Consultant physicians working with patients 5th edition - FSEM

All other clinical duties and responsibilities should be
cancelled for all clinical staff working on AMU or
participating in the direct supervision of the acute
medical intake. 2,15 Consultants should be involved in
the acute take at a minimum equivalent to one day per
month. These recommendations are equally applicable
where the intake is managed by an acute physician or
by a physician with another specialty interest who is
qualified to lead the acute medical intake.
The work of an acute physician
Acute medicine is a young discipline, and as such its
styleofworkingisstillinevolution.However,itis
apparent that there is more opportunity for variety of
practice in acute medicine than in many other
specialties. Classic acute physicians will normally have
access only to beds on the AMU, where their patients’
length of stay is usually limited to between 24 and
72 hours. Acute physicians are therefore able to manage
the total episode of care of patients who do not require
a longer admission. Managing patients in the AMU, or
its related short-stay unit, is beneficial in minimising the
number of ward-to-ward transfers that are disruptive
to care. The acute physician should also have time to
manage alternative strategies to admission, such as
ambulatory care and rapid access clinics.
In addition to work on the AMU, the RCP recognises
the value of the acute physician in ensuring close
relationships with all medical specialties and with
emergency medicine and critical care. 7,8 Sessional work
in either of these fields would be appropriate for acute
physicians who have the required competencies.
Similarly, it may be appropriate for an acute physician
to retain an interest in another discipline in which they
have demonstrated the relevant competencies, such as
thoracic medicine or gastroenterology, or in procedures
such as echocardiography. This can be maintained by
continuing sessional work in that field. Other models
exist where a significantly greater proportion of working
time is spent in another discipline or where there is a
cycle of differing activities such as working for periods
of one or more weeks in acute medicine and
subsequently similar periods in another discipline.
All acute physicians should have the competencies to
deliver high dependency care to most patients with
medical needs defined as Level 2 by the Intensive Care
Society. 21,22 In some hospitals, a medical high
dependency unit could be embedded within the AMU. 2
2 Specialties Acute medicine
Inpatient work
The usual day-to-day work of an acute physician can
include a formal contribution to the supervision of the
acute medical intake as the sole responsible consultant
for a period of time. Alternatively, an acute physician
might work together with another consultant, seeking
the more severely ill patients for early assessment or
patients suitable for management as short-stay or
ambulatory-care patients. Where a number of acute
physicians are in post, their contribution to the
supervision of the acute medical intake will obviously
be greater.
Outpatient work
Outpatient work in acute medicine is divided between
rapid-access clinics, which usually offer same-day or
next-day appointments for selected patients, and
ambulatory care. In the outpatient service, the numbers
of patients seen should follow the recommendations for
a number of specialties – approximately 30 minutes
should be allocated for a new patient and 15 minutes for
a follow-up appointment. In ambulatory care, it is more
difficult to define set numbers as the patients managed
in this way are more varied.
The work of a general physician
General internal medicine is the origin of many medical
specialties and is at the heart of physicians’ work. There
are two components to the work of a general physician;
the immediate care of the acutely ill medical patient
and the longer term management of some of these
patients. The general physician needs the same core
acute care skills as the acute physician and these have
been discussed previously. The acute component of a
general physician’s work is highly significant and, with
the development of acute physicians working on the
AMU during the day, this work is increasingly taking
place outside the normal working day. In 2004, the RCP
recommended that every district general hospital
(DGH) should have a minimum of three acute
physicians.Giventhisworkforce,eveninahospital
needing only one physician involved in the acute
medical intake, more than half of the 24-hour
consultant cover for the intake will still need to be
provided by general physicians. This situation will of
course vary where hospitals have larger numbers of
admissions or more acute physicians, but it remains the
case that it is unlikely that acute physicians will be
numerous enough to provide all acute medical care in
the near future.
C○ Royal College of Physicians 2011 21