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2 Specialties Acute internal medicine and general internal medicineDetailed recommendations for the implementation of7-day consultant working in the AMU are made in theRCP Acute care toolkit 4: 12-hour, 7-day consultantpresence on the acute medical unit. 15With the on-call consultant present in the hospital for12 hours daily, typical hours of work would be from8am to 8pm. During the working week, this predictableemergency work would represent three sessions of PAsin direct clinical care, mainly in non-premium time.Similar working on weekends and during holidays, inpremium time, would represent four sessions of PAs indirect clinical care.Consultant work patterns should include protectedsessional time for AMU work, ideally in blocks of days.Single-day rotas contribute to poor continuity of carebut 7-day blocks are considered too onerous. Precisework patterns should be developed to reflect local needs.All other clinical duties and responsibilities should becancelled for all clinical staff working on AMU orparticipating in the direct supervision of the acutemedical intake. 2,13 A consultant’s eligibility to continueparticipating in the acute take should be assessedannually during his or her appraisal. Theserecommendations are equally applicable where theintake is managed by an acute physician or by aphysician with another specialty interest who isqualified to lead the acute medical intake.The work of an acute physicianAcute medicine is a young discipline, and as such itsstyle of working is still in evolution. However, it isapparent that there is more opportunity for variety ofpractice in acute medicine than in many otherspecialties. Classic acute physicians will normally haveaccess only to beds on the AMU, where their patients’length of stay is usually limited to between 24 and 72hours. Acute physicians are therefore able to manage thetotal episode of care of patients who do not require alonger admission. Managing patients in the AMU, or itsrelated short-stay unit, is beneficial in minimising thenumber of ward-to-ward transfers which are disruptiveto care. The acute physician should also have time tomanage alternative strategies to admission, such asambulatory emergency care and rapid access clinics.In addition to work on the AMU, the RCP recognisesthe value of the acute physician in ensuring closerelationships with all medical specialties and withemergency medicine and critical care. 10,11 Sessionalwork in either of these fields would be appropriate foracute physicians who have the required competencies.Similarly, it may be appropriate for an acute physicianto retain an interest in another discipline in which he orshe has demonstrated the relevant competencies, such asthoracic medicine or gastroenterology, or in proceduressuch as echocardiography. This can be maintained bycontinuing sessional work in that field. Other modelsexist where a significantly greater proportion of workingtime is spent in another discipline or where there is acycle of differing activities, such as working for periodsof one or more weeks in acute medicine andsubsequently similar periods in another discipline.All acute physicians should have the competencies todeliver high dependency care to most patients withmedical needs defined as level 2 by the Intensive CareSociety. 8,25 In some hospitals, a medical highdependency unit could be embedded within the AMU. 2Inpatient workThe usual day-to-day work of an acute physician caninclude a formal contribution to the supervision of theacute medical intake as the sole responsible consultantfor a period of time. Alternatively, an acute physicianmight work together with another consultant, seekingthe more severely ill patients for early assessment orpatients suitable for management as short-stay orambulatory emergency care patients. Where a numberof acute physicians are in post, their contribution to thesupervision of the acute medical intake will obviouslybe greater.Outpatient workOutpatient work in acute medicine is divided betweenrapid access clinics, which usually offer same-day ornext-day appointments for selected patients, andambulatory emergency care. In the outpatient service,the numbers of patients seen should follow therecommendations for a number of specialties –approximately 30 minutes should be allocated for a newpatient and 15 minutes for a follow-up appointment. Inambulatory care, it is more difficult to define setnumbers because the patients managed in this way aremore varied.The work of a general physicianGeneral internal medicine is the origin of many medicalspecialties and is at the heart of physicians’ work. Thereare two components to the work of a general physician:the immediate care of the acutely ill medical patient andthe longer-term management of some of these patients.C○ Royal College of Physicians 2013 21
Consultant physicians working with patientsThe general physician needs the same core acute careskills as the acute physician and these have beendiscussed previously. The acute component of a generalphysician’s work is highly significant and, with thedevelopment of acute physicians working on the AMUduring the day, this work is increasingly taking placeoutside the normal working day. In 2004, the RCPrecommended that every district general hospital(DGH) should have a minimum of three acutephysicians. Given this workforce, even in a hospitalneeding only one physician involved in the acutemedical intake, more than half of the 24-hourconsultant cover for the intake will still need to beprovided by general physicians. This situation will ofcourse vary where hospitals have larger numbers ofadmissions or more acute physicians, but it remains thecase that it is unlikely that acute physicians will benumerous enough to provide all acute medical care inthe near future.The recommendation that hospitals undertaking theadmission of acutely ill medical patients should have aconsultant physician on site for at least 12 hours per day,7 days a week applies as much to general physicianswhen they are supervising the acute medical intake as itdoes to acute physicians. As out-of-hours activity ispredictable work, it should be recognised as such in theconsultant’s job plan and may attract compensatoryperiodsoftimeawayfromwork.Inpatient workThe development of the medical specialties has led tomany patients admitted with single organ disordersbeing transferred to specialist care as soon as ispracticable, because there is evidence that the outcomefor such patients is better under specialist care ratherthan generalist care. There remain, however, manypatients whose presentations do not meet the localcriteria for specialist care and these patients remainunder the care of general physicians. In practical terms,only a relatively small number of hospitals can offer carein all 30 medical specialties. Most DGHs will be able toprovide specialist care in the major specialties ofcardiology, gastroenterology, geriatric medicine,diabetes and endocrinology, and respiratory medicine,together with rheumatology and haematology. It is,however, unlikely that a typical DGH will havespecialists in neurology, renal medicine or infectiousdiseases based in the hospital. In the absence of thesespecialist services locally, care for patients withdisorders in these specialties must be delivered bygeneral physicians. In addition, the high frequency ofsome cardiac and respiratory conditions is such that allpatients with these relatively common disorders will notreceive specialist care when the severity of theseconditions is mild. These patients too will remain underthe care of general physicians. Lastly, it must beremembered that specialist care has been shown to bebeneficial where the patient has a single disorder. Thesame may not be true when patients have manycomorbidities, as is the case in elderly patients whomake up much of the intake. Such patients often have anumber of conditions including frailty and dementia. 5For all these reasons, there is a need to maintainphysicians with the relevant skills to be able to care forthese groups of patients.7 Opportunities for integrated careGood working relationships between acute medicalservices and social care services are essential if patientsare to avoid inappropriate or unduly prolonged stays inhospital. Early discharge can be facilitated by outreachservices from the hospital into the community, such as‘hospital at home’ schemes for patients with chronicobstructive pulmonary disease. Elderly patients canbenefit from the services of a hospital-basedre-ablement team or falls service working with the localsocial care services.8 Workforce requirements for acuteinternal medicineIn 2004, the RCP recommended that there should be acore group of acute physicians in every acute hospital totake primary responsibility for the organisation of theacute medicine service and the management of AMU.The recommendation was for at least three acutephysicians in every acute hospital by 2008. 1Subsequently the Working Group on Acute and InternalMedicine, 26 set up by the Joint Committee on HigherMedical Training (JCHMT), reported that a workforceof three acute physicians per acute hospital wouldrequire over 600 new consultant posts in the specialty ofAIM. The 2006 census of consultant physicians 27 foundthat there were 140 acute physicians in post at that time.By 2011, this number had increased to 295 28 but wasstill well short of the 2004 recommendation. Moreover,out of the 155 consultant appointments advertised inEngland and Wales in 2009, 60 were either cancelled orno appointment was made. This rate of 60% specialistsavailable suggests a shortage of acute medicine22 C○ Royal College of Physicians 2013
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