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

2 Specialties Acute internal medicine and general internal medicineAcute internal medicine and general internal medicineDr Rhid Dowdle OBE MB BChir FRCP FEFIM FSAM Consultant physicianand cardiologist1 Description of the specialtyI have heard the fear expressed that in this countrythe sphere of the physician proper is becoming moreand more restricted, and perhaps this is true; but Imaintain . . . that the opportunities are still great, thatthe harvest truly is plenteous, and the labourers scarcelysufficient to meet this demand.Sir William Osler, 1897Acute internal medicineAcute internal medicine (AIM) is defined as ‘that part ofgeneral internal medicine (GIM) concerned with theimmediate and early specialist management of adultpatients suffering from a wide range of medicalconditions who present to, or from within, hospitals,requiring urgent or emergency care’. 1,2 All physiciansparticipating in the acute medical intake should havethe skills to manage any patient presenting with anacute medical problem for up to 72 hours, whether theypractise AIM as a sole specialty or GIM with anotherspecialty. However, consultant physicians specialising inAIM – acute physicians – are expected not only toparticipate in the delivery of acute care but also to leadin the organisation of care for acutely ill patients. Acutephysicians should provide the clinical andorganisational lead for the assessment wards and theacute medical unit (AMU) and often now act as thelead clinicians for the organisation of acute carethroughout the hospital, particularly in the context ofhospital at night and the out-of-hours medical team(OoHMT). 2General internal medicineThere remains a need for most physicians who havecontinuing responsibility for inpatients, other thanthose on the AMU, to have the skills to manage patientssuffering a variety of common disorders or havingcomplex needs. Although many hospitals admit patientswith acute illnesses to the most appropriate specialtiessoon after their admission, there are still circumstanceswhere this cannot or does not take place. This mayoccur where the patient’s illness does not fit the criteriaused to define the appropriateness of specialtycare or in smaller hospitals where specialty care isnot always practicable and patients remain under thecare of the admitting team. This inpatient work,together with the management of the acute take,defines GIM.All the curricula, both in AIM and in GIM, are based onthe symptoms with which patients present, emphasisingthe critical part that diagnosis plays in delivering goodpatient care. 3 The majority of current trainees in AIMare dually training with GIM, which offers flexibility incareer progression, and many aspire to accreditation inintensive care medicine as well.2 Organisation of the service and patternsof referralTraditionally, the acute medical intake has beenmanaged by general physicians with an additionalinterest in a particular specialty, and such physicians arelikely to continue to provide the majority of theconsultant workforce in this situation for the immediatefuture. However, increasing numbers of acutephysicians are being trained and appointed to leadthe service and to develop alternatives to orthodoxcare.Most hospitals have now created specific units for theassessment and treatment of acute medical emergencies– a strategy supported by the National ConfidentialEnquiry into Patient Outcome and Death (NCEPOD). 4The Royal College of Physicians (RCP) recommendsthat the term AMU now be adopted for these facilities 2and the report of the RCP’s Acute Medicine Task Forceprovides a detailed description of the rationale andrequirements for AMUs. 2 Although small hospitals mayfunction successfully without such units, it has beenshown that, in larger hospitals, AMUs can enhance thequality of care for the acutely ill medical patient andfocus attention on the admission process itself. 5 AllC○ Royal College of Physicians 2013 17