Consultant physicians working with patients The duties, responsibilit ies and practice of physicians in medicine Revised 5th edition 2013 (online update) Consultant physicians working with patients The duties, responsibilities and practice of physicians in medicine Revised 5th edition 2013 (online update) 1 Physicians in the NHS today 2 The work of the specialties 3 The Royal College of Physicians: supporting the delivery of high-quality care The Royal College of Physicians The Royal College of Physicians plays a leading role in the delivery of high-quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing more than 28,000 fellows and members worldwide, we advise and work with government, patients, allied healthcare professionals and the public to improve health and healthcare. Citation for this document: Royal College of Physicians. Consultant physicians working with patients, revised 5th edition (online update). London: RCP, 2013. Review date: 2015 Production Team Editor Linda Patterson OBE Project manager Urooj Asif Akhtar Copyright All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to reproduce any part of this publication should be addressed to the publisher. Copyright C Royal College of Physicians 2013 eISBN 978-1-86016-512-2 Royal College of Physicians 11 St Andrews Place Regent’s Park London NW1 4LE www.rcplondon.ac.uk Registered Charity No 210508 Typeset by Aptara Inc., India Contents Acknowledgements iv Foreword v Abbreviations vi 1 Physicians in the NHS today 1 2 The work of the specialties 15 Acute internal medicine and general internal medicine 17 Allergy 27 Audiovestibular medicine 35 Cardiovascular medicine and paediatric cardiology with adult congenital cardiology 47 Clinical genetics 59 Clinical neurophysiology 67 Clinical pharmacology and therapeutics 73 Dermatology 81 Diabetes and endocrinology 91 Gastroenterology and hepatology 99 Genitourinary medicine 111 Geriatric medicine 119 Haematology 127 Immunology 137 Infectious diseases and tropical medicine 145 Medical oncology 153 Medical ophthalmology 161 Metabolic medicine 167 Neurology 173 Nuclear medicine 181 Palliative medicine 189 Pharmaceutical medicine 199 Rehabilitation medicine 205 Renal medicine 213 Respiratory medicine 225 Rheumatology 235 Sport and exercise medicine 251 Stroke medicine 255 3 The Royal College of Physicians: supporting the delivery of high-quality care 263 C Royal College of Physicians 2013 iii Acknowledgements We would like to thank the following people who gave freely of their time and expertise. Their contributions to this edition were greatly valued. Sir Richard Thompson President Dr Patrick Cadigan Registrar Professor Tim Evans Former academic vice-president Dr Andrew Goddard Director, Medical Workforce Unit Dr Ian Starke Clinical director of revalidation Jane Ingham Director, Clinical Standards Dr Kevin Stewart Director, Clinical Effectiveness and Evaluation Unit Dr Ian Mungall Director, Invited Service Reviews Professor John Williams Clinical director, Health Informatics Unit Winnie Wade Director, Education Department Professor David Worrell Director, International Office Professor Bill Burr Medical director, Joint Royal College of Physicians Training Board Joanna Reid Managing editor, Corporate Communications and Publishing team iv C Royal College of Physicians 2013 Foreword The revised fifth edition of Consultant physicians working with patients is more relevant than ever, as it coincides with the major change in commissioning arrangements in England. I hope that the information contained here on service organisation and standards, workload, job plans and the role of the Royal College of Physicians in supporting these activities will also be of particular value to clinical commissioning groups as they take up their new role. To support the commissioning process, the RCP has developed a clinical commissioning hub on its website, containing all the elements of its work that can contribute to commissioning decisions – clinical guidelines, audit results, quality improvement programmes, and information relating to all 30 medical specialties covered by the RCP. Each specialty chapter of this book contains major recommendations specifically for commissioners. Further information on the role of the Royal College of Physicians and the clinical commissioning hub can be found on our website (www.rcplondon.ac.uk). This information is also relevant to the planning processes in the devolved nations. Consultant physicians working with patients will also help individual physicians and clinical teams demonstrate how the structures and resources described here will result in high-quality patient care, which is vital at a time when the NHS faces major financial constraints. We underline the importance of multidisciplinary team working, not just within the hospital, but stretching out across primary, community and social care, to support integrated care for patients and bring care ‘closer to home’. I am enormously grateful to all those who have contributed, and in particular to our clinical vice-president Dr Linda Patterson OBE, and to Urooj Akhtar, who has quietly and efficiently put it all together. June 2013 Sir Richard Thompson President, Royal College of Physicians C Royal College of Physicians 2013 v Abbreviations A&E accident and emergency AACs Advisory Appointment Committees KBA knowledge-based assessment AMUs acute medicine units LAT locum appointment for training ARCP Annual Review of Competence MAU medical admissions unit Progression MDT multidisciplinary team CCGs clinical commissioning groups MINAP Myocardial Infarction Audit Project CCST Certificate of Completion of Specialist mini-CEX mini clinical evaluation exercise Training MMC Modernising Medical Careers CCT Certificate of Completion of Training MRC Medical Research Council CEEU Clinical Effectiveness and Evaluation MTAS Medical Training Application Service Unit NCGC National Clinical Guideline Centre CESR Certificates of Eligibility for Specialist NHDs notional half days Registration NHS National Health Service CMO chief medical officer NICE National Institute for Health and Care CMT Core Medical Training Excellence CPD continuing professional development NSFs National Service Frameworks CQC Care Quality Commission NTN national training numbers DFID Department for International OoHMT Out-of-Hours Medical Team Development PAs programmed activities DGH district general hospital PACES Practical Assessment of Clinical DH Department of Health Examination Skills DOPS directly observed procedural skills PbR Payment by Results EWTD European Working Time Directive PCN Patient and Carer Network GIM general internal medicine PGDs patient group directions GMC General Medical Council PIU Patient Involvement Unit GPwSI general practitioner with a special PMETB Postgraduate Medical Education and interest Training Board GSF Gold Standards Framework PwSIs practitioners with a special interest HDU high dependency unit RITA Record of In-Training Assessment HES Hospital Episode Statistics SAC specialist advisory committee HIU Health Informatics Unit SAS staff and associate specialists HPA Health Protection Agency SPAs supporting professional activities HWDU Health and Work Development Unit StR specialty registrar ICUs intensive care units WHO World Health Organization IOG Improving Outcomes Guidance WTE whole-time equivalent JRCPTB Joint Royal College of Physicians Training Board Note: this edition uses the terminology specialty registrar (StR) to update the term specialist registrar (SpR). vi C Royal College of Physicians 2013 1 Physicians in the NHS today 1 Physicians in the NHS today The unique skill of the consultant physician is the ability We are also committed to reducing harm, from alcohol, to diagnose and make clinical decisions in difficult, tobacco, obesity, health inequalities and climate change. complex and uncertain circumstances. Development of this skill takes comprehensive and thorough learning, Consultant physicians have several roles. We are time and experience. It is more than a collection of pre-eminently clinicians working with individual competencies. It reflects, individually and collectively, a patients. We practise in clinical teams both as leaders culture of striving for excellence that has been built up and as members. We learn, teach and research. As over centuries. doctors our main responsibility is to our patients. But it is the exercise of additional activities and roles that The Royal College of Physicians (RCP) supports this supports standards of excellence. practice with education, training, continuing professional development (CPD) and quality Doctors in society: medical professionalism in a changing improvement. It sets and measures standards and works world2 describes the moral and ethical context of with other bodies to ensure that consultants practise the medical practice: highest standards of medical care and constantly strive to improve practice. Medical professionalism signifies a set of values, behaviours, and relationships that underpins the trust The RCP has a vision of