Re: Renaissance of hospital generalists
The recent article by Wachter and Bell1 and associated commentary by Temple et al2 outlines very clearly the need for a review of the care of in patients in acute hospitals in the UK. The lead author Dr Wachter has provided a significant lead in the US with the introduction of the Hospitalist and this is mirrored by the enthusiasm of the authors from the Royal College of Physicians of London for the ‘generalist’ model of care. The closest analogy in the UK to the genesis of the Hospitalist movement in the US has been the development of Acute Internal Medicine (AIM).
The expansion of this new speciality has been dramatic: There are currently over 450 consultant acute physicians in the UK and almost 350 trainees following the higher specialist training curriculum in AIM. As Wachter and Bell indicate, the restriction on training spaces has limited the expansion of AIM but the service continues to demand more of such doctors with new consultant posts being advertised each week. As AIM has developed there have been a number of supportive documents produced, especially from the Royal Colleges of Physicians.
The Acute Medicine Task Force report3 in 2007, suggested that acute physicians should provide care for patients with acute medical illness both within the hospital in addition to those who have presented to the acute medical unit from the community. As most trainees now aim for a dual CCT in AIM and General Internal Medicine (GIM) we believe that Acute Physicians can provide the solution to the need for more generalists. The AIM curriculum4 demands acquisition of competences for the care of the acute medical patient but also recognises care of the surgical patient with medical needs and there are on-going discussions to introduce obstetric medicine as a special skill within the AIM curriculum. We recognise clearly the need for specialist care of hospital in-patients including that provided by specialists in Medicine for the Elderly. Indeed the significance of expertise in managing older patients’ needs will become an increasingly important aspect of hospital medicine over the coming years. The AIM training curriculum requires that all trainees undertake a period of specific training in elderly care medicine, as well as cardiology, respiratory medicine and critical care, complementing the expertise provided by specialists in these areas.
Specialist acute physicians who have undertaken dual training in AIM / GIM are ideally placed to provide the general medical care of acutely unwell patients throughout their hospital stay. Increased emphasis should be given to combined training programmes in AIM/GIM in order to generate the required numbers of consultants in this growing speciality.
1 Wachter RM and Bell D. Renaissance of hospital generalists BMJ 2012;344:e652
2. Temple RM, Kirthi V, Patterson LJ. Is it time for a new kind of hospital physician? BMJ 2012;344:e2240
3. Acute Medical Care. The right person in the right place - first time. Report of the Acute Medicine Task Force October 2007 RCPLondon
4. Acute Internal Medicine curriculum 2009. Joint Royal Colleges of Physicians Training Board
Competing interests: No competing interests