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Global Perspectives: Iceland

Runolfur Palsson, MD FACP

President, the European Federation on Internal Medicine (EFIM)

Iceland is a Nordic island country of Europe located in the North Atlantic Ocean. It has a population of 348,580 and an area of 103,000 km2 (40,000 sq. mi.), making it the most sparsely populated country in Europe. The capital and largest city is Reykjavík. Reykjavík and the surrounding areas in the southwest of the country are home to over two-thirds of the population. Iceland is volcanically and geologically active. The interior consists of a plateau characterized by sand and lava fields, mountains, and glaciers, while many glacial rivers flow to the sea through the lowlands.*

*Source – Wikipedia

What inspired you to become a physician?

During my early education, I was fascinated by the biology and physiology of the human body. I found the work of physicians interesting, particularly the combination of clinical work and scientific activities. I was also inspired by physicians whom I knew when I was considering my future.

What do you enjoy about being an internist?

I enjoy the broad scope of internal medicine, combining work in the hospital and community setting. The emphasis on pathophysiology of disease together with diagnostic skills and clinical reasoning is particularly interesting. However, it is the variety of tasks, ranging from disease prevention to comprehensive care of complex and sometimes life-threatening illness that makes the work of an internist enlightening.

What is the role of the internist in Europe? What are the education and training requirements needed to practice internal medicine or one of the subspecialties of internal medicine?

There is some variability in the way internal medicine is practiced in European countries. Limited information on the role of the internist in Europe was available until we, through the European Board of Internal Medicine, performed surveys of the practice of internists and postgraduate training in internal medicine several years ago. The results were published in the European Journal of Internal Medicine (Cranston et al. The practice of internal medicine in Europe: organization, clinical conditions and procedures. Eur J Intern Med 2013; 24:627–632; Cranston et al. Postgraduate education in internal medicine in Europe. Eur J Intern Med 2013; 24:633-638).

In general, internal medicine tends to be a hospital-based specialty, while office practice is common in several countries. In Southern Europe, namely the Mediterranean countries, Spain, Portugal, Italy and Greece, traditional internal medicine has prevailed as a very strong specialty. Internists are key members of the medical staff of acute care hospitals where they generally run the inpatient service and sometimes the emergency services as well. Physicians practicing specialties related to internal medicine, or so-called subspecialties of internal medicine, usually have no or minimal training in internal medicine. Medical school graduates directly enter training programs in specialties like cardiology, respiratory medicine and so forth. In the Northern part of Europe and in several countries in Eastern Europe, a system similar to the United States is in place, i.e. physicians undergo training in internal medicine followed by another specialty. In some European countries almost all internists have another specialty as well, whereas in other countries there are internists, internists-subspecialists and pure subspecialists who have not qualified in internal medicine.

What are some of the most significant challenges that physicians throughout Europe face? What are your thoughts on the best way to meet those challenges?

The growing elderly population with multiple medical problems and associated polypharmacy has become a major challenge. Commonly, there is lack of coordinated care for these individuals, who see many specialists, none of whom is assuming responsibility for the overall care. Hence, the care tends to be fragmented. There is also a lack of hospital beds because many of these elderly, chronically ill individuals require frequent hospitalization and this frequently causes congestion in the emergency ward. In Europe, we advocate a much stronger role for internal medicine in coordinating the care of patients with multimorbidity and polypharmacy. Indeed, this is one of the main objectives of the European Federation of Internal Medicine (EFIM).

We are also focusing on improving the organization of patient care in the hospital setting and increasing the collaboration between hospital physicians and physicians in the community. In the United Kingdom, this has turned into a big project called The Future Hospital and is already gaining some success. One of the key features is early assessment of acute exacerbations among chronically ill patients for early intervention and to avoid unnecessary visits to the emergency ward. Part of the strategy is the establishment of urgency care clinics run by internal medicine services at major hospitals, or so-called Acute Medical Units. In addition, allocation of medical care to refugees is an emerging challenge in a number of countries in Europe. Finally, the provision of high-quality medical care in an era of rapidly rising healthcare expenditures is an important challenge. I strongly believe in value-based care models and that internists should lead the way in promoting rational and cost-effective use of available resources.

What can other countries learn from your healthcare system?

In European countries, the healthcare system is generally public with universal access for the inhabitants. However, in some countries private medical clinics do exist and in some cases the services are reimbursed by private insurance companies, whereas in other instances services provided by the private sector are reimbursed by the national health insurance (single-payer system). I believe that the universal access to care is an important feature that others can learn from.

Are enough young physicians in Europe choosing to be internists? What makes them choose (or not choose) to practice internal medicine?

This varies between countries in Europe. Overall, internal medicine remains an attractive specialty, particularly in Southern Europe. In Portugal, for example, internal medicine is very popular and a leading specialty in the hospital setting. In several European countries, physicians who train in internal medicine and a subspecialty, decide to practice the subspecialty only. In those countries a shortage of practicing internists may exist. Currently, several countries are attempting to create a system that utilizes the qualified internal medicine workforce to provide general medical services, whether they are pure internists or internist-specialists. Of course, this calls for enhanced strategies for competence and qualification in internal medicine among internists-subspecialists. I believe the reason young physicians continue to choose internal medicine is the broad and holistic nature of specialty together with a variety of career options.

What advice would you give to someone who is thinking about going into internal medicine?

I would stress that they are making a very good choice and would encourage them to go ahead and enter internal medicine. Moreover, I would strongly advise a young physician to select the specialty if he/she possesses the characteristic attributes of a good internist. This includes attention to detail, good problem-solving abilities and demonstration of passionate patient care.

Describe your position as President of The European Federation of Internal Medicine (EFIM).

The President of EFIM is elected for a 2 year-term. The presidency is preceded by a 2-year term as President-Elect and is followed by the role of Past President for another 2 years. The long period of service provides continuity in the operation of the Executive Committee. The role of the President is mainly to lead the Executive Committee and represent EFIM across Europe and internationally. The President has a leading role in strategic planning and in creating a future vision for the organization. Also in overseeing the daily operations and ensure that decisions made by the Executive Committee are carried through. EFIM has an office in Brussels where daily activities are handled by an office manager, who also assists the President and the Secretary General in their work. The President is invited to many national congresses and is frequently asked to give a lecture and/or a speech.

Can you describe the role of The European Federation of Internal Medicine? What are the missions and goals of the organization?

The mission of EFIM is to promote the clinical practice and science of internal medicine in Europe and worldwide. Besides the annual scientific congress, EFIM runs the European School of Internal Medicine which is held twice a year for internal medicine trainees. The flagship of EFIM is our journal, the European Journal of Internal Medicine, which has been growing at a steady pace in recent years. One of the principal objectives is harmonizing postgraduate education and qualification in internal medicine at the European level. The work towards this aim takes place within the European Board of Internal Medicine, formed jointly with the UEMS Section of Internal Medicine. In 2016, the European Board completed a new European internal medicine curriculum which hopefully will be implemented in all member states. Another objective of EFIM is to promote high-quality, cost-effective care for patients in the European countries. Recently, EFIM launched a Choosing Wisely project where we plan to build on previous work in several member states. In addition, quality and safety measures in medical practice and medical professionalism will continue to be important activities. Furthermore, EFIM supports the initiatives of the Young Internists, who have become an essential part of the organization. It is very important to nurture the young generation of internists as the future lies in their hands. Finally, we wish to create a stronger alliance with the ACP and other leading internal medicine organizations with the goal of strengthening the voice of internal medicine worldwide.

EFIM recently hosted its 16th European Congress of Internal Medicine (ECIM) in Milan. Could you describe the planning process behind this meeting?

The planning for ECIM 2017 in Milan began immediately following the congress in Amsterdam in September of 2016. ECIM 2016 was the first independent European Congress of Internal Medicine but prior to that the congress was held in conjunction with a national internal medicine congress in one of the member states. The planning for the congress is in the hands of the EFIM Executive Committee with support from a local organizing committee. The theme of the congress in Amsterdam was Connecting with the Patient and in Milan the theme was Thinking Outside of the Box in Internal Medicine. The focus of the program tends to be on key challenges of internal medicine practice, combining important general topics and updates in specialized areas. Furthermore, approximately 1000 submitted abstracts are presented as posters during the congress.

Please explain the efforts towards High Value Care in Europe.

High-value care is one of the main objectives of EFIM. We have established a Choosing Wisely Working Group and invited participation from every national internal medicine society in Europe. The plan is to compile the top five choosing wisely items from each country and critically review those to generate a series of choosing wisely items for the European level. Cost containment is a very important issue as well as avoiding overuse and misuse of resources.

Why is it important for physicians in Europe to belong to professional organizations like ACP and attend the Internal Medicine Meeting?

The ACP is a big and very powerful organization that provides leadership and guidance for practicing internists, not only in the United States but worldwide. The Internal Medicine Meeting is the top internal medicine conference in the world with a very strong educational value. Physicians in Europe are faced with the same challenges as physicians in the United States and at meetings such as the ACP Internal Medicine Meetings there is an opportunity to share experiences and network with physicians from other parts of the world. This way we can create a stronger voice for internal medicine internationally. Likewise, I believe it is important for physicians to visit the European Congress of Internal Medicine and other internal medicine congresses in the world.

Please share your most memorable ACP international experience.

On a personal note, my most memorable experience was at the ACP Internal Medicine Meeting in San Francisco in 2004, when I had been elected as a fellow of the ACP and participated in the Convocation Ceremony.

Back to the March 2018 issue of ACP International