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

Consultant physicians working with patientsrenal units, further specialist clinics (often shared withother disciplines) may focus on specific clinical issuesfor people with kidney disease – eg clinics for peoplewith diabetes, pregnancy, lupus and vasculitis.A whole-time equivalent (WTE) consultant renalphysician should expect to work in three clinics perweek, which is likely to reflect a mixture of generalnephrology, predialysis, haemodialysis, CAPD, renaltransplant and specialty clinics. The number of patientsseen will vary considerably according to the clinic andthe support staff available. For example, a new patientwith established kidney failure may require 1 hour of aconsultant’s time if seen in a clinic without support staffbut might spend half an hour with the consultant andhalf an hour with other staff, including a specialist nurseand a dietitian, in a dedicated low clearance clinic.Similarly, a follow-up patient with established renalfailure may need to spend 10–30 minutes with aconsultant, depending on the availability of specialistsupport staff, who might advise on management ofanaemia, access for dialysis and diet. The need forongoing multidisciplinary specialist input into manylong-term renal conditions means that the ratio offollow-up appointments to new patient appointments isunusually high.Specialist investigative proceduresSpecialist procedures undertaken by renal physiciansinclude renal biopsy, placement of temporary andpermanent central venous catheters, and insertion ofcatheters for peritoneal dialysis. The procedures areoften shared with specialist nurses, radiologists andsurgeons.Specialist on callA census of all consultant renal physicians in 2010reported that 33% have a regular on-call commitmentfor unselected emergency medical admissions (Dr PhilMason, personal communication) – a decrease from52% in the census in 2002 and 40% in 2006. 33,34 On-callwork for renal medicine is often highly intensive,particularly because of the need to support patientswith AKI and the complexity of intercurrent illness inpeople on RRT. A frequency of no more than one infour is recommended.Other specialist activity, including activitiesbeyond the local servicesMany consultant renal physicians provide cover forsatellite dialysis units and give telephone advice oraccept referrals from neighbouring hospitals that areunable to provide 24-hour nephrology cover.Advice is increasingly given to patients, GPs and otherhealthcare professionals by phone or email, which mayobviate or replace outpatient clinic visits. Such ‘virtual’clinical practice, which is in keeping with NHScommitments to environmental sustainability, saves thepatient time and money and encourages patient‘empowerment’, must be recognised in consultant jobplans and in contractual arrangements.Clinically related administrationClinical activity in renal medicine often generatesclinically related administrative duties that can require afurther 50–100% of the time spent in direct contact withpatients, eg after a renal transplant clinic, the consultantrenal physician will need to check laboratory results forall patients, arrange admission or rearrange follow-up ifunexpected results are identified, contact patients orGPs concerning any alterations to treatment, anddictate and sign relevant correspondence. This clinicallyrelated administration should be taken into accountwhen time for direct clinical care is allotted inconsultant job plans.7 Opportunities for integrated careAs well as the obvious links with transplant surgeonsand vascular access surgeons, renal physicians now oftenprovide integrated care with other specialists: egobstetricians, diabetologists, geriatricians and palliativecare physicians. They also typically work inmultidisciplinary teams with (for example) dietitians,pharmacists, psychologists, podiatrists, vasculartechnicians, etc.8 Workforce requirements for the specialtyA census of all renal units by the RCP’s JSC establishedthat there were 525 consultants in renal medicine(106 women; 404 WTEs dedicated to renal medicine; asmany renal physicians also have other commitments,especially GIM or academia) as of February 2010(Dr Phil Mason, personal communication).More renal physicians are required. The justification forthis statement comes from the recommendations of theBRS’s National Renal Workforce Planning Group(2002), 35 which are endorsed by the RCP’s working220 C○ Royal College of Physicians 2013