Sunday, July 9, 2017

Full circle?

Lets start this blog with a simple request. If you are an Acute Physician, then you are welcome to respond as long as you don't take this personally. Its a blog where I ask a few questions with a general physician hat on. Its a question about a specialty from a fellow colleague- who is a bit torn between its function in the present NHS structures…anyway, here goes!

Acute Medicine is seen as a specialty- and in my mind, so far, it has been that too. A separate entity existing on a similar footing to my own specialty. However, as time has progressed, I have started having second thoughts- is it anything different from general medicine? Lets start from where we were- the days before any acute units happened. Admitting team saw patient from ED or GP-and they looked after them through their journey. Then came the era of specialism. Cardiology peeled off, followed by others. Acute medicine appeared- bound by the walls of their unit or hours post admission. Suddenly general medicine was no longer we all did. We had divided general medicine into small little convenient parts- the initial, acute bit (acute medicine), the single organ bits (specialism) and the rest which no one quite wanted to do. Elderly care physicians carried on regardless - while rest of medicine withdrew into their silos- leaving a few carrying on this ethereal beast called general medicine- stripped off its acute or specialist bits- a former pale shadow of its self.

As time progressed, the system realised that no one quite wanted to do general medicine- and the brakes started to apply-in a desperate bid to bring back generalism. The College has gone full tilt at it- creating a variety of opinions- and existing folks who left general medicine because of a variety of reasons (don't need to be at front door as acute physicians are here- OR - don't need to do general medicine on wards as specialist patients to look after) started to feel disgruntled at the fact of being asked to go back to the "olden days".

If you break it down, very simply- there are basically 2 models of care. Hospitals run entirely by acute physicians and elderly care physicians with in reach from specialists OR everyone pitches in and helps out. Problem with model A? Not enough of acute physicians. Problem with model B? Not many want to do it- and when you don't want to do something, questions start to rise. What is it acute medicine is contributing if all of "us" are back where we started before acute medicine came into being?

Beyond that, there also arises a simple question- acute medicine - granted- is indeed a specialty with a skill mix. The question is what is it that differentiates it from what used to be called general medicine? Is it just the 1st few days of it or something entirely different? Is it something only trained folks can do- or is it that anyone can do? If anyone with GIM training can do, then that makes it GIM, doesn't it? Lets take that thinking further- when I see a patient, I ask for a specialist opinion when there is something i am not trained in to the extreme degree, beyond the initial assessment, resuscitation etc. I can think of many such examples in Cardiology or Gastroenterology. What is it in acute medicine? What will the patient have for which I will call an acute physician- something I cant do as a general physician? Its a tricky one- and frankly, I haven't found the answer yet.

At the moment, the call is for all to pitch in and help (model B-as above) but if I am doing the exact same work as a present acute physician does, what makes it different from my work as a general physician? I know for a fact that I wouldn't ask any one else to do an insulin pump clinic- what is the equivalent in acute medicine- or does it not exist? Is there a need for acute medicine to step forward and define their roles- or are we heading back to a full circle where we all do the together- and we are all called general physicians?

As said at the very beginning, this blog is an effort to raise debate and ask questions- not to cast doubt. I am open to being questioned about the role and existence of my own specialism- what is the equivalent in acute medicine?


  1. I'm an Acute Physician. I've spent my registrar training dedicated to the early, acute management of the unwell adult patient. I've had experience in gastro, resp, cardio, elderly care, ITU at SpR grade and have a reasonable understanding of them all. This I think helps to make me an expert generalist. I'm very comfortable in resus and peri-arrest scenarios and enjoy the buzz of acute care. I passionately believe that I offer more to the majority of acute admissions than many GIM 'trained' specialists who dabble in the take occasionally.

    I liken it to the idea that all Cardiology Consultants must still be competent at echo just because they once held British Society of Echocardiography qualifications as a registrar. Sure, they could give it a good go. And probably wouldn't make many major mistakes. But would I want them doing my echo if they didn't do it day-in, day-out anymore? Absolutely not!
    In the same way, just because GIM physicians once did the take as a registrar I don't think that means that years down the line they should consider themselves as competent or up to date as someone who has dedicated their registrar or consultant career to it.
    Of course, AIM is much more than the take. I suggest without AIM many DVTs would continue to be admitted, as would all PEs. Cellulitis would probably still be an inpatient condition. Ambulatory Care is a sea change in how patients can and should be managed - I could go on.
    It may be difficult for me to pin down the exact patient that you may ask for my opinion on as an Acute Physician, but that doesn't make me feel my expertise are any less valid than other specialists or that I add any less to patient care.

    1. Nick- you are absolutely correct. The question thereby becomes - if its a specialist skill, which clearly it is- then why does the view get perpetuated that anyone can cover AMU at any time? Is that due to resource (we are waiting for the cavalry to come) or a perceived misnomer from powers that be?
      Back to the main qs: does AMU need to define areas which without training others shouldn't venture into- as its not right for patients?

    2. Hi. I too an a acute physician and can I also add the role of the acute physicians as an advocate for the acute medical patient and best practice in the acute area. By taking ownership of this space and being passionate about patient care in the acute areas the medical patient is not stranded at the whim of which medical teams turn it is to do the acute take. Admission AVOIDANCE is also key in our remit and the ongoing emerging role of ambulatory emergency medicine as a means of managing patients comes with the need for its own consultants experienced & confident in discharging patients that traditionally would have been admitted. And finally, good acute physicians try to interface with our primary care colleagues to again facilitate best care.
      If acute medicine and AMUs did not exist, there would be no group of physicians taking ownership of the entire acute medicine patient pool and the pathways in and out if the acute setting. Many thanks.

    3. If AMU didnt exist…isn't that what we had when all did have ownership and ran hospitals?

  2. Provocative blog. There are a couple of points you make that we’d like to elaborate on.

    It’s true that a Consultant can practice acute medicine, as long as they have general medicine training. But that is because there isn’t the workforce to fill the demand. As you know acute medicine is a young specialty, therefore there isn’t the number of trained acute physicians required; hence, the plugging of this gap by clinicians trained in general medicine is a short term fix. Before the emergence of Emergency medicine as a specialty, general practitioners and surgeons did this important function. No-one would argue that this means Emergency Medicine is not a distinct specialty in its own right.

    With regard to asking for an opinion from the specialty of acute medicine. Again I refer you back to the analogy of Emergency Medicine. As a general physician, you wouldn’t ask for an opinion from an ED doctor – that doesn’t mean it is not worthy of being a specialty.

    As acute medicine trainees we spend a time in cardiology, respiratory medicine, elderly care and intensive care working the level of a registrar. Most general medicine training does not include that. The ethos and culture of acute medicine is also different from general medicine – anecdotal evidence from our training suggests that general physicians tend to ask for more specialist reviews and take longer to discharge a patient compared to a physician with acute medicine training or mindset.

    Also acute medical units benefits from acute physicians, acute medicine nurses, OTs and Physios working together. An occasional visiting general medicine physician cannot create or sustain those relationships.

    In the UK we do not have general internal medicine as a pure specialty. It is specialist with general medicine training. Work by Weingarten et al. 2002, Arch Intern Med suggest that specialists order more inappropriate tests, and have an increased cost of care and increased mortality.

    I suggest spending time with an acute physician to see if your views are borne out.

    Tehmeena Khan & Shamim Nasally

    1. Thank you for your post- and you are both absolutely right. The query I have is this- its indeed a specialty- so why does the system perpetuate the myth that "anyone can do it?" Is that not harmful in the long run? There is no question about role acute medics have and will continue to play- but system thinking needs to be different with areas such as X,Y,Z whereby you have to be trained in certain areas to do it- otherwise not. Perhaps the clear definition of the role would help stop the thinking- we went through this in diabetes many years back- and took years to correct. It seems acute medicine could enter the same sphere- which is unwanted IMO.
      Finally? I do actually spend a fair time in acute units- as part of my job plan- the distinction appears to be blurred by the day

  3. As a geriatrician who works (now, since recent retirement, occasionally as a locum) in an acute geriatric assessment unit, may I put in my two pence worth?

    Firstly, another problem with 'model A' is that there are not enough geriatricians, either, to sustain it.

    Secondly, there is good evidence (see Cochrane review via*) that comprehensive geriatric assessment - the iterative, interdisciplinary and multi-dimensional assessment process - especially if based on a geographical unit (ie not 'roving') improves outcomes, both in terms of function and mortality.

    The danger of implementing a 'good idea' in medicine, without a good evidence base, is that it proves either mistaken, costly, or both. See many attempts to treat (other than in hyper-acute situations) heart failure with positive inotropes. Great idea, but it kills people!

    Second example: the push in the 90s to train a cohort of cardiac surgeons to deal with patients dying on CABG waiting lists. Just as they started emerging from their training, percutaneous techniques rendered them redundant.

    Thus Mencken's aphorism: 'There is an obvious simple solution to each complex problem ... that is invariably wrong' may be apparent here. Quick fix solutions to long term problems are highly unlikely to prove cost effectiveness, or high value medicine. Increased activity, and higher throughput, certainly - but this is not necessarily (and I would argue necessarily not) the best way to manage frail older patients. This demographic constitutes the majority of acute admissions; medication problems account for some 10% of acute admissions, and older, multimorbid, patients are more at risk of polypharmacy. Geriatricians are also expert at planning early discharge (and admission avoidance) and community management, in a non-risk averse way.

    Long term, strategic, approaches are needed to address these challenges. Comprehensive geriatric assessment, together with the 'slow medicine' movement, although not sexy, might provide more cost-effective solutions. Usually, new interventions are subjected to proper trials before general implementation, why not here?

    We are woefully short of geriatricians, but the history of NHS planning in general (and workforce planning in particular( doesn't fill me with that much hope!

  4. Sorry, omitted CGA reference here:

  5. GPs should be the second arm of general medicine, along with the Geriatricians but at present the skills aren't there. It can be very frustrating from a primary care perspective to get a patient a proper comprehensive outpatient (or even inpatient, sadly) work-up, with too few specialists confident in reaching outside of their narrow remit, resulting in more and more unnecessary (often unhelpful) opinions. I'm afraid that this is includes many Acute medics, who are super at the acute stuff but - unsurprisingly - less good at the complex long term or even medium term diagnoses and treatments. (DOI - GP with SI in Gerries).

  6. OK. Declaration of interest first-I am an Acute physician, a little late to the party here, sognipostes to your blog by Prof Oliver's BMJ article.

    The question you repeatedly pose is "why does the system perpetuate the myth that anyone can do it". The answer is within your blog; there aren't enough Acute Physicians yet so we need the bodies to do the job, and someone with GIM qualifications can run an MAU adequately - clearly there are variations within that, some excellent, some would explicitly rather be on their ward.

    I can titrate insulin, I can manage a hyperthyroid patient, I can (and have) diagnose Addison's disease; I can do none of these things as well as an endocrinologist.

    An endocrinologist can treat cellulitis on an ambulatory basis, differentiate the NEAD from the atypical TLE, and then the patient with PAF to see if it's safe to use flecainide...but not as well as a trained Acute Physician.

    1. Thank you- so in short, we seem to agree- that "un-trained" folks are asked to do acute medicine- as there is a shortage. As regards specialty bit you mention, lets put it this way- when I am struggling to fill a gap regards a pump or pituitary clinic, I don't ask an acute med to do the role. The vice versa isn't however applicable at the moment. And finally, the case you mention? Comfortably as well as anyone else.

    2. If the test of a specialty is "can someone else do it adequately and safely?" then A(I)M maybe fails the test. I agree that a G(I)M physician can do an A(I)M shift reasonably well, and often does. Maybe this is unique among the specialties.

      But why not allow an exception? Change your test to "can someone else do it well, safely, and efficiently?" and you find that G(I)M physicians lag behind:

      - A(I)M know the rapid access clinics; G(I)M keep the patient in for review tomorrow
      - A(I)M know the ambulatory pathways; G(I)M keep the patient for inpatient treatment
      - A(I)M are a little bit more in touch than the specialists in their silos - more likely than anyone else (except cardiologists) to think about a CT aortogram, more likely than anyone else (except neurologists) to think about venous sinuses.

      A(I)M are the engine room of guidelines. Fed up with specialists coming down and sniping? Get those specialists to write a guideline (if they can't or won't then at least stop complaining). When was the last time gastro asked cardiology for a guideline on ACS?

      A new consultant has sufficient medical knowledge from their registrar training. But later, as specialists they will also be judged on the organisation and development of their department. Who other than A(I)M will do that for the admissions unit?

      Bottom line is, you want people interested in the AMU to be on the AMU, and what's wrong with calling them acute medics?