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

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