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

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2 Specialties Gastroenterology and hepatology(up to 6 metres) and easily forms loops whenintubated. Passage may be assisted with balloons orspirals. These procedures are usually used to providetherapy to abnormalities found by capsule orradiological procedures. Numbers of tests in asession depend on the complexity of theprocedure.On call for GI emergenciesFor the safety of patients, it is necessary that NHSorganisations have formal and robust arrangementsto care for emergency patients presenting with upperGI bleeding, every day of the year, throughoutthe UK.The BSG have published documents on out-of-hourscare 4,7 calling for a reorganisation of services(‘hub-and-spoke’ model) to provide for safe care of allGI emergencies. In larger units (‘hub’) emergency covermay be available 24 hours a day, 7 days a week. On-callrotas should include all of those with appropriate skills,particularly members of the medical and surgical GIteams and interventional radiologists. 7 Even in thesmaller units (‘spoke’), as far as possible, the aimshould be to schedule sessions during the week and atweekends to manage patients admitted with acute GIbleeding.The BSG strongly endorse the need for 7-day care (notnecessarily 24 hours) for patients with acute severeupper GI bleeding and acute severe entero colitis andfor those with acute liver failure or acute cholangitis: anacute GI service is needed that covers all hospitals. Thiswould require a consultant gastroenterologist toundertake a ward round at weekends and on bankholidays in addition to standard care.Nutrition serviceNutrition teams responsible for enteral and parenteralfeeding services are usually led by consultant physicianswith an interest in gastroenterology. This should bewithin the context of an MDT with core memberscomprising dietitians, nurses, pharmacist and clinician(usually a gastroenterologist). These teams haveexpertise in the promotion of adequate nutrition, egphysical help, protected mealtimes, nasogastric tube,PEG feeding or parenteral nutrition.Supervision of home-based parenteral nutrition forpatients with type 2 or 3 intestinal failure is usuallyprovided from specialist centres. Nutritional roundsneed to be regular and would be expected to account for2 hours per week for the gastroenterologists who takeresponsibility for the nutritional service. Such roundswill often include critical care and surgical wards.All acute hospitals should have at least one nutritionnurse. 8Gastroenterologists are responsible for the placement ofPEG tubes and are now required to be intimatelyinvolved in the pre-assessment of patients referred forthe procedure and in obtaining consent.HepatologyHepatology has developed as a subspecialty such thatmost gastroenterology units will require one or twohepatologists or at least someone who takes a lead rolefor liver disease, while transplant hepatology is deliveredin tertiary supra-regional units. Training in hepatologyhas been boosted by an extra sixth year specialtyhepatology training module. Alcoholic liver disease hasincreased the burden of acute hospital admissions, whilespecialist hepatitis B and C clinics are provided on anoutpatient basis. Hepatocellular cancer (HCC) isincreasing in incidence, and hepatologists areresponsible for surveillance of patients with cirrhosis,and often for discussions on treatment of HCC as partof MDT meetings.Academic medicineAcademic gastroenterologists are crucial for thedevelopment and implementation of new ideas aboutdisease pathogenesis and treatment. Clinical academicsoften provide specialist clinical services and tertiaryadvice related to their research activity and play acrucial role in training the future consultant body. Theclinical contribution of academic gastroenterologistsvaries widely depending on their other responsibilitiesand some academics may take on clinical leadershiproles within the NHS. Most hold an honoraryconsultant contract with their local NHS trust, and theusual ratio of academic work to service work is 50:50,although wide variations and great flexibility exist inpractice. The academic gastroenterologist would beexpected to provide proportional input into thegastroenterology service according to the nature of thecontract and the job plan which should be agreed byuniversity and NHS as part of the joint appraisalprocess. It should be stressed that this will beproportionate for all activities in a gastroenterologist’sjob description, including support, training,governance, teaching (often undertaken duringC○ Royal College of Physicians 2013 103
Consultant physicians working with patientsacademic part of job plan) and administrative roles, aswell as direct patient-related activities.7 Opportunities for integrated careA more fluid relationship between primary andsecondary care is developing, eg Choose and Bookguidance and advice. There are opportunities for GPs todevelop special interests and to work within GP clustersto advise on referrals to secondary care and to undertakespecialist clinics in the community. Future managementof chronic conditions such as irritable bowel syndrome(IBS), dyspepsia and coeliac disease will need to involveintegrated care to decrease referrals to secondary care.By collating activities such as referral management, useof Choose and Book (guidance/advice), clinicalassessment services, telephone helplines, GP educationand feedback for improvements in integrated care maybe achievable. Shared care protocols for monitoring ofdrugs such as thiopurines are required to facilitate safefollow-up in the community.Diagnostic endoscopic procedures such as flexiblesigmoidoscopy may be undertaken in communityhospitals but the JAG standards will make this a lessattractive option.8 Workforce requirements for the specialtyCurrent workforce numbersOn 30 September 2012, there were 1,005 consultantgastroenterologists in England. A whole-timeconsultant currently serves a population of around51,000; however, there is considerable variation.Presently, 15% of consultants are women and only 14%of consultants work part time (receive
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Consultant physiciansworking with p
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The Royal College of PhysiciansThe
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AcknowledgementsWe would like to th
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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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2 Specialties Medical oncologyMedic
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2 Specialties Renal medicineRenal m
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2 Specialties Renal medicineInvolve
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2 Specialties Renal medicineAcademi
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2 Specialties Renal medicineTable 1
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2 Specialties Renal medicinekidney
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