Consultant physicians working with patients - Royal College of ...
Consultant physicians working with patients - Royal College of ...
Consultant physicians working with patients - Royal College of ...
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<strong>Consultant</strong> <strong>physicians</strong> <strong>working</strong> <strong>with</strong> <strong>patients</strong>contribute substantially to provision <strong>of</strong> the acutegeneral medical service. Usually they participate in aone in eight to one in fourteen acute-take rota thatincludes post-take ward rounds on the emergencymedical admissions unit. Additionally, they will lead award-based team responsible for about16–20 unselected general medicine in<strong>patients</strong>.Most diabetes/endocrine consultants are also trained ingeneral medicine and take part in acute medicine ‘takes’on a rotational basis. A small number <strong>of</strong> consultantsmay deal <strong>with</strong> diabetes <strong>with</strong>out endocrinology, and asomewhat larger number may be endocrine specialistsalone. There is an increasing number <strong>of</strong> diabetologists<strong>with</strong> a community diabetes specialty.Inpatient workDiabetes is over-represented in hospital populations(about 17% <strong>of</strong> NHS beds are occupied by diabetic<strong>patients</strong>), mostly due to complications such as coronaryartery disease or foot ulceration <strong>with</strong> infection.Treatment alterations and glycaemic control are doneon an outpatient basis by diabetes specialist nurses.Similarly, endocrine investigation and treatment arealmost entirely done <strong>with</strong>out hospital admission.Diabetes/endocrine specialists therefore have anunusually high inpatient load <strong>of</strong> general medical, ratherthan specialty, <strong>patients</strong>. Diabetic foot disease (the mostcommonly admitted diabetes-related disorder) is alsoincreasingly managed on an outpatient basis <strong>with</strong> thesupport <strong>of</strong> multidisciplinary foot care teams. Inpatientconsultation work varies considerably depending on theco-specialty pr<strong>of</strong>ile <strong>of</strong> the hospital. Because <strong>of</strong> the highprevalence <strong>of</strong> diabetes comorbidity among hospitalin<strong>patients</strong>, there is a substantial workload in supportingcolleagues in other specialties; this is increasedconsiderably if there are tertiary referrals: maternity,renal, vascular or cardiac services. 1 For endocrinology,the workload is greater where a hospital hasneurosurgery, a cancer centre or a specialist endocrinesurgical service.Outpatient workOutpatient work comprises the following elements: General internal medicine (GIM): this load variesconsiderably. Most consultants will either run aseparate general medical clinic or see such <strong>patients</strong>as part <strong>of</strong> their endocrine clinic. Diabetes services: new patient consultations forpeople <strong>with</strong> diabetes are complex and requireapproximately 30 minutes <strong>of</strong> consultation time.Review diabetes <strong>patients</strong> require approximately20 minutes but may require more time. Additionaltime <strong>with</strong> other healthcare pr<strong>of</strong>essionals (egspecialist nurses and dietitians) may also be needed. Endocrine services: new endocrine <strong>patients</strong> requireabout 30 minutes <strong>of</strong> consultation time and review<strong>patients</strong> about 15 minutes. Complex reviews forpituitary <strong>patients</strong> or endocrine tumours, paediatrictransition or genetic consultations may take longerand arrangements for joint consultation <strong>with</strong> otherspecialities are recommended. Nurse-led clinics: increasingly specialist services anddiabetes and endocrinology are being provided bynurse-led clinics. These are an invaluable resourcethat ensure that the appropriate review <strong>of</strong> many<strong>patients</strong>. They do, however, still require consultantsupport.Academic medicinePhysicians in the specialty who have university contractsgenerally divide their time equally between research anda clinical work programme similar in configuration butreduced by 50% <strong>of</strong> the volume to their NHS colleagues.Quite frequently, the clinical contribution will berestricted to the specialty (eg no GIM, or onlyendocrinology). The academic component <strong>of</strong> such postsusually focuses primarily on research, but there is likelyto be a substantial teaching load and other academic,administrative and managerial responsibilities.7 Opportunities for integrated careThese have been partly covered in section 4. Examples<strong>of</strong> integrated care in the specialty <strong>of</strong> diabetes andendocrinology include: the diabetes team: consultant, specialist nurse,dietitian and podiatrist the extended diabetes team: vascular surgeon,orthopaedic surgeon, nephrologist,ophthalmologist, optometrist, psychologist, etc diabetes links <strong>with</strong> primary care, includingcommunity diabetologists and GPwSIs in diabetes endocrine links <strong>with</strong> nuclear medicine (fortreatment <strong>of</strong> thyrotoxicosis): endocrine surgeons,geneticists and paediatricians joint management <strong>of</strong> <strong>patients</strong> <strong>with</strong> pituitary disease<strong>with</strong> pituitary surgeons, in pituitary centres transitional care (in both diabetes andendocrinology) for the efficient and sensitive movefrom paediatric to adult care.94 C○ <strong>Royal</strong> <strong>College</strong> <strong>of</strong> Physicians 2013