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2 Specialties Acute internal medicine and general internal medicineCertificate of Completion of Training (CCT) holders tofill consultant posts and supports the case for moretraining numbers in AIM, either as new posts or as postconversions. Despite these problems, AIM has remainedthe fastest growing medical specialty in the past 5 years.A workforce of three acute physicians per acute hospitalis clearly not able to provide all the consultant inputrequired to manage the acute medical intake, and in thissituation there will still be a need for consultantphysicians with specialist interests to be involved in theacute take. Some acute hospitals have, however,demonstrated their intention to employ larger numbersof acute physicians, with groups of six or seven beingappointed. If this trend is followed, then an average of 6acute physicians in each acute hospital would need aworkforce of over 1,300 acute physicians, but the needfor the continued involvement of other physicians in theacute take would be reduced and acute physicianstrained in both AIM and GIM could take part in thelonger-term care of inpatients. This would, however,demand even more training numbers in AIM.In planning workforce requirements, a consultantphysician should be expected to spend an average of 15minutes reviewing each patient after their formalassessment. 1,29 This should allow time for theconsultant on call to assess each new patient, review thecase and relevant documentation and talk to relatives.To this should be added time for opportunist teachingand the assessment of trainees using the ACAT.Time must also be allowed for the review of existingshort-stay patients on the AMU on post-take rounds.Thus in a typical extended working day, the consultanton call should be expected to review no more than 32new patients.Where attendances at the AMU are likely to exceed 32per 24 hours, there should be more than one consultanton duty and the number of consultants involved dailyon the AMU should reflect pro rata the number ofpatients expected to attend. 29 Consultant work programme/specimenjob planThe models recommended in Tables 1 and 2 should beregarded as standard with respect to the activities of aconsultant in acute medicine but may be altered byagreement according to local need.Table 1 Acute physician with no additional special interestActivity Workload per session SessionsDirect patient careAcute medical unit ward rounds or hot review sessionsRapid access clinicsAmbulatory care sessionsInvestigational sessions – eg endoscopyOther specialty sessionsSupporting professional activities (SPAs)Up to 32 new patients per 24 hours6 new or 12 old patientsVariableVariableVariable⎫⎪⎬6.5 sessions in total⎪⎭2.5 sessionsTable 2 Acute physician with a major additional special interest, including general internal medicineActivity Workload per session SessionsDirect patient careAMU ward rounds or hot review sessionsRapid-access clinicsAmbulatory care sessionsSecond specialtySupporting professional activities (SPAs)Up to 32 new patients per 24 hours6 new or 12 old patientsVariable⎫⎪⎬4 sessions in total⎪⎭3.5 sessions2.5 sessionsC○ Royal College of Physicians 2013 23
Consultant physicians working with patientsAll work programmes should conform to the RCP’schecklist for consultant job descriptions. 3010 Key points for commissionersAcute medical services1 Hospitals providing assessment and admission ofacutely ill medical patients should have AMUs orequivalent facilities (RCP, SAM, NCEPOD).2 AMUs should have defined medical and nursingleads, written operational policies and regular auditsincluding 24-hour mortality, 7-day readmission anddirect discharge rates.3 The consultant physician on call should be on site forat least 12 hours per day, 7 days a week, and shouldhave no other duties scheduled during this time.4 The consultant on call should review patients assoon as possible after their formal assessment hasbeen completed. During the working day this reviewshould take place within 6–8 hours of the patient’sadmission to the AMU. Patients admittedovernight should receive a consultant review within14 hours.5 The acute medicine service should offer alternativesto admission including rapid access outpatientclinics and an ambulatory emergency care service(RCP, SAM).General medical services1 Hospitals have a responsibility to provide enoughexperienced medical and nursing practitioners todeliver prompt high-quality care to all their patientsin facilities appropriate to their patients’ needs. Noprovider should provide any service that does notcomply with fundamental standards of service.2 It should be evident that general physicians haveused some of their CPD to acquire and maintainexpertise in the management of patients whosedisorders are not appropriate for specialist carewithin their hospitals. This could include, forinstance, neurological, renal or infectious diseases.3 A consultant physician should visit every medicalward daily, including at weekends, to addressproblems of patients already in hospital and shouldbe supported in this task by junior medical staff(RCP). This should be a priority duty in the firsthour of the working day – ‘golden hour’ review.4 Rapid access to imaging, laboratory tests and otherdiagnostic and support services is crucial and shouldbe available 7 days a week to inform treatment andfacilitate discharge (RCP, RCPEdin).5 Patientobservationsonallwardsshouldincludecontinuous evaluation by NEWS, with clearprotocols in place to escalate or redefine care on thebasis of these scores.References1 Royal College of Physicians. Acute medicine: making itwork for patients. Report of a working party. London: RCP,2004.2 Royal College of Physicians. Acute medical care: the rightperson, in the right setting – first time. Report of a workingparty. London: RCP, 2007.3 Federation of the Royal Colleges of Physicians of the UK.The physician of tomorrow. Curriculum for generalinternal medicine (acute medicine). London: RCP, 2007.4 National Confidential Enquiry into Patient Outcome andDeath. Emergency admissions: a journey in the rightdirection? A report of NCEPOD. London: NCEPOD, 2007.5 Moore S, Gemmell I, Almond S, et al. Impact of specialistcare on clinical outcomes for medical emergencies. ClinMed 2006;6:286–93.6 Society for Acute Medicine. Recommendations for medicalassessment (admission) units.Reportofaworkingparty.SAM, 2003.7 NHS Institute for Innovation and Improvement. Thedirectory of ambulatory emergency care for adults,3rdedition. London, 2012. www.institute.nhs.uk/option,com joomcart/Itemid,194/main page,document productinfo/products id,181.html8 Royal College of Physicians of Edinburgh. UK consensusstatement on acute medicine. Edinburgh: RCP Edin, 2008.www.rcpe.ac.uk/clinical-standards/standards/finalstatement-rcpe-consensus-conference-on-acutemedicine-nov-2008.pdf[Accessed 20 March 2013].9 Society for Acute Medicine. Guidelines for physiotherapyin medical assessment units. Reportofaworkingparty.SAM, 2004.10 Royal College of Physicians. Interface of accident andemergency and acute medicine.Reportofaworkingparty.London: RCP, 2002.11 Royal College of Physicians. Interface between acutegeneral medicine and critical care. Report of a workingparty. London: RCP, 2002.12 Houghton M. Acute medicine – an alternative take. ClinMed 2011;11:26–7.13 Royal College of Physicians. Council statement on acutemedical care out of hours. London: RCP, 2011.http://pressrelease.rcplondon.ac.uk/Archive/2010/Patients-deserve-better-out-of-hours-care-says-RCP-President [Accessed 20 March 2013].14 Royal College of Physicians. National Early WarningScore (NEWS): Standardising the assessment of acuteillness severity in the NHS. Report of a working party.24 C○ Royal College of Physicians 2013
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