and tachypnoea. Chest x-ray and ECG were similarly normal. Mrs B’s d-dimer was elevated and a CT scan confirmed multiple pulmonary emboli. She recovered uneventfully.
To get to the bottom of this problem, the physician will rely on a combination of accumulated knowledge, experience, as well as the ability to think clearly, logically and objectively. (It is hazardous to be influenced by the patient’s subjective fears or the diagnosis of another doctor. A consultant should always strive to be objective.)
REMUNERATION Public service
Salaries have recently improved in state hospitals and are not to be sneezed at.
Income is somewhat better than in state hospitals, but seldom reaches that of surgical disciplines.
WORKING HOURS Public service
Mostly office hours. On-call once or twice a week, which is rarely taxing in a teaching hospital.
All hours, but physicians tend to share after- hours duty, making it much more palatable. Still, at times it can become quite hectic.
CASE 2 Mrs C, a 51-year-old shop assistant, was admitted with stroke and left sided paralysis. Subsequent investigations revealed the cause of her stroke to be a critical mitral stenosis with large thrombus in the left atrium. She also had severe pulmonary hypertension. The cardiologist advised mitral valve replacement semi-urgently. However, Mrs C and her husband found it extremely difficult to understand why a heart operation was suddenly necessary if her problem was clearly a stroke; her heart hadn’t given her any trouble so far.
In this case the communication skills of the physician will be tested. The only option is to sit down with this couple, pen and paper ready for copious drawings, and spend some time explaining at a very basic level why her heart is the real culprit and what is hoped to be achieved. (The most difficult part for the physician is often to accept the patient’s decision with equanimity, even if it is diametrically opposite to what is recommended.) Mrs C wished to be with
her family and promised to return after a couple of weeks for cardiac surgery. She was discharged on anticoagulants.
The future. Is there one? There is some concern in the USA that the generalist physician is a dying breed.1 The majority of registrars, it seems, are taking up sub- specialisation for various reasons. In South Africa it doesn’t seem to be a major problem. It is to be hoped that we do not follow the example of the USA and that a healthy mix of generalists and sub-specialists persists in the forseeable future.
Concerned with diseases of the stomach, bowels, pancreas and liver, gastroenterologists spend a large part of their day performing endoscopies.
■■ Geriatrics. Holistic care for illnesses of the elderly.
■■ Medical oncology. Administration of chemotherapy for various types of malignancies is the main function of the oncologist. Decisions surrounding this form
It is to be hoped that we do not follow the example of the USA and that a healthy mix of generalists and sub-specialists persists in the forseeable future
The sub-specialties: a bird’s-eye view You can only enter into sub-specialty training after being registered as a specialist physician. You will then spend the next two years working and studying in your subspecialty. This will culminate in a final examination, after which you will receive your certificate to practise your chosen profession. A list of sub-specialties,
acknowledged by the HPCSA: ■■ Cardiology. Although ischaemic heart disease predominates, cardiologists need to manage the whole spectrum of heart diseases. Coronary angiography/ angioplasty is an important part of the cardiologist’s armamentarium.
■■ Clinical haemotology. Haematologists focus on diseases of blood and bone marrow.
■■ Critical care. Intensivists are responsible for treating critically ill patients in ICU.
■■ Endocrinology and metabolism. Diabetes mellitus is usually the principal disease in the practice of the endocrinologist, but they also manage a wide range of other interesting diseases. ■■ Gastroenterology.
of treatment can be very challenging.
■■ Nephrology. Nephrologists are principally responsible for managing acute and chronic renal failure. However, they obviously cover the whole range of renal diseases.
■■ Pulmonology. Asthma and COPD usually predominates, but the pulmonologist faces a challenging spectrum of other respiratory maladies.
■■ Rheumatology. The rheumatologist manages disorders of joints and muscles as well as autoimmune diseases. Rheumatoid arthritis is usually the most common condition in a rheumatologist’s practice.
■■ Infectious diseases. This specialist’s opinion is often sought by a variety of other consultants about all manner of infections, especially hospital acquired infections. The spectrum includes viral, bacterial or fungal infections, as well as parasitic and tropical diseases.
1. West CP et al, Changes in Career Decisions of Internal Medicine Residents during Training, Ann Intern Med 145:774-779 (2006)
JUNIOR DOCTOR | VOLUME 2 | ISSUE 1 | 2011 | SOUTH AFRICA www.medicalprotection.org
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