Acute Med V10 N1.Qxd 16/02/2011 16:10 Page 3

Acute Medicine V10 N1_Acute Med V10 N1.qxd 16/02/2011 16:10 Page 3

Acute Medicine 2011; 10(1): 3-4 3 Guest Editorial

The Rebirth of General, ‘Acute’ Medicine: will the baby survive?

Professor Sir George Alberti

uring the 1980s and 1990s general medicine specialty. Unfortunately this was not the conclusion was progressively displaced by medical of the first working party! However, a subsequent D specialties as the major focus of a consultant group did indeed agree that the development of physician’s career. Fewer and fewer people were acute medicine was important, leading to the appointed as ‘general physicians with a specialist creation of Acute Medicine as a subspeciality of interest’, which had been the norm prior to this. GIM. Concerns were expressed that consultants Specialists whose main focus was their ‘ology’ were appointed to such posts would suffer burn-out; continuing to be expected to take their share of acute inevitably those appointed in the first waves were medical “takes”. Training for most medical also accredited in another speciality. A 4 year training specialties still encompassed training in General programme, which provided accreditation in GIM Internal Medicine (GIM). However, this often was with recognition of the subspeciality training in truncated in favour of the main specialty and was Acute Medicine was developed. Later, the even resented, by some, as interfering with their recognition of Acute Internal Medicine (AIM) as a “proper” training. None of this was surprising: speciality in its own right ensured the development medical specialties were becoming more complex & of a specific AIM curriculum with its own set of many more treatments, interventions and diagnostic competencies allowing dual accreditation with GIM. tools were becoming available. Simultaneously, working hours were decreasing, and training was taking place within a much more formalised Development of acute medical units… structure. The development of Acute Medical Units At the same time, concerns were being expressed (AMUs) has been a significant contributor to the about the care of acutely ill medical patients. Initial success of the speciality of acute medicine. care had traditionally been undertaken by very junior Historically, medical admissions were admitted to staff, supervised by registrars and senior registrars. In the ward of the admitting physician where there was the mid-1990s the Royal Colleges of Physicians frequently insufficient capacity for the number of (RCP) suggested strongly that the on-call consultant patients admitted. The remainder went wherever a should conduct a post-take ward round which, to be bed could be found - often on surgical wards with an fair to my colleagues, was already occurring in many inevitable impact on elective admissions. Nursing places. Nonetheless, care was often slow and at times care was often not tuned to acutely ill medical sub-optimal. Patients could be admitted to virtually patients and there were long pauses between visits by any bed in the hospital and ‘safari’ post-take ward the medical team. AMUs provided an environment rounds, encompassing patients on a variety of into which acutely ill medical patients and the different wards, were commonplace. In addition, the required staffing resources could be concentrated. traditional team structure was eroded by reductions Many incorporated a day-time emergency in working hours and the move towards shift assessment function for direct referral by GPs, working. Often the consultant ended up as the only preventing an unnecessary visit to the emergency person who knew where patients were. department (ED) and streamlining care. Clearly a paradigm shift was required. When I Over the past decade we have moved to a arrived at the RCP in 1997 there was very little focus position where virtually every acute admitting Professor Sir George Alberti , on general medicine, whilst specialties were well hospital in England has an AMU. This does not Senior Research catered for. At the same time there was government mean that all are yet fit for purpose, but this has Investigator, concern about the state of Emergency Departments, represented a major move in the right direction. The Imperial College, particularly the inordinate time that many patients AMU provides the ideal base for the acute physician London spent before being seen or admitted. The College set - indeed it is now difficult to envisage how the new President, Royal College of Physicians up a working party to examine acute medicine, breed of acute physician would function in the of London, 1997-2002 which I hoped would establish acute medicine as a absence of an AMU. George.alberti@ newcastle.ac.uk © 2011 Rila Publications Ltd. Acute Medicine V10 N1_Acute Med V10 N1.qxd 16/02/2011 16:10 Page 4

4 Acute Medicine 2011; 10(1): 3-4 The Rebirth of General, ‘Acute’ Medicine: will the baby survive?

The four-hour target… no other duties on that day and to provide a presence on The development of AMUs as a place and means to the AMU during daytime hours. Indeed, the RCP has focus services and to accelerate and improve early care of recently stated, unequivocally, that the physician medical emergencies was greatly assisted by the responsible for acute admissions should be on the AMU 12 introduction of the 4 hour ED target in the NHS Plan of hours a day on every day of the week, including Saturday 2000. It was clear from an early stage that “waiting for a and Sunday. This service needs to be provided by a bed” was a major reason for hospitals’ failure to meet the combination of acute physicians and other physicians target; focussing initial medical care in one inpatient area participating in the acute medical take. was likely to improve this. However, streamlining the whole acute care pathway was also necessary, with How far from medical ‘Valhalla’...? particular attention paid to discharges. The process was This all sounds eminently logical and should be the further accelerated by the creation of the Emergency target for every acute hospital. But how far are we from Services Collaborative in 2001, which was intended to this medical Valhalla? The short answer is - a long way! We facilitate achievement of the 4 hr target. The Collaborative are still, woefully short of consultants, both acute brought together a wide range of clinicians involved in physicians and other specialists who share acute duties. acute care, to enable sharing of ideas and innovations. Proper staffing of an AMU in a busy acute hospital requires 6 to 8 acute physicians. The RCP recommended The need for early consultant review…. that there should be 3 in every hospital by 2008 - and even In 2004 the RCP and Royal College of Surgeons this target has not been met. This was partly due to delays strongly recommended that decisions to discharge patients in establishing training programmes, but also because should be made by an experienced clinician early in the insufficient priority has been given to such appointments day and on 7 days per week. The same report stated that by acute Trusts. Nonetheless, movement is occurring & any acute medical patient admitted or referred from the most acute trusts now realise that an AMU cannot ED should be seen within 1 hour by an “experienced” function properly with only one or two acute physicians. physician (consultant or senior specialist registrar). This There is also the implication that if other physicians are represented a significant change from the way in which spending their entire take day doing only acute medicine most of us used to function. Previously the first person to then they will spend less time in their speciality & more see the patient was often the most junior member of the specialists will be required. The situation will not be team with subequent review by a registrar or senior improved by current financial constraints. registrar; consultant review would have been delayed until Despite the current challenges, there are reasonable the post-take round unless there was a major problem. I grounds for optimism. Acute physicians have an can indeed remember being reprimanded by the College irreplaceable niche. New roles have also been developed- visitors for doing a ‘mid-take’ round because this such as ambulatory care and emergency clinics. As interfered with training! It is, of course, obvious that the numbers grow, so pressure is removed from the sickest patients should see the more experienced physician consultants in other medical specialities. quickly, so that appropriate investigations are rapidly So will the baby survive? Much still remains to be done undertaken and treatment can be implemented. This to improve acute medical care. However, after a lengthy recommendation had wide ranging implications. It gestation and a difficult birth, acute medicine is now a required the physician on call for acute medicine to have rumbustious infant with a bright future.