Is it time for a new kind of hospital physician?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e2240 (Published 04 April 2012) Cite this as: BMJ 2012;344:e2240
All rapid responses
As a geriatrician who attends on a general medical teaching team located in the Emergency Department, I welcome the stance of Temple et al. that the growth in the numbers of frail older adults who present with acute illness requires that hospitals focus on providing care which meets their needs. An emphasis on the need for generalism, and a recommendation for repatriation of some subspecialty resources, strikes me as remarkable and deserving re-emphasis.
A central problem appears to be that we have come to build acute hospital care on the idea of single system illness. Such hospitals prefer that patients have only one thing acutely wrong at a time, should be well enough otherwise to fend for themselves and should have good social support. To meet this ideal, we continue to train physicians whose skills commonly are irrelevant to most of the people who actually get sick. Such subspecialists now are in relative over-supply compared with generalist physicians.
Going forward, we must train all doctors in the minimum skill set needed to care with competence and enthusiasm for patients with multiple, interacting medical and social problems, especially when they are acutely ill. Ensuring that we offer essential geriatric medicine skills should be the priority if the "future hospital" is to serve future sick people.
Competing interests: No competing interests
We agree that the time has come to think of a new breed of hospital physician. This will be most noticeable in the surgical and orthopaedic wards.With the increase in geriatric population in these wards the medical care is needed as a routine ratherbthan waiting for referrals. They will also help the patients to be at their optimal levels of health in the perioperative period. They will also be discharged sooner with less complications.
Competing interests: No competing interests
The British Geriatrics Society (BGS) represents the largest of the physician specialties in the UK. We are working closely with colleagues in the RCP London in their enquiry into the shape of the future hospital. No one group of doctors is likely to be the complete answer to the many complex patients that pass through the doors of our acute hospitals in increasing numbers each year. However, we do agree with Temple et al that further deployment of geriatricians and geriatric training in other multidisciplinary teams has an evidence base that indicates that this would provide a likely benefit, improving continuity of care and clinical outcomes to those older people that make up the majority of these complex admissions. It will be important that geriatric medicine and acute medicine specialists work closely together to define appropriate new systems in the coming years.
Competing interests: No competing interests
A focus on how we deliver of the most acute stages of hospital care (1) is important in a world where those presenting as acute medical admissions are most likely to be older and to suffer from multi-morbidity, frailty and polypharmacy. It is particularly timely as a recent Cochrane review demonstrates striking efficiency of the acute geriatric medicine model, with substantial reductions in death, disability and institutionalization compared to general medicine (2).
It is disappointing that the perspective of this editorial and accompanying paper (3) appear not only agnostic of this evidence but also to dismiss a leading role for geriatric medicine and universal training in geriatric medicine for doctors of all specialties in responding to this combination of complexity and acuity. Age-attuning the acute medical system is a critical success factor in responding to this challenge.
A wider perspective on developments in Europe affords us more encouragement in terms of enlightened approaches in a number of countries – Ireland, Belgium, Austria and Switzerland – which have formally incorporated significant geriatrician input as critical to the development of acute medical services, and other countries such as Finland are in the process of incorporating such measures. In addition, some hospitalists in the USA have recognized the value of a joint approach with geriatric medicine with promising results (4).
Barriers remain to ensuring expertise, particularly low rates of reimbursement in some countries with procedure-related payment (5), and the persistence of an unhappy and unscientific dilettantism among some physicians, the ‘we all look after older patients’ syndrome.
That there are low numbers of geriatricians in some countries should be a prompt for urgent development of the specialty rather than by-passing an important locus of gerontological and practical expertise in acute medical care. Not all older patients can, will, or need to be looked after by geriatricians: but the least they should expect is that those who provide their care have training and competence in geriatric medicine as a core element of their training (6), that geriatricians are involved in the design and delivery of their acute medical services, and that they have due access to consultation with specialists in geriatric medicine and old age psychiatry.
References
1. Temple RM, Kirthi V, Patterson LJ. Is it time for a new kind of hospital physician? BMJ 2012;344:e2240.
2. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011;343:d6553.
3. Wachter RM, Bell D. Renaissance of hospital generalists. BMJ. 2012;344:e652.
4. Merel SE, McCormick W. Geriatricians and hospitalists: opportunities for partnership. J Am Geriatr Soc 2010;58:1803-5.
5. American Geriatrics Society. Five Reasons Health Reform Helps Older Americans. New York: American Geriatrics Society, 2010.
6. Demanding dignity, and competence, in older people's care. Lancet 2012;379(9819):868.
Competing interests: No competing interests
Temple et al rightly say we need to look forward and not back to solve the issues of ever expanding medical takes overwhelmed with complex, elderly patients.
Expecting the "med reg" to run the whole hospital is potentially unsafe and increasingly unviable. Unwell medical patients want, need and deserve rapid and frequent consultant input, and there is increasing evidence that this improves outcomes.
As someone with dual CCST in geriatric and general medicine, I recognise the two are clearly distinct. It would be simplistic to suggest that more geriatricians can be anything other than part of a solution.
In my view the relegation in the UK of general internal medicine accreditation to an "add-on" competency additional to a CCT in another specialty has been a huge mistake, compounding the decline of general medicine as a distinct entity.
Acute medicine as a specialty solves some of the issues, but not those of ongoing management and continuity, particularly for a patient population with multiple chronic problems.
The solution seems clear to me - reinstate a CCT in GIM, with a curriculum appropriate for the 21st century, and create meaningful consultant jobs in general medicine. It's time to put the general physician back at the heart of the hospital, not picking up the scraps left by other specialties.
Competing interests: No competing interests
We read the article by Temple et al (BMJ 2012; 344 doi: 10.1136/bmj.e2240) with interest, who make a timely suggestion of defining physicians in the lines of Hospitalists and Office Physicians. This will be much more compliant with their lifestyle choices rather than the rather ambiguous distinction between generalists and specialists (to use an analogy from cricket: a bowler from a Test Cricket team is likely to be a better batsman compared to an average 'specialist' batsman from the 4th division local village league!).
In keeping with Temple et al.'s suggestion of reviving high quality General (Internal) Medicine and to deliver successfully on the efficiency challenge that the health service faces, our view is that:
1. It is absolutely essential to distinguish between Hospitalists and Office Physicians
2. Preferentially those Office Physicians should be encouraged to practice in hospital who deliver the QIPP (Quality Innovation Productivity Prevention) agenda on Long Term Conditions, i.e.
a. 25% reduction in LOS
b. 20% reduction in unscheduled care utilisation
c. 20% reduction in readmission rates
(more on http://www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPPworkstream...).
All other Office Physicians should be encouraged to work directly in Primary Care. We have got excellent examples of a select group of such Office Physicians in the health service, who have already voluntarily given up some Programmed Activities, enabling the recruitment of high quality Hospitalist colleagues.
Also, it is high time that training programmes are broadened in such directions as suggested by Temple et al., so that all trainees receive a foundation of exposure to health care management and health services delivery, enabling them to participate as informedcitizens in the systems in which they work and learn and future physicians are better equipped to interpolate themselves in the wider context of the whole health economy.
Competing interests: No competing interests
The authors rightly describe the increase in the provision of care by acute medical units, which they attribute to a combination of increasing costs, the need to provide quality care, and the restriction in junior doctors' hours. However, I would argue that the real reason for this increase is actually the rising burdens of older, sicker patients, coupled with the 4-hour A&E target that was instituted by previous governments. This resulted in hospitals having to move patients from the emergency department to an inpatient bed for treatment before the arbitrary time-limit of 4 hours was reached. In many other countries, a patient might be seen and treated in the emergency department within in the acute period and discharged before needing to be moved to another inpatient area. I have worked with colleagues from Australia who have come to the UK and have expressed confusion over the purpose of the acute medical unit, which they see as an unnecessary development.
Competing interests: No competing interests
Re: Is it time for a new kind of hospital physician?
The rapid responses have eloquently underscored the key point of the editorial - it is urgently necessary that acute hospitals are transformed to become fit, safe and effective providers of acute care for older people. This means recognising frailty and multi-morbidity and the associated geriatric syndromes as core issues. Falls, delirium, loss of functional abilty etc are relatively preventable adverse events affecting patients in medical and surgical services.
Clinical trial evidence has shown that exceptional effort and innovation can make an impact but what's also needed is a re-orientation of practice at a "whole hospital" level. The principles need embedding in generic physician (and nurse) teaching and training, but progress can be made now by interspecialty collaboration in service delivery and clinical governance. Unfortunately traditional management structures and commissioning patterns are constraints to the transformations needed, so leadership from health professionals is vital.
Recent improvement in hip fracture care and outcomes as demonstrated by the National Hip Fracture Database (www.nhfd.org.uk) is an example of what can be achieved by geriatricians, orthopaedic surgeons, anaesthetists and specialist nurses working together towards shared standards, armed with reliable data. Surgery rates are growing fastest in the oldest patients and the BGS has now established an interspecialty interest group to address "The Proactive care of Older People undergoing Surgery (POPS)" Shortly we will be publishing quality standards for care of older people with urgent and emergency care needs "the Silver Book", in partnership with the College of Emergency Medicine and many other partners. Delivering these standards in practice in an age-attuned healthcare system is everybody's business but geriatricians, and enough of them, are vital to success.
Competing interests: Member of the RCP London Future Hospital Commission, and Co-chair of the National Hip Fracture Database