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

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2 Specialties Gastroenterology and hepatology provide consultant input into clinical managementat a high level facilitate research and academic interests whereappropriate use evidence-based national and local guidelines onpatient management.Consultants will also work closely with colleagues inother trusts to provide clinical networks to ensure thatpatients receive the highest quality of care. The BSG hasproduced a document on care standards for patientswith GI disorders 3 and recommendations onout-of-hours care. 4Resources required for a high-quality serviceSpecialised facilitiesSpecialised facilities are described clearly in the BSG’sworking party report of 2001 (Provision ofendoscopy-related services in district general hospitals) 5and in the RCP’s 2005 report. 6 Specialised facilitiesinclude: diagnostic and therapeutic endoscopy unit;facilities for parenteral nutrition; operative, anaestheticand intensive therapy unit (ITU) support;interventional radiology; and access to oncologyand tertiary referral units (eg regional livercentres).Adequate secretarial support for every consultant isessential. Communication is central to the safemanagement of patients, and good informationtechnology (IT) is necessary for auditing standards ofpractice within the department. There should becomputer terminals at all workstations and inendoscopy rooms and offices. In most gastroenterologydepartments, specialist nurses in endoscopy, cancer andpalliative care are fully integrated into the managementstructure.Quality standards and measures of the quality ofspecialist servicesSpecialist society guidelinesIn 2006, the BSG produced a quality standardsdocument backed up by data gathered over a 1-yearperiod. 3 This provides information on all aspects ofgastroenterological practice and how this can beimproved. The BSG provides guidelines for the higheststandards of care in all areas of clinical practice ingastroenterology. These have been publishedby Gut and are available on the BSG’s website(www.bsg.org.uk).6 Clinical work of consultantsContribution to acute medicineAbout 60% of gastroenterologists participate inunselected medical take. They therefore commit a majorpart of their time to the management of patients withgeneral medical problems as part of their unselectedacute medical take, ward work and outpatient work.The workload associated with acute medical take willincrease after the president of the RCP recommendedthat consultant physicians should be on site for 12-hourstretches each day at weekends and bank holidays whenon call.Many larger departments are adopting new models ofservice delivery to allow the consultant ‘on the wards’time to focus on the delivery of high-quality care toinpatients which also includes responsibility for GIbleeding. Elective outpatient clinics and endoscopy listsare usually cancelled while ‘on the wards’ so that time isavailable for seeing inpatient referrals and emergencyprocedures, etc.Many consultant gastroenterologists act as trainers inboth the specialty and general medicine for foundationyear 1 and 2 trainees, core medical trainees and specialtyregistrars. Calculations suggest that the time taken totrain, appraise and complete the e-portfolio should be aminimum of 0.25 programmed activities (PAs) pertrainee.This section describes the work of a consultantphysician providing a service in acute general medicineand gastroenterology and recommends a workloadconsistent with high standards of patient care. It sets outthe work generated in gastroenterology by a 250,000population and gives the consultant workload as PA foreach element of such a service.The gastroenterology committee of the RCP and theBSG have published several studies concerned with theprovision of a combined general medical andgastroenterology service. The most recent summarisedthe nature and standards of gastrointestinal and liverservices in the UK. 3Working for patientsA consultant-led team should look after no more than20–25 inpatients at any time. Most patients areadmitted on emergency ‘take’ days with various generalmedical problems or are gastroenterologicalC○ Royal College of Physicians 2013 101
Consultant physicians working with patientsemergencies triaged to the ward. A minority areadmitted, urgently or electively, for evaluation of GIproblems. PAs need to be allocated for at least threespecialist ward rounds per week and one post-take wardround per week per consultant, bearing in mind theRCP’s recommendations on the amount of time thatshould be devoted to each patient. 6Outpatient workNew patient clinicA consultant physician in gastroenterology workingalone in a new patient clinic may see 6–8 new patients ina session, usually equivalent to one PA. The exactnumber of patients is dependent on experience and thecomplexity of the problem. Each new patient should begiven approximately 30 minutes.Follow-up clinicsA consultant physician working alone in a clinic forselected patients after acute medical orgastroenterological admission may see 12–15 patients ina session, usually equivalent to one PA. Each follow-upconsultation should be given about 15 minutes. Aphysician working alone in a specialist follow-up clinicfor chronic GI and liver disease sees 10–12 patients inone session. In practice, most gastroenterologists willrun clinics that involve a mixture of new and oldpatients.Support from junior medical staffOutpatient clinics are often run with doctors intraining; time must be allocated to review the patientsseen by the trainees. The number of patients seen byjunior members of staff depends on their experience butin general the outpatient workload is increased by about50% of that undertaken by the consultant. It should benoted that this creates a potential saving only inoutpatient and endoscopy consultant sessions and notin the other components of the consultant’s work.Moreover, this saving (which amounts to perhaps onesession) is counterbalanced by the need for theconsultant to devote time to training (includingtraining in endoscopy). A specialist trainee should beable to see 4 new patients or 10 follow-up patients orsome combination of the two.Diagnostic and therapeutic endoscopyIt is essential that adequate time for training is allowedand that dedicated endoscopy training lists arescheduled into the programme. Training sessionsinevitably reduce the service throughput. Hands-ontraining cannot be carried out during a busy serviceendoscopy list.The workload of a consultant physician undertakingendoscopy depends on the procedure: Diagnostic upper gastrointestinal endoscopy:allowing 15–20 minutes per procedure, a maximumof 10–12 procedures should be carried out in asession equivalent to one PA. For a teaching session,6–10 patients should be allocated, with the numberdepending on the experience of the trainee. Diagnostic flexible sigmoidoscopy: a maximum of8–10 procedures should be carried out in a sessionequivalent to one PA. Therapeutic upper gastrointestinal endoscopy: thisincludes oesophageal or pyloric dilatation, treatmentof bleeding ulcers, endoscopic resection of polyps orhigh-grade dysplasia in Barrett’s oesophagus,palliative treatment of oesophageal or gastric cancerand placement of feeding tubes (percutaneousendoscopic gastrostomy (PEG)). Such procedurestake two to three times as long as routine upper GIendoscopy and, allowing 30–40 minutes perprocedure, 5–6 might be undertaken in a session(4–5 for a teaching session). Therapeutic flexible sigmoidoscopy: this usuallyinvolves polypectomy and takes twice as long asroutine flexible sigmoidoscopy; 5–8 proceduresmight be undertaken in a session. Diagnostic and therapeutic colonoscopy: thereshould be a maximum of 6 colonoscopies persession (3–4 for a teaching session), allowing30–40 minutes per procedure. Diagnostic and therapeutic endoscopic retrogradecholangiopancreatography (ERCP): a maximumof4proceduresshouldbecarriedoutinonesession. Endoscopic ultrasound: 4–6 procedures should becarried out in one session but this will depend uponthe complexity (oesophagogastric or hepatic,pancreatic or biliary) and type (diagnostic ortherapeutic) of procedures. Video capsule endoscopy technology allowsdiagnostic views of the small intestine. Numbers ofcapsule studies read in a session depend on theexperience of the operator and the length of thestudy. Endoscopic tests of the small intestine (enteroscopy)are time-consuming because the small bowel is long102 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 Cardiovascular medici
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