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2 Specialties Infectious diseases and tropical medicineMentoring and appraisal of medicaland other staffAll infectious diseases physicians undergo annualappraisal through their trusts or universities, or both. Inaddition, many take on management roles and thereforethey often act as appraisers for their organisations. Theyalso help with assessments and appraisals of traineesand other staff.Continuing professional developmentAll physicians take part in continuing professionaldevelopment (CPD) activities locally, nationally andinternationally through the CPD scheme. Many, if notall, contribute by providing teaching and training forothers to contribute to their CPD. There is a minimumrequirement for consultants to achieve an average (overfive years) of 50 hours of CPD annually.Clinical governancePhysicians in infectious diseases understand the needfor good clinical governance. Through organisationssuch as the British Infection Association (BIA), theBritish HIV Association (BHIVA), the British Society ofAntimicrobial Chemotherapy (BSAC), the Royal Societyof Tropical Medicine and in collaboration with theRoyal College of Pathologists (RCPath), physiciansdevelop guidelines (eg management of meningitis, feverin returning travellers and SARS) and help toimplement these locally. Through the RCP, infectiousdisease physicians have key roles on the JointCommittee on Infection and Tropical Medicine. Allphysicians will undergo appraisal.Research – clinical and basic scienceCompared to most medical specialties, a largeproportion of physicians in this specialty have academicappointments. At least half are academics (up to 80% ofthose in tropical medicine have academicappointments) and contribute significantly to researchnationally and internationally. Research varies frombasic science, often virological or immunological,through to clinical science and clinical trial work.British tropical medicine continues to have a highinternational profile in subjects as diverse as malaria,HIV, TB, dengue fever and rickettsial diseases.Local management dutiesMost infectious diseases physicians play an active role inlocal management, either as clinical leads or serving oncommittees for infection control. Most have taken onclinical directorships and some have become medicaldirectors of trusts. Most will have managementresponsibilities relating to MDTs.Specialty and national guidelinesInfectious diseases physicians and their professionalsocieties help to formulate and comment on guidelinesfrom the National Institute for Health and CareExcellence (NICE), the RCP and other organisations.Manyindividualshaveservedoncommitteestoformulate guidelines such as those dealing withmeningitis, TB and HIV. These have been published byBIS, BHIVA and other organisations.Specialty and national auditInfectious diseases physicians routinely take part innational audits organised by the HPA, BHIVA andothers, and contribute to the surveillance of infections.In addition, they are involved in the use of audit toassess clinical and other services in their own trusts.6 Clinical work of consultantsThe clinical work of infectious diseases consultantsincludes the following: Inpatient work: most infectious diseases physiciansare responsible for the care of acute admissions withinfection-related problems. A typical physicianwould be responsible for 500–600 admissions perannum. Outpatient work: outpatients is an important facetof the physician’s work and increasingly involves thecare of those with HIV and hepatitis virusinfections. A physician would be expected to see1,000–1,200 outpatients per year. Specialist procedures: infectious diseases is not aprocedure-based specialty but physicians often haveto deal with occupational exposure to blood-bornepathogens in healthcare workers and sort outpost-exposure prophylaxis for HIV exposures.However, an important ‘procedure’ is the need toprovide timely consultations to other services toprovide the best infection care. Consultation work isan important part of the infectious diseasesphysician’s workload. Specialist on call: most physicians will take part in aregular on-call rota for infectious diseases. Due tothe acute nature of the specialty this often requiresthe presence of the physician in the hospital out ofhours and involves weekend ward rounds. Mostphysicians would expect to be part of an on-call rotaof one in three or less.C○ Royal College of Physicians 2013 149
Consultant physicians working with patients Other specialist activity: infectious diseasesphysicians often provide advice beyond the boundsof their local hospital trusts, either by telephoneadvice to DGH physicians and GPs or by providingeasy-access outpatient review for patients fromoutlying areas. Clinically related administration: all physicians needto keep on top of the administration related to theirclinical activity, including good data collection,appropriate audit and management of junior staff.Good communication with other colleagues is animportant aspect of this.Balance between acute and specialty careMost infectious diseases physicians take part in generalmedicine on-take in addition to their specialty role.This is important as the specialty is not ‘organ-based’and still requires a breadth of general medicineknowledge and experience. Many will divide their timebetween specialty and general medicine by doing somemonths of general medicine and the remainder ininfectious diseases, while maintaining their specialtyclinics throughout.Balance between direct work and supervisionMuch of the work of infectious diseases is ‘hands on’,although the clinical work does involve the delegationof some duties to junior doctors and requires theconsultant to supervise such work. Increasingly, withthe reduction in junior doctors’ hours of work and theimplementation of the ‘Hospital at night’ in NHShospitals, infectious diseases consultants are often oncall with none of their own specialty junior staff andend up doing more direct care than in previous years.Other workAlthough infectious diseases physicians rarely, if ever,work in the community they are involved withsupervising intravenous antibiotic therapy in thecommunity as part of OPAT programmes. Some willhave other duties including infection control work orthey may, with microbiology colleagues, have a role inthe supervision of diagnostic laboratories. Infectiousdiseases physicians have an active role in academicmedicine and research.7 Opportunities for integrated careMuch infectious diseases practice is, necessarily, basedin the acute hospital, whether running a ward orconsulting on patients admitted under other specialties.However, opportunities do exist for integrated care. Theprovision of OPAT is a good example of this. There willalso be increasing opportunities for the management ofpatients with chronic blood-borne virus infections, likeHIV, and those with tuberculosis.8 Workforce requirements for the specialtyCurrent workforce numbersThere are currently around 136 whole time equivalentconsultants in infectious diseases and tropical medicine.About two-thirds are also involved in some way in acute(on-take) general medicine and a large number are inacademic positions. The infectious diseases physicianstend to be in teaching hospitals with a relative paucity inDGHs so the number of specialists is well below thatrequired for the population and is approximately halfthe number per 250,000 population compared tocountries in northern Europe. Numbers of infectiousdiseases consultants would need to expand by about40% in order to satisfy the RCP and specialist societyrecommendations for adequate provision of specialistservices (to around 190 WTE). Although fewretirements are expected in the next few years, thespecialty may expand as more trainees emerge who arejointly trained in infectious diseases and medicalmicrobiology. The expectation is that these jointtrainees will be appointed to hospitals withoutinfectious diseases specialists at present and will be ableto provide clinical inpatient work as well as infectioncontrol expertise and microbiology advice.Recommendations for providing servicesThe UK has a very low number of infectious diseasesspecialists in comparison to other western countries.Currently there is only about one infectious diseasesphysician per 500,000 population in England and Wales.In Scotland, the ratio is better, with one per 270,000.Scandinavian countries with good provision have aboutone infectious diseases specialist per 50,000 population.Countries more akin to the UK, such as the Netherlandsor Australia, have one per 200,000. It is thought that thisfigure would be more appropriate for the UK – oneinfectious diseases physician for each district hospital.Medical microbiologists contribute greatly to themanagement of infection in the UK, but even if theirnumbers were included in the tally of infectious diseasesspecialists, the UK is underprovided compared to othersimilar countries. In addition, the fact that at least halfof the infectious diseases physicians contribute to thegeneral medicine on-take service means that there areeven fewer WTE physicians devoted purely to infectiousdiseases.150 C○ Royal College of Physicians 2013
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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