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What does the future hold for acute medicine?

I didn’t train in acute medicine. In 1994, when I started ‘specialist’ training, this was not an option. The idea, back then, that consultants be trained specifically to manage and run the medical ‘take’ was as alien as the sight of a consultant clerking a patient on the ward. Medical take was the responsibility of the on-call medical registrar. The consultant was available for moral support, and possibly for the admission of royalty or an A-list TV personality, but was certainly not a ‘hands on’ presence.

On my first day as a medical registrar I led the post-take ward round with two ‘juniors’. I was not fazed by this – after all I had been an SHO in a DGH for 2 years and had passed my MRCP two months earlier; medical take was easy….or so I thought. I traded my white coat for a pin-striped suit to ensure that nobody doubted my credentials and off I went. If I had known then half of what I have learned since, I suspect I would not have been quite so confident in my abilities.

It is hard to believe how much has changed in the intervening 17 years. Nobody wears a suit now – ‘bare below the elbows’ made sure of that – and every patient gets a consultant review within 24 hours. In some hospitals, the consultant will see patients within minutes of their arrival and there is increasing pressure to provide this level of care seven days per week.

This will require a considerable increase in the numbers of hours of consultant time devoted to acute medical care, but who will be providing this? Will it be the new breed of full-time, trained ‘acute physicians’ or an ongoing responsibility for doctors trained in other medical specialities, dually accredited in general medicine?

Let’s consider the numbers – a seven day, 12 hours per day, consultant-led service, as recently proposed by the Royal College of Physicians, would require at least seven full-time acute physicians; double this if an overnight presence were also required. Over a thousand new appointments at a time when the NHS is tightening its belt? I think not.

There will be many acute medicine consultant appointments over the next few years; most of these will go to trainees who have completed an acute medicine training programme. A full-time acute physician can lead and develop the service and should provide value for money in their daily role on the AMU. However, in reality most hospitals will have to rely on ‘general’ physicians participating in the acute take for the foreseeable future.

So, would I recommend junior doctors to train in acute medicine? Unequivocallyyes’. If you want to be an acute physician the training is designed to prepare you for the role. I have filled in many of the gaps from my general medicine training in the 12 years since I was appointed, but I am envious of the experience which our current trainees (and my recently appointed acute medicine-trained colleague) have been able to attain.

As yet there are no data to prove that a trained acute physician is more effective on the AMU than a dually accredited specialist/general physician, but I suspect this will come with time. In the meantime a balance needs to be maintained – general and acute physicians, working side-by-side, is a model which is likely to continue and should be supported.

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One Response to “What does the future hold for acute medicine?”

  1. Malcolm Morrison says:

    An excellent assessment of the present and future needs for acute ‘medicine’.
    The same principles apply to Accident and Emergency surgery.
    Retired Orthopod

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