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Internal Medicine: Global Perspectives
Verena Briner, MD, FACP

Verena Briner, MD, FACPInternal Medicine: Global Perspectives is a new feature of the ACP International newsletter, designed to give our audience different perspectives from across the global medical community. Presidents of internal medicine societies worldwide share their thoughts on how medicine is practiced in their country, what they may stand to learn from other countries, as well as the challenges and rewards of leadership. Verena Briner, MD, FACP, Immediate Past President of the Swiss Society of Internal Medicine (SGIM) in Switzerland, is our first profile.

Switzerland At A Glance

  • 30,000: number of physicians in Switzerland
  • 6,000: number of internists in Switzerland
  • 3,300: number of internists working in private practice
  • 1,600: number of internists working in hospitals
  • 490: average number of patients per physician
  • 84: life expectancy for women
  • 80: life expectancy for men

The Doll Healer

What inspired you to become a physician?

My family says that since childhood I was eager to become a dentist and treated the dolls of all my friends, but I changed my mind when my sister’s baby boy became sick. Suddenly I wanted to become a very good doctor, so I could help people quickly to minimize their suffering in an emergency!

What motivated you to take on this role?

Because I felt and knew that internists are necessary to provide good medical treatment for our population. Internists are especially important in hospitals and private practice since continued specialization will result in fewer physicians who can effectively treat various problems a patient may have. Therefore, I am convinced that internists will be needed in the future more than ever and that specialists will understand this too.

People get older and develop multiple chronic conditions, and now we’re seeing younger patients developing multiple chronic conditions (metabolic syndrome). These groups in particular need the internist, who will take all aspects into account. Internists are best able to guide patients through a complex medical system.

What do you think you accomplished during your tenure?

I was fighting very hard for internal medicine to be the major unit of the departments of medicine at the big hospitals such as the university hospitals. It was a challenge and, of course, also a political issue. I tried to position internal medicine as a main column of a modern health care system.

What have you found to be the most challenging part of leadership and the most rewarding?

The most challenging for me was to motivate people who were not interested and lacked the motivation to contribute anything to the profession. The most rewarding part was to work with enthusiastic, interested people who do like to achieve more than average and make visions/dreams come true.

What were your responsibilities as president of an Internal Medicine society?

Although I was the president, it was not a one-person job. The Board of the Swiss Society of Internal Medicine has 20 members. Ten are internists working solely in the hospital and ten are in a private practice. Of these 20 internists, there are five people who are called “the nucleus” of the SGIM. These five people are in charge of the daily business. One of them is the president. The president works the most, but the others are working too. These four nucleus members contribute much to the success of the society. Together, we worked on topics like training programs, life long education, politics, and service for members. The daily business was done by us in a manner compatible with the SGIM strategy. The SGIM is responsible for the training program in internal medicine at all teaching hospitals in Switzerland. There are about 170 clinics providing part of the program. It is required to change the hospitals at least once during the fellowship, and like a puzzle to add years of training to fulfill the whole program. There are no private medical schools or teaching hospitals providing another program! Thus, the SGIM has to adapt the program whenever there are new scientific, ethical or other aspects influencing our profession. We also investigate whether a clinic fulfills the criteria to become a teaching hospital.

Also, continuous education for physicians is mandatory by federal law. Every three years, the SGIM verifies that all the internists working in medicine have fulfilled the required education. In Switzerland, we have an annual meeting of the SGIM that is similar to ACP’s annual meeting. About 3,500 internists attend. In addition to that meeting, there are a great number of small meetings which we call “symposia,” which are educational in nature and provide a good brush up on events, etc.

Medicine in Switzerland

What is the role of “internist” in Switzerland?

In a private practice, the internist provides primary care in an outpatient setting for acute illnesses as well as for long term care. They serve as the family doctor for the population. By federal law, internists also are required to be on duty regularly for outpatient emergencies in their area. Around 1,600 internists work solely in the hospital. In small hospitals, the internist(s) and their team are in charge of all the patients with medical problems. In larger hospitals, an internist is head of the department of medicine and takes care of patients with multiple chronic conditions, or unclear cases.

What do patients and/or family members want or expect from an “internist”?

Very often the internist is the family doctor for common diseases and for smaller accidents. He or she is the personal advisor for discussions when rather difficult decisions have to be made, such as operation, transplantation, chemotherapy or sometimes little things like changing medication. In the hospital the internist is a generalist. In small and medium size hospitals he is in charge of the medical emergency, intensive care, and the medical units. Patients expect all-around care and internists provide it.

Are there special challenges internists in Switzerland face? What are your thoughts on the best way to meet these challenges?

Only a few young doctors are planning to work in a private practice. When family doctors (internists and general practitioners) retire nowadays they often do not have a successor to take their place. On average there are 490 patients per physician in Switzerland. In rural areas, the number is higher so a shortage of local medical care will be seen in those areas first. In Lucerne, where I am the head of the department of medicine, we offer emergency primary care medicine for the people in that area. Taking care of patients in an outpatient setting at the hospital but with physicians from a private practice is a new approach. Fellows of the hospital and about 40 internists with a private practice share the work. So I hope that young internists will love this work and that some will go into private practice with colleagues or maybe open some kind of a ‘doctors house’ together.

To become an internist and also to become a general practitioner, in Switzerland it requires five years of training. Due to a required adaptation of the two programs to the European Union, the SGIM will change the training program. A track for private practice and another for internists in the hospital will be provided. The program for internists will have two years of options of the five-year training: private practice options include 6-12 months of training in surgery, pediatrics, etc; the hospital track offers anesthesia, basic research, etc. The final exam will still be the same for both. General practitioners of the future will only have 3 years of training. This change will be a challenge for the SGIM but also the Swiss Society of General Medicine.

Modern medicine requires more and more technical skill, and in recent years, specialization was necessary, and, as a consequence, fragmentation of the care of a patient occurred. These days, fragmentation also continues in specialized fields such as cardiology, gastroenterology, and also in surgical areas. Interestingly enough, there are now many surgical clinics in Switzerland recruiting internists for the patient care on their wards.

Repopulating our clinical research field is becoming problematic. Without research in medicine there is no future. Fewer and fewer fellows are interested in basic clinical research. I remember well the fantastic time I spent in the lab of Robert Schrier in Denver, Colorado. The experiments, but also the discussions, were very important for the understanding of diseases and therapy options. I think combined together they work well.

Are there enough young physicians choosing to be internists? What makes them do so? What are the barriers?

The number of internists finishing the training program is rising little by little. However, the majority of these colleagues continue with another training program such as cardiology or intensive care. This allows them to stay in the hospital for a longer time. However, medical school is very cost effective here, so they don’t have to pay back loans, which is very different from the U.S.

Working in private practice in Switzerland is less attractive for several reasons: patients require emergency treatment for any symptom, even minor disturbance of well being; spouses and the family of the physician are less likely to accept very long working hours; and the reputation and the income of an internist remains less than that of a specialist.

Is there public debate about Switzerland’s health care system?

Anyone who is sick has access to any kind of treatment they need, independent of income, social states, or age. Very good care for everybody is provided, however, new diagnostics and treatments, along with the increasing number of younger patients with metabolic syndrome, cause a rise in demand. Costs for medical care and, therefore, the premium for health insurance are rising every year. Debate started some years ago about limiting medical care, but no model has been found which is accepted from the majority of the Swiss population. A debate about end of life was initiated 10 years ago. In Switzerland it is allowed to provide assisted suicide as long as there is no self-interest. In contrast, any form of active ending of life is forbidden. More lately ‘Exit’ and another company provided assisted suicide to ‘tourists’ from Germany and other countries where assistance in suicide is forbidden. Political steps are now required.

What could other countries learn from yours?

In Switzerland we have more physicians, nurses, imaging, radiation equipment, and hospital beds per person. Everybody receives quality medical care. Even catastrophic illness for most does not lead to poverty, and yet we still do not have the highest cost for health care per person.

Is access to electronic information or products influencing what patients want from their doctors in Switzerland?

Yes, television, newspaper and the web are providing a lot of information about medical topics in a scientific manner, and many people are acquiring pseudo knowledge as a result. They get frightened, which forces physicians to perform unnecessary CT scans and MRIs. These superfluous analysis and checks are contributing to the rise in health care costs.

Does your society have collaborative relationships with other societies and if so has it been beneficial to your society and how?

We are very lucky to have good contacts with ACP! It is wonderful to attend the annual meeting. Our members benefit from very interesting teaching programs, MKSAP, scientific books, etc. Our society is a member of the International Society of Internal Medicine and the European Federation of Internal Medicine (EFIM). Each year, a few outstanding young fellows are invited to the summer school of EFIM. In the scientific board of the annual meeting of the German Society of Internal Medicine there is always a Swiss internist as a permanent member. In Switzerland, we always invite other societies to our annual meeting of our society.

My Point of View

William Osler used clinical skills and common sense. These days, technology and laboratory methods and market forces seem to replace both. Furthermore, in the past there were hardly any lawsuits in Switzerland. It is changing now and therefore diagnostic services and therapies are initiated more and more not because of medical requirement, but rather for safety reasons. The volume of analysis therefore rises and thus costs increase any further.

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