Consultant physicians working with patients - Royal College of ...

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2 Specialties Gastroenterology and hepatologyGastroenterology and hepatologyDr Adam Harris BSc MBBS MD FRCP Consultant physician and gastroenterologist1 Description of the specialtyThe specialty of gastroenterology and hepatology caresfor patients with both benign and malignant disordersof the gastrointestinal (GI) tract and liver. The specialtyencompasses a wide range of conditions – fromcommon disorders, such as indigestion and irritablebowel syndrome, to highly complex problems, such asinflammatory bowel disease (IBD) and liver failure –and specialised procedures such as endoscopic resectionof cancers and liver transplantation.Gastroenterologists also see patients with a varietyof general medical problems, particularly anaemiaand weight loss. Much of the work, particularly toexclude organic disease in symptomatic patientsand to provide rapid diagnosis and treatment forpatients with suspected GI cancer, is based inoutpatients. The investigations required often includeendoscopy and imaging. An acute and emergencyinpatient service is needed for common problems suchas gastrointestinal haemorrhage, acute IBD anddecompensated liver disease (particularly due toalcohol).Gastroenterologists are involved in the National BowelCancer Screening Programme and provide a highquality,safe, diagnostic and therapeutic (removal ofpolyps) colonoscopy service.Gastroenterology departments have an essential role inthe implementation of urgent referral for patients withsuspected cancer (‘2-week referrals’) to improve thediagnosis and treatment of GI cancers. Severaldepartments have combined to form multidisciplinaryteams (MDTs) in order to provide the critical massof specialists needed to meet the standards forEngland of the Department of Health’s (DH’s) ClinicalOutcomes Group (COG) for the provision of specialistservices. 1 Tertiary referral units may receive patients withcomplex IBD or hepatobiliary disease or complexnutritional problems (who may require home totalparenteral nutrition) or who require advancedtherapeutic endoscopy. Patients who require transplantation of theliver and small intestine are referred to the smallnumber of units that undertake organtransplantation.Malnutrition is common in hospital patients(∼35%) and associated with increased morbidityand mortality. 2 Every healthcare facility should bescreening nutritional status using the MalnutritionUniversal Screening Tool (MUST), or equivalent.Patients found to be at risk should ideally bereferred to a multidisciplinary nutrition supportteam.2 Organisation of the service and patternsof referralMost symptomatic patients are looked after by their GP,and most problems are resolved by discussion, primarycare-initiated investigation, advice and medicaltreatment. Nonetheless, there has been a continuingsteady increase in outpatient and inpatient work forgastroenterologists, particularly in relation to alcoholicliver disease and the increasing numbers of cancers ofthe GI tract that occur in an ageing population. Theinpatient casemix usually comprises patients with GIbleeding, cancer, severe alcoholic liver disease and acutesevere IBD.Close liaison with colleagues in surgery, radiology,pathology and oncology facilitates the treatment ofdifferent forms of GI disease. Combined outpatientclinics (ie colorectal surgeon and gastroenterologist)undoubtedly improve management, and weekly cancermultidisciplinary team (MDT) meetings are a usefulforum for discussing all complex cases. Meetings withradiologists and pathologists should take place at leastonce a week and can be combined with formal trainingsessions for trainees.C○ Royal College of Physicians 2013 99
Consultant physicians working with patientsMany units have established posts for nursesspecialising in IBD, liver disease, disorders of bowelfunction and nutritional support. The specialistnurses are used in the main for task- andprocess-oriented services to streamline clinicalpathways. One effect of this is to increase thecomplexity of cases for medical staff in clinics. Largerdepartments may employ consultant GI nurses,nurse endoscopists and GPs with a special interest(GPwSIs) who will often carry out sessions in thehospital unit.3 Working with patients: patient-centredcarePatient choice and involving patients in decisionsabout their treatmentMuch of the outpatient work in gastroenterology relatesto the management of chronic conditions such aschronic liver disease and IBD. Success depends on agood working relationship with the patient, whereby thepatient has a full understanding of and participates inthe management of their condition and it is clear whereresponsibility lies in patient care for the specialist,patient and GP. An example of this is where patientswith IBD will often initiate a change in their treatmentin the face of a relapse of their disease, usually in closeliaison with the specialist team or GP, or both. A furtherexample is the self-help strategies and biofeedback thatare used to treat the highly prevalent symptoms of gutdysfunction.Patients are represented on the joint gastroenterology/hepatology committee of the Royal College ofPhysicians (RCP) and, through Crohn’s and Colitis UK(NACC), are involved in the generation of standards ofcare for patients with inflammatory bowel disease.Similarly, patients have been involved in settingstandards for nutritional support through Patients onIntravenous and Nasogastric Nutrition Therapy(PINNT) – a core group of the British Association forParenteral & Enteral Nutrition (BAPEN). The BritishSociety for Gastroenterology (BSG) endoscopy sectionhas devised comprehensive information leaflets for allpatients undergoing endoscopy. The British Liver Trustand Core – the main GI charity – also produce manyhelpful documents for patients. All of the charitablebodies have excellent interactive websites, as does theBSG, with a website that has a dedicated patientinformation area.4 Interspecialty and interdisciplinaryliaisonMultidisciplinary teams and working with otherspecialistsThe practice of gastroenterology involves manyspecialties, such as radiology and pathology, andperhaps a greater overlap between medical and surgicalpractice than for any other specialty. This is coordinatedthrough MDT meetings, and facilitating close liaisonwith tertiary referral centres is an integral part of themanagement of complex GI problems – eg IBD,complex liver disease, pancreatic cancer, liver or smallbowel transplantation, and complex nutritionalproblems that often require home parenteral nutrition.Specialist nurses in nutrition, stoma care, GI oncology,general gastroenterology and management of thetreatment of viral hepatitis play an increasingly valuablerole in improving the quality of service, communicationand liaison between disciplines within the team.Hospital and community dietitians are vital members ofthe GI team.Working with GP specialistsThe development of primary care practitioners with aninterest in gastroenterology and/or endoscopy has beena major advance during the last decade. Nationally,primary care specialists have been closely involved inthe production of guidelines by the National Institutefor Health and Care Excellence (NICE).5 Delivering a high-quality serviceCharacteristics of a high-quality serviceCare for patients with GI symptoms should be timely,evidence based, patient focused and consultant led.Although most patient care takes place in the outpatientdepartment, this should be supported ideally by acombined medical and surgical inpatient unit thatprovides senior-level expertise for the management ofinpatients with GI emergencies 7 days a week. Ahigh-quality service will: have properly timetabled audit and clinicalgovernance meetings fulfil the Joint Advisory Group (JAG) on GIEndoscopy’s requirements for endoscopy have sufficient time for staff development andappraisal100 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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1 Physicians in the NHS todaycan be
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2 Specialties Medical oncologyMedic
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