016/j.ejim.2021.12.007

      Highlights

      • Patients with individual conditions have been shown to benefit from specialist care.
      • Specialist care did not result in shorter length of stay, mortality & readmission rates.
      • Widespread adoption of specialist care may not be beneficial for all patients.
      • There is a role for general physicians caring for an ageing and complex population.
      • This supports dual specialist training with general internal medicine.

      Abstract

      Introduction

      : The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care.

      Aim

      : To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates.

      Design/Methods

      : A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty.

      Results

      : 5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009).

      Conclusion

      : Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.

      1. Introduction

      In an era of increasing hospital admissions and a growing older population with multiple co-morbidities [], the discussion surrounding generalist versus specialist medical acute admissions continues to stimulate debate. Annually, the demand and volume of hospital admissions are increasing with more patients being treated on trolleys []. There remains an onus on hospital clinicians to manage existing resources efficiently.
      Generalist medical admissions (“take”) are common practice in general hospitals across Ireland and the United Kingdom. General medical admissions refer to all unselected medical patients admitted to a hospital during a 24 hour period being admitted under the care of one consultant physician, and remaining under the care of that consultant for the duration of their admission regardless of the patients’ presenting complaints. Most consultant physicians are qualified dually in general internal medicine (GIM) and in their specialty. If there is a need for specialist advice, specialist consultations are sought. In recent years, some hospitals have moved to a specialist medical admissions system, where care of patients is taken over by the most relevant specialist.
      There is evidence that patients cared for by specialties aligned to their presenting complaint, have better outcomes and shorter lengths of stay (LOS) [
      • Bini EJ
      • Weinshel EH
      • Generoso R
      • et al.
      Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis.
      ,
      • Pothirat C
      • Liwsrisakun C
      • Bumroongkit C
      • et al.
      Comparative study on health care utilization and hospital outcomes of severe acute exacerbation of chronic obstructive pulmonary disease managed by pulmonologists vs internists.
      ,
      • Tseng FY
      • Lai MS.
      Effects of physician specialty on use of antidiabetes drugs, process and outcomes of diabetes care in a medical center.
      ,
      • Chew DP
      • Horsfall M
      • McGavigan AD
      • et al.
      Condition-specific streaming versus an acuity-based model of cardiovascular care: a historically-controlled quality improvement study evaluating the association with early clinical events.
      ,
      • Moore S
      • Gemmell I
      • Almond S
      • et al.
      Impact of specialist care on clinical outcomes for medical emergencies.
      ]. This evidence applies to a variety of conditions including myocardial infarction, unstable angina, congestive heart failure, diabetes, stroke, community-acquired pneumonia, pneumothorax, pleural effusion and gastrointestinal haemorrhage. One of the major contributors to prolonged inpatient stay is delay associated with specialist consultations [
      • Rahman AS
      • Shi S
      • Meza PK
      • et al.
      Waiting it out: consultation delays prolong in-patient length of stay.
      ]. This would support the conjecture that specialist care may reduce LOS. Furthermore, streamlining patient care to the appropriate specialty from day one of admission, reduces consult burden, outpatient referrals and the peaks and troughs of patient numbers between general take/admissions days [
      • Tseng FY
      • Lai MS.
      Effects of physician specialty on use of antidiabetes drugs, process and outcomes of diabetes care in a medical center.
      ,
      • Chew DP
      • Horsfall M
      • McGavigan AD
      • et al.
      Condition-specific streaming versus an acuity-based model of cardiovascular care: a historically-controlled quality improvement study evaluating the association with early clinical events.
      ,
      • Donohoe MT
      • Kravitz RL
      • Wheeler DB
      • et al.
      Reasons for outpatient referrals from generalists to specialists.
      ].
      Previous studies have examined the impact of generalist care compared to specialist care for individual conditions. The overall impact of adopting a widespread specialty care admission programme has not yet been studied despite this practice becoming commonplace in many hospitals in recent years [
      • Moore S
      • Gemmell I
      • Almond S
      • et al.
      Impact of specialist care on clinical outcomes for medical emergencies.
      ]. We aimed to assess the impact of this practice in our hospital. We hypothesized that introduction of a specialty-directing early redistribution of care programme would reduce inpatient LOS. We performed a prospective, cohort and single-centre study of patients admitted acutely to our hospital under a team participating in the GIM admissions roster.

      2. Methods

      Data from patients who presented to our hospital's emergency department and who were admitted acutely under the care of a GIM team during two time-periods between October 2017 and December 2019 were analysed. Our hospital is a medium-sized general Irish university teaching hospital which is administered by the Irish Health Service Executive(HSE). Between October 2017 and December 2019, the hospital had an emergency department (ED) open 24 hours per day, 7 days per week with 340 acute inpatient beds and 10 clinical teams of physicians participating in a GIM admission roster. Each clinical team consisted of one consultant physician and four to five non-consultant hospital doctors. Each clinical team is responsible for the care of patients who are admitted during a 24-hour period (on GIM “take” or acute admissions) and GIM admissions recurred for each clinical team every 10 days (Fig. 1). Medical admissions are referred from the emergency department or directly from a general practitioner.
      Fig. 1
      Fig. 1Flow of medical admissions pre-specialty directing programme.
      In October 2018, a specialty-directing redistribution of care intervention was introduced whereby on the morning following admission, each of the clinical teams had transferred to their care one patient appropriate to their specialty (Fig. 2). This decision was made on the basis of the presenting complaint (e.g pneumothorax transferred to respiratory team) (Supplemental Table A). Prior to the introduction of a specialty-directing programme, it is important to note than conditions such as stroke, inflammatory colitis, ST elevation myocardial infarction, hyperglycaemia emergencies, severe hyponatraemia and conditions requiring a pleural drain were decanted usually to the appropriate specialty but at the discretion of the consultant on call and relevant specialty consultant.
      Fig. 2
      Fig. 2Flow of medical admissions post-specialty directing programme.
      Seven of the ten GIM clinical teams (two endocrinology, two respiratory and three geriatric) opted into the specialty-directing redistribution of care system. Three of the ten GIM clinical teams (two gastroenterology and one cardiology) chose not to participate in the redistribution of care system due to clinical commitments. The treating clinicians were aware of whether or not they were a specialty-directing team –this was not a blinded study.
      Ethical approval for the study protocol was obtained from the (Irish) North East Research Ethics Committee. Informed consent was not obtained from the admitted patients as they were treated according to the usual hospital practice.
      We compared patient data across two three-month time-frames. The first time-frame, involved patients admitted 9-12 months prior to the introduction of the intervention (October 2017 – December 2017). The second time-frame involved patients who were admitted 12-15 months after introduction of the intervention (October 2019-December 2019). We compared also data from patients who were admitted when a specialty-directing team was on acute admissions for GIM to data from patients who were admitted when a non-specialty-directing team was on acute admissions for GIM. For this latter analysis, data from patients who, were mostly ambulatory and admitted under the care of an acute medical unit physician, on the basis that they were likely to be discharged within 72 hours of admission, were excluded from the analysis dataset.
      Data were collected in real time, during the patients’ hospital admission, by hospital clerical and nursing staff, using the hospitals’ electronic patient administration system(i.PM). The primary outcome was patient LOS. Secondary outcomes were discharge to home, inpatient death and re-admission to hospital within 30 days of discharge.
      Statistical analysis was performed using MedCalc® Statistical Software version 19.8. Continuous variables were compared initially between the groups using the independent-samples t-test - linear regression analyses were used to adjust for potential co-founders (age greater than 80 years, gender, marital status, health insurance status, Manchester Triage Category score greater than 2 and whether the patient had presented to the emergency department in the preceding year). Categorical variables were compared using the Chi-Squared test and logistic regression analyses were used also to adjust for potential co-founders. No attempt was made to adjust for missing data. The level of statistical significance was set at less than 0.05 for all analyses.

      3. Results

      Data on 5,144 patient-care episodes were analysed (Table 1). The average age of the patients was 65.3 (±19.7) years, 50% were female, 43% were married and 22% had private health insurance (Supplemental Table B).
      Table 1Characteristics and Outcomes of those admitted before and after introduction of the intervention.
      Parameter1 year pre-intervention (October 2017 to December 2018)1 year post-intervention (October 2019 to December 2019)PaPb
      N26222522
      Age, years64.2 ±20.166.5 ±19.4<0.001
      Female, n (%)1324 (50.5)1251 (49.6)0.522
      Married, n (%)1124 (42.9)1073 (42.5)0.815
      GP referral, n (%)765 (29.2)586 (23.2)<0.001
      Health insurance, n (%)593 (22.6)557 (22.1)0.648
      Manchester Triage Category 3 or more, n (%)1400 (53.4)1315 (52.1)0.368
      Length of stay, days°7.3 ±7.58.5 ±8.4<0.001<0.001
      Died while an in-patient, n (%)144 (5.5)165 (6.5)0.1130.263
      Re-admitted within 30 days of discharge, n (%)269 (10.3)229 (9.1)0.1530.060
      Data are expressed as mean ±standard deviation or as number (percentage).
      Pa, P values were calculated using the independent-samples t-test or Chi Square analyses.
      Pb, P values were calculated using regression analyses adjusting for age greater than 80 years, gender, marital status, whether the patient had been referred to ED by a primary care physician, health insurance status, Manchester triage category greater than 2 and whether the patient had presented to the emergency department in the preceding year.
      °, length of stay was capped at 30 days.
      n, number.
      For our primary analysis, we compared the outcomes of interest across the two time-frames (Table 1). The average age of patients admitted to the hospital increased significantly and by ∼3.5% over the two-year study period (Table 1). The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019 (p == 0.009) (Supplemental Table B). There were no other significant differences in patients’ baseline characteristics across the two time-frames.
      Length of stay was more than 15% longer one year after the intervention was introduced, compared with one year prior to the intervention (Table 1). The proportion of the patients who stayed in hospital for more than 30 days was 75% higher one year after the intervention (7.4%), compared with one year prior to the intervention (4.2%, p < 0.001). Both of these findings remained statistically significant after adjustment for potential confounders (Table 1 and Supplemental Table B). No differences were found in the proportion of patients who were discharged home, died while an in-patient, or who were re-admitted within 30 days of discharge. We further subanalysed outcomes of interest over three time periods (Time 0: 1 year pre-intervention, Time 1: Immediately post-intervention and Time 2: 1 year post-intervention) with similar findings (Supplemental Table B).
      We compared outcomes in patients who were admitted when a speciality-directing team was on acute GIM admissions to outcomes in patients who were admitted when such a team was not on acute GIM a (Table 2). Being admitted under a speciality-directing team, or not, was a random occurrence. No differences were found between these two patient groups in any of the baseline characteristics or outcomes compared (Table 2 and Supplemental Table C).
      Table 2Characteristics and outcomes of those admitted under when a speciality-directing team was on-call and when a non-speciality-directing team was on-call.
      ParameterSpeciality-directing teamNon-speciality-directing teamPaPb
      N32601404
      Age, years66.5 ±19.466.4 ±19.30.823
      Female, n (%)1627 (49.9)695 (49.5)0.799
      Manchester Triage Category 3 or more, n (%)1689 (51.8)724 (51.6)0.879
      Length of stay, days°8.4 ±8.18.1 ±7.90.2980.224
      Died while an in-patient, n (%)203 (6.2)101 (7.2)0.2200.211
      Re-admitted within 30 days of discharge, n (%)333 (10.2)137 (9.8)0.6340.601
      Data are expressed as mean ±standard deviation or as number (percentage).
      Pa, P values were calculated using the independent-samples t-test or Chi Square analyses.
      Pb, P values were calculated using regression analyses adjusting for age greater than 80 years, gender, marital status, whether the patient had been referred to ED by a primary care physician, health insurance status, Manchester triage category greater than 2 and whether the patient had presented to the emergency department in the preceding year.
      °, length of stay was capped at 30 days.
      n, number.
      Independent predictors of length of stay included: age greater than 80 years; marital status; primary care physician referral; Manchester triage category greater than 2; presentation within the past year; and presenting after implementation of the speciality-directing programme (Fig. 3). Age greater than 80 years, for example, increased length of stay by an average of 4.7 days. Being admitted after implementation of the speciality-directing programme conferred an average independent increase in LOS of 1.0 days.

      4. Discussion

      Contrary to our a priori hypothesis, length of stay, for patients admitted under our hospital's GIM service, increased by more than 15% one year after the introduction of a specialty-directing programme. We found no difference in LOS, 30-day readmission rate, discharge home rate or inpatient mortality among patients who were admitted when a specialty-directing team was on acute admissions compared to other patients admitted under the GIM service. The difference in LOS, between the two time-frames, remained statistically significant after adjustment for age which increased markedly during the three years that the study examined.
      One of the strengths of our study is the presence of control groups. We compared outcomes during time periods before and after implementation of the redistributed care programme. Treating physicians in the control group were all dual trained generalists and specialists (cardiologists and gastroenterologists) who were part of the on acute admissions GIM roster, but who did not take over the care of patients most relevant to their subspecialty. Physicians in the intervention group were also dually trained generalist and specialist consultants (respiratory, endocrinology and geriatric medicine) who did take over care of patients whose presenting complaint fit best with their subspecialty interest. Another strength of our study was completeness of data collection. Data were obtained from the hospital's patient administration system and there were no missing data. This permitted adjustment, without loss of power, for factors known to be associated with LOS– age, health insurance status, Manchester triage category status and whether the patient had presented to the emergency department in the past year.
      Our study has some limitations. Firstly, clinical teams had the option to participate in the specialty redistribution programme - not all of the clinical teams chose to take part. This introduces selection bias. It is notable also that only one patient was distributed to each of the specialty-directing teams when one of these teams was on acute GIM admissions - thus the remainder of the patients under that consultants’ care were undifferentiated GIM patients. Similarly, all consultant physicians in both intervention and control arms were trained dually in GIM and their specialty. Thus, their routine practice may have been quite similar and the reconfiguration of the service may have disrupted the efficiency of previous inter-professional working relationships rather than impairing their GIM skills. This view is supported by the fact that the LOS of both the participating and non-participating consultant-led teams increased equally after the intervention. These study design flaws would have increased the likelihood of type two error, limiting our ability to find a difference between groups, if one had existed. Furthermore, we did not look at outcomes for specified conditions, but rather gathered information on patients admitted under the GIM service as a whole. Also, although data were compared to a time-frame prior to intervention introduction, this cannot control for external factors which may have changed between the two time-frames. It is recognised that shorter LOS stay occurs in areas with robust community and home care facilities for patients who are discharged [
      • Walsh B.
      • Wren M.-A.
      • Smith S.
      • et al.
      An analysis of the effects on Irish hospital care of the suppy of care inside and outside the hospital. Economic & Social Research institute (ESRI).
      ]. We did not assess for change in the uptake of community services or requirement for home care upon discharge, nor did we assess whether any prolonged hospital stay was associated with delays in providing community care, so we cannot determine whether these factors had an impact on the study's results. We did not have data regarding co-morbidity or frailty status, so could not adjust for these factors. Increasing age is associated with multimorbidity [
      • Shreiber TL
      • Elkhatib A
      • Grines CL
      • et al.
      Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes.
      ] and we were able to adjust for age. The generalizability of this study is limited due to it being a single-site study. We did not assess patient satisfaction or healthcare professionals’ satisfaction and these would be interesting outcomes to study in future.
      Most positive studies, demonstrating a benefit of specialist care, have examined individual conditions or emergency presentations [
      • Moore S
      • Gemmell I
      • Almond S
      • et al.
      Impact of specialist care on clinical outcomes for medical emergencies.
      ] including myocardial Infarction [
      • Nash IS
      • Nash DB
      • Fuster V.
      Do cardiologists do it better?.
      ], unstable angina [
      • Shreiber TL
      • Elkhatib A
      • Grines CL
      • et al.
      Cardiologist versus internist management of patients with unstable angina: treatment patterns and outcomes.
      ], asthma [
      • Pearson MG
      • Ryland I
      • Harrison BD.
      National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society.
      ], pneumothorax [
      • Selby CD
      • Sudlow MF.
      Deficiencies of management of spontaneous pneumothoraces.
      ], pleural effusion [
      • Walsh LJ
      • Macfarlane JT
      • Manhire AR
      • Sheppard M
      • Jones JS.
      Audit of pleural biopsies: an argument for a pleural biopsy service.
      ], acute upper gastrointestinal haemorrhage [
      • Masson J
      • Bramley PN
      • Herd K
      • et al.
      Upper gastrointestinal bleeding in an open-access dedicated unit.
      ], diabetes [
      • Tseng FY
      • Lai MS.
      Effects of physician specialty on use of antidiabetes drugs, process and outcomes of diabetes care in a medical center.
      ] and stroke [
      Trialists'Collaboration, Stroke Unit
      How do stroke units improve patient outcomes? A collaborative systematic review of the randomized trials.
      ]. By contrast, we studied the outcomes for all patients admitted under the GIM service without regard to their presenting complaints. There are multiple reasons why our results have not mirrored previous studies showing that specialist care improved outcomes [
      • Bini EJ
      • Weinshel EH
      • Generoso R
      • et al.
      Impact of gastroenterology consultation on the outcomes of patients admitted to the hospital with decompensated cirrhosis.
      ,
      • Pothirat C
      • Liwsrisakun C
      • Bumroongkit C
      • et al.
      Comparative study on health care utilization and hospital outcomes of severe acute exacerbation of chronic obstructive pulmonary disease managed by pulmonologists vs internists.
      ,
      • Tseng FY
      • Lai MS.
      Effects of physician specialty on use of antidiabetes drugs, process and outcomes of diabetes care in a medical center.
      ,
      • Moore S
      • Gemmell I
      • Almond S
      • et al.
      Impact of specialist care on clinical outcomes for medical emergencies.
      ]. Our hospital is not a tertiary referring centre and not all specialties are available daily on site.
      Furthermore, 3/7 (42%) of the participating teams in the specialty redistribution programme were geriatric medicine teams. We may assume that patients allocated to these teams would be among the most frail and complex patients, who are at higher risk of longer admissions [
      • Rose M.
      • Pan H.
      • Levinson M.R.
      • Staples M.
      Brief communications.
      ]. Patients allocated to geriatric medicine would include also stroke patients with a mean LOS in Ireland of 18±28 days, which is above the average LOS in our study [].
      Other studies have reported shorter LOS of patients under general internists relative to those under the care of specialists [
      • Parekh V
      • Saint S
      • Furney S
      • et al.
      What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service?.
      ,
      • Bai AD
      • Srivastava S
      • Smith CA
      • et al.
      General internists versus specialists as attendings for general internal medicine inpatients at a Canadian hospital: a cohort study.
      ,
      • Horwood CM
      • Hakendorf P
      • Thompson CH
      Comparison of specialist and generalist care.
      ]. These papers cite a more integrated approach to patient care rather than disease or organ-centric focus, more efficient care delivery and greater familiarity with the processes required in looking after a GIM patient outside of their specialty [
      • Card SE
      • Clark HD
      • Elizov M
      • et al.
      The Evolution of General Internal Medicine (GIM) in Canada: international implications.
      ] as reasons why these generalists had a shorter LOS than specialists.
      The results of our study highlight yet again the importance of generalism in medicine. Although multiple studies show better outcomes with subspecialist care for certain conditions and in younger populations [
      • Moore S
      • Gemmell I
      • Almond S
      • et al.
      Impact of specialist care on clinical outcomes for medical emergencies.
      ], this practice does not reflect the reality of hospital medicine where the majority of patients are older with multiple interacting comorbidities [
      • Goddard Andrew.
      Ensuring a general medicine workforce for the future.
      ]. A previous survey of consultant physicians in the UK indicated that for two-thirds of medical consultants, GIM was part of or made up the bulk of their medicine practice, despite being specialists [
      Federation of the Royal Colleges of Physicians of the United Kingdom
      Census of consultant physicians and medical registrars in the UK, 2013-14: data and commentary.
      ,
      • Moore A
      • Newbery N
      • Goddard AF.
      Consultant perception of general internal medicine: a survey of consultant physicians.
      ]. Medical training reviews and reports in Ireland and the UK have been released to summarise training recommendations in general internal medicine and the need for physicians with broad general medicine skills. These reports highlight the need for expert physicians skilled in GIM to manage and treat patients with common acute and long-term medical conditions and comorbidities and to refer appropriately for specialist input when required [
      Keane M Report
      Review of the ICHMT higher specialist training programme in general internal medicine.
      ,
      • Greenaway D.
      Securing the future of excellent patient care.
      ]. When patients were surveyed, their preference was for an expert treating physician in their particular illness; however older patients felt often there was a lack of continuity of care with fragmented specialty input and it is felt a generalist can often provide more holistic and patient centred care [
      • Oldham J.
      What do patients want? Generalists versus specialists and the importance of continuity.
      ]. The term generalist in medicine often has pejorative connotations and acute GIM work may be seen has increasingly burdensome while trying to maintain specialty commitments [
      • Jenkins Paul F.
      Medical generalists and specialists: time for proportional representation?.
      ]. However, our study empowers the role of the generalist physician by demonstrating better patient outcomes. Looking to the future, dual training with GIM is of vital importance for medical trainees, as a high proportion of inpatients have multiple co-morbidities and not one specialty fits all. Furthermore, not all models of hospitals have the staffing levels and breadth of specialities to allow for specialty redistribution of care.

      5. Conclusion

      The introduction of a specialty-directing early redistribution of care programme was not associated with improved LOS, 30 day readmission rate or inpatient mortality. This study highlights the importance of the generalist in provision of inpatient hospital care and the need for continued prioritisation of GIM training for the benefit of our patients.
      • Ethical approval for the study protocol was obtained from the (Irish) North East Research Ethics Committee.
      • All authors have no conflict of interest to declare.

      Declaration of Competing Interest

      None.

      Appendix. Supplementary materials

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      Linked Article

      • Surprising outcomes of general internal medicine care versus specialty care in acutely admitted medical patients
        European Journal of Internal MedicineVol. 98
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          Biomedical knowledge, resulting in better treatment for patients, is accumulating at a breathtaking pace. As these developments occur, in some situations medicine gets increasingly complex, requiring highly specific and multifaceted infrastructure and demanding skills of medical and paramedical professionals. One of the responses of the medical professionals is increasing specialization, that is not only widely present in internal medicine, but in virtually all medical specialisms [1]. Moreover, as medicine is getting more and more complex and (bio)technology-driven, it is seeing a considerable increase in subspecialization [2].
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      • Internists or specialists-that is the question!
        European Journal of Internal MedicineVol. 98
        • Preview
          Over the past few decades the rising burden of chronic disorders and multimorbidity has heavily challenged health systems worldwide. In general terms, the architecture of a healthcare service should be dictated by the needs of the population it serves [1]. Chronic, multimorbid disorders would benefit from a broader and “holistic” approach and management but are individual diseases that nowadays impact health-care resources, medical research, and even medical education, where students are less and less attracted by generalist disciplines [2].
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