Editor – Kirthi et al (Clin Med August 2012 pp316–9) argue a case for the management of emergency-admitted medical patients by general physicians. There is, however, evidence that patients with a range of acute problems including coronary artery disease, stroke, asthma, acute upper gastro-intestinal bleeding and ulcerative colitis all have better outcomes when looked after by relevant specialists.1–4 Moreover it seems illogical that we might condone a system in which patients who are well enough to come to an outpatient clinic will be seen by a relevant specialist whereas those who are so ill that they require emergency admission will not. We have shown in Liverpool that changing the system for hospital medical admissions from care by general physicians (with a specialty interest) to one in which patients have their initial care on an acute medical unit followed by early transfer to the appropriate specialty team reduced mortality significantly for those aged under 65.3 Kirthi points out that this did not improve mortality for those aged over 65, but nor did it worsen it. Older patients with multiple pathologies should surely be appropriately looked after by specialists in the care of the elderly medicine who are likely to be better able to deal effectively with the complexities of their medical and social care. We have more recently demonstrated, in a prospective assessment of medical admissions to our Acute Medical Unit (AMU) with a primary gastroenterology problem, that specialist gastroenterology consultant review within 24 hours of admission increased the proportion of patients who were discharged direct from the AMU from 3% to 23%.
A return to general internal medicine as a specialty to provide care for acutely admitted patients might be an appropriate solution for a small hospital serving an isolated rural community, but as a general model of care we think it would be a retrograde step. Seven-day cover by the acute medical specialties, which should include care of the elderly and acute medicine expanded appropriately, would, we feel, be a much better way forward. Moreover it will be very difficult to establish seven day consultant working for the acute medical specialties if they are going to be encouraged to participate at the same time in seven day rotas for general internal medicine.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2013 Royal College of Physicians
References
In patient care: should the general physician now take charge?
We agree with Collins et al. about the importance of specialist pathways in delivering improved outcomes and high quality care to medical patients admitted as emergencies with clearly defined conditions, including stroke and myocardial infarction.
The focus of our article was on the delivery of care to older in-patients with multiple co-morbidities and whether generalists, particularly geriatricians and general internal medicine (GIM) physicians, should have a greater role in their ongoing care. Despite the rise in the proportion of elderly frail patients admitted on the acute medical take in the last two decades, postgraduate medical training has remained largely centred on single organ system specialism.
Our concern is for those patients aged over 80, who may comprise up to a third of the acute medical take and whose presenting problems often do not fit neatly within a single-organ-defined medical specialty. The pressure on acute medical services is such that many of these patients are allocated to the first available bed in a specialist medical ward loosely aligned to their perceived major illness. However, in this ward setting there is little tolerance of GIM problems1 and a continuing risk of transfer out to another ward (and clinical team) to make way for patients deemed more appropriate for the specialist bed. It is not uncommon for older patients to be moved up to four or five times during a hospital admission, causing considerable distress and compromising patient safety, with each transfer adding up to two days to the length of stay2. Physicians report that lack of continuity of care is their principle concern, trumping budgetary constraints and staff shortages3.
The changing profile of hospital inpatients requires health services that have championed increasingly specialised medicine to evolve to meet the care needs of the rising numbers of older patients. Organising care so that a generalist (ideally a geriatrician or alternatively a GIM physician) can consistently ‘take charge’ of continuing care in this cohort of elderly, vulnerable in-patients, would deliver more holistic, safer care and shorter lengths of stay.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2013 Royal College of Physicians
References
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