The main problems of the extension of the Acute Physician to immediate
management of the medical patient centre around duplication. If you're going
to have both acute physicians and EPs looking after the same sort of
patient, then you need double the numbers. Working on the basis that you
want readily available consultant assessment of every critically ill patient
(which in many departments implies resident), you'll need a lot of
consultants to get this. There's also a bit of an issue with trainees- there
aren't that many doctors who want to commit to having a job that centres
around coming in in the early hours for sick patients. If you split that
number between two specialities (or if ITU emerges, three), then there may
not be enough good candidates to go around.
To the speciality, of course, use of "acute physicians" to deal with the
sicker patients in A and E could be seen as a threat. Previous presidents of
the RCP have suggested that the role of A and E is to deal with minor
injuries (and the smallish amount of major trauma that is still found in the
UK). Other countries have what are essentially "casualty departments".
Removing the medical emergencies from emergency medicine would be disastrous
for the speciality in terms of image and recruitment; and would be a gross
waste of skills.
I wasn't entirely sure of the run of the paper, though. I note they said
that these acute physicians need not have MRCP. This suggests a certain
degree of overlap, with medical emergencies being covered by a composite
rota of EPs with an interest in acute medicine and acute physicians with an
interest in EM. This seems eminently sensible as it would use the skills
already available in a more efficient way (reducing the duplication one
finds at present where sick patient gets treated by a different person and
in a different way depending on where they are in the hospital rather than
on their clinical condition); and would allow development of skills by those
with an interest regardless of initial speciality background (and is also
likely to be the only way "Hospital at Night" can be workable in the long
term).
Matt Dunn
Warwick
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