A career in acute internal medicineBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h2704 (Published 01 June 2015) Cite this as: BMJ 2015;350:h2704
- Nick Smallwood, year 6 specialty trainee, East Surrey Hospital,
- Nigel Lane, consultant in acute internal medicine, North Bristol NHS Trust
Nick Smallwood and Nigel Lane describe what to expect from a career in acute internal medicine
Acute internal medicine (AIM) has evolved to deliver excellence in the diagnosis and treatment of all acute medical conditions. In time sensitive conditions where early intervention is paramount—such as stroke, sepsis, and acute kidney injury—AIM physicians can make a real difference to outcomes for patients.
AIM physicians provide the initial assessment, investigation, diagnosis, and management of patients during the first 72 hours of their hospital stay with an acute medical illness. This usually takes place on an acute medical unit. The specialty also provides expertise in the management of medical patients who can be cared for in an ambulatory setting (box 1). In practice, this means working at the front door of the hospital, in close collaboration with the emergency department and primary care teams, seeing most unscheduled medical attendances.
In addition to the assessment and admission of adult patients, AIM physicians have an important role in developing services to enable the safe delivery of care in an outpatient setting. Many patients previously admitted to hospital for investigation or treatment of conditions such as deep vein thrombosis, pulmonary embolism, and cellulitis can now be treated safely as outpatients with the help of AIM led ambulatory care services and follow-up clinics. Rapid access medical clinics also allow unwell patients access to consultant physicians and rapid diagnostics without admission to hospital.
As AIM is a developing specialty, and many acute medical units have a varied configuration and consultant presence, the role of the AIM physician varies from hospital to hospital. The AIM consultant must therefore have good leadership and management skills to develop services best suited to the local population.
The five year AIM with general internal medicine training programme entails experience in a wide variety of posts. Rotations in respiratory medicine, cardiology, elderly care, and critical care give the trainee a wide range of specialty experience, including considerable outpatient clinic experience. During this time, trainees will usually be on the standard general internal medicine on-call rota, which means they are on call as often as their registrar colleagues. Trainees on the acute medical unit will be involved in acute admissions, ambulatory care, rapid access medical and follow-up clinics, and with the care of inpatients who remain on the ward for their ongoing diagnosis and treatment. This ensures continuity of care for patients who require ongoing medical treatment.
A large number of procedures are undertaken as part of the acute care of patients, such as lumbar punctures, chest drains and aspirations, ascitic drains, and knee aspirations. AIM training teaches competence in all of these areas and also enables trainees to supervise junior colleagues who are keen to learn these skills. Many acute medical units have set up rooms where these procedures can be carried out in an ambulatory setting.
Trainees are given dedicated time to learn a specialist skill. This is a unique opportunity during higher specialist training when trainees have sessions set aside to explore an area of medicine of particular interest. This may take a number of forms: a procedural skill (for example, echocardiography, endoscopy, or bronchoscopy); leadership or management in the form of postgraduate diplomas or masters qualifications; or another area of medicine (such as palliative care, inpatient diabetes, or stroke medicine).
The career pathway
After graduation, trainees currently do two years of foundation training. They then have the option of two years of core medical training or three years on the acute care common stem (acute medicine). Either route will allow physicians to gain all the competencies required to enter AIM at specialty training year 3. By the time trainees apply for higher specialty training they must have achieved membership of the Royal College of Physicians (MRCP) part 1, and by the time they take up a specialty training year 3 post they must have successfully completed all parts of the MRCP diploma.
The AIM training programme is usually offered with training in general internal medicine as part of a five year programme. Single AIM accreditation may limit future employability but still provides a valid certification of completion of training. As well as successfully passing each annual review of competence progression throughout training, trainees must also complete the specialty certificate examination in acute medicine, offered once a year by the MRCP (currently in November). This is required by the certification of completion of training date but ideally should be achieved by the time of the penultimate year assessment. In theory, it can be taken at any time from year 1 of core training onwards, but it is recommended that it is taken in the first couple of years of higher specialist training.
Once specialist training is completed, trainees can apply for a consultant post. The number of consultant jobs currently outstrips the number of training posts, so job prospects now and for the future are excellent and allow some flexibility with job planning. Both teaching and district general hospitals employ AIM consultants, which means that trainees will have a good choice of posts throughout the country.
With a drive towards consultant led acute services seven days a week there will be an increasing number of AIM consultants delivering high quality care at the front door. Working evenings and weekends will mean compensatory days-off in the week. A drive for more care delivered in the community will be led by AIM physicians, who will develop and adapt pathways to serve the local population. The number of conditions safely managed by ambulatory emergency care will increase, while the increasing complexity of adult medical admissions means that the clinical skills of the acute physician will continue to be in high demand.
Box 1: Roles of the AIM physician
Prompt practical management of acute presentation of medical illness
Management of medical patients in an inpatient setting
Development of new patient pathways to maximise safe, effective care in the community where feasible
Provision of leadership skills within an acute medical unit
Development of multiprofessional systems to promote optimal patient care
Care of patients requiring more intensive levels of care than would be generally managed in a medical ward. These competencies are generally acquired from experience within a critical care unit
Adapted from the Joint Royal Colleges of Physicians Training Board website (Nov 2014)
Box 2: Possible positives and negatives of a career in AIM
Exposure to a wide range of medical conditions ensures variety of work each day
Primarily shift based work allowing flexible working patterns and good work-life balance
Great opportunities to introduce and develop new services and quality improvement
Expanding consultant body so there are excellent job opportunities for trainees
Specialist skills training encourages development of an area of expertise
Close working in a multidisciplinary team ensures that professional support is available
Ample opportunity for practical procedures, teaching, and supervision of junior colleagues
Developing specialty allows trainees to shape training and career as they want
Rapid access to consultant review means that most acute medical units discharge 30-40% of their acute admissions within 24 hours
Working at the front door can be a high pressure environment
Fast pace of AIM and high acuity of illness can be emotionally tiring
Continuity of care can be limited by the rapid throughput of patients
Move towards increasing consultant presence and seven day working is likely to require more antisocial hours at work
Box 3: Useful websites
Society for Acute Medicine—www.acutemedicine.org.uk
Royal College of Physicians—www.rcplondon.ac.uk/update/specialty-month-acute-medicine
Joint Royal College of Physicians Training Board acute internal medicine— www.jrcptb.org.uk/specialities/acute-medicine
Acute care common stem training information—www.accsuk.org.uk/index.htm
Competing interests: We have read and understood BMJ’s policy on declaration of interests and declare the following interests: None.