Is it time for a new kind of hospital physician?

Today’s consultant physician manages inpatients who are older and have more comorbidities and a greater complexity of acute illness than in the past. Since the inception of the NHS in 1948, life expectancy in the United Kingdom has increased by 18% and 16.7% for men and women, respectively.1 Half of those aged over 60 years have at least one chronic illness, and this proportion will increase over the next 20 years as the population aged over 85 doubles.2 These demographic shifts place increasing strain on a service that is required to deliver £20bn (€24bn; $32bn) of efficiency savings by 2014.

In a linked article (doi:10.1136/bmj.e652), Wachter and Bell describe the transformation of the organisation of hospital care in the United States and UK over the past 15 years.3 Although changes in US and UK hospital care have been shaped by the structure and culture of the respective healthcare systems, common drivers of change include increasing costs, a need to provide quality care, and restricted resident (US) and junior doctor (UK) hours. The result in both systems is strikingly similar; a new cadre of generalist physicians who are equipped to meet the complex acute care needs and changing demographics of patients newly admitted to hospital has emerged. Wachter and Bell draw attention to the emerging body of research showing that care delivered by hospitalists in the US reduces length of stay and costs, with a variable impact on quality of care,4 while in the UK, delivery of care by acute medical units has been associated with reduced mortality and duration of hospital stay.5

Fundamental differences and questions remain, however. The US hospitalist provides continuity of care throughout the admission, whereas acute physicians in the UK provide care up to the first 48-72 hours, after which patients who are still in hospital are handed over to another doctor. Furthermore, unlike in the US, the UK model encompasses two kinds of hospital based generalist: doctors who provide general internal medicine alongside their subspecialty and geriatricians who specialise in the care of older people. These geriatricians represent the largest single cohort of medical consultants in the UK—1201 in 2010.6 Although subspecialty physicians make an important contribution to generalist service provision, general internal medicine as a career path is declining in popularity in the UK. In 2010, 60.5% of doctors from the six major medical subspecialties practised general internal medicine, down from 76.1% in 2002.6 Currently 3838 (54.4%) medical registrars are registered for dual accreditation in general internal medicine and a subspecialty, but of these only 1597 would wish to practise general internal medicine on becoming a consultant.7 The unpopularity of consultant general internal medicine practice has been attributed to increasing service requirements and out of hours care.7 Other factors probably include an unselected workload, lack of specialist prestige, the breadth of medical knowledge that is needed, and disproportionate depletion of the ward team owing to on-call duties and training accreditation based on the acute medical unit. The main concerns reported by general internal medicine trainees about their training are inflexible training posts, burgeoning workload and rising levels of sickness in junior doctors.7 The on-call general internal medicine registrar is widely viewed as being overburdened by duties that include managing acutely ill patients both throughout the hospital and on the acute medical unit, and 80% of recently qualified doctors report this workload to be “unmanageable” or “very unmanageable.”8

Health services that have championed medical specialism must now meet the care requirements of older patients, which increasingly fail to align to a single system specialty when patients present with an acute illness. In the context of the recent reports of undignified and inhumane standards of care in hospital, the question of how well equipped the NHS is to care for older patients has never been more relevant.9 Does the US model, whereby generalist hospitalists deliver continuity of care throughout a patient’s admission, offer particular benefits for acutely ill older patients? Geriatricians in the UK have the right set of skills to care routinely for complex older patients—from admission to the acute medical unit through to discharge—but their number is insufficient to meet the needs. Rather than the expertise of a geriatrician being available only if there is sufficient capacity on a specialist ward, it would make sense to embed a geriatrician on the acute medical unit alongside geriatric services to improve delivery of existing geriatric expertise to patients. Moreover, extending acute physician care beyond the acute medical unit to medical and surgical wards may improve patient outcomes and reduce length of stay, as it has done on the acute medical unit.

In the UK and in Europe,10 doctors trained in general internal medicine are most similar to the US hospitalist model because they provide continuing care to inpatients who are not managed by subspecialty care. Although the early assignment of patients to subspecialist care achieves better patient outcomes for specific conditions, data on this approach for older adults are much less convincing.11 Most patients admitted as a medical emergency in the UK may now benefit from continuing care from a generalist, with subspecialists taking a consulting and interventional role. In such a scenario, subspecialties would retain specialty registrar trainees but release other trainees to generalist teams. This would amount to a redeployment of trainee doctors, and, with a renewed emphasis on acquisition of the skills necessary to manage the changing demography of patients within a ward based team, may help re-enthuse trainees and consultants.12

The evidence base for best practice in organising acute care pathways is limited, which has prompted the Royal College of Physicians, London, to launch a commission on the “future hospital,” which is due to report in spring 2013. Ongoing evaluation of services and research is crucial to determining the nature of working patterns, skills, and expertise of doctors that would have the greatest impact on patient outcomes. We all have an interest in ensuring that the next generation of doctors is equipped and organised to meet the requirements of older patients.