Caring for and about acute general medicine

British Medical Journal, June 26, 1999

Expansion in consultant numbers is needed

EDITOR--Forgacs's review provides an excellent picture of the unpleasant reality of acute medicine, as practised at present.[1] The Royal College of Physicians is well aware of the need to cost future improvements in increasing the number of hospital doctors and to provide evidence of the likely benefits. The latter will be a difficult task but must be tackled. Indeed, a working group of the three Royal Colleges of Physicians is currently reviewing all aspects of the problems regarding acute medicine.

As chairman of the group which produced the document "Consultant physicians working for patients" and main author,[2] I (JDW) can assure readers that I have had experience, on many occasions, of handling more than 20 acutely ill patients during a 94 hour period of acute medicine as a general physician in Sheffield. Our working group realises that hundreds more consultants tomorrow and much smaller numbers of "take patients" is unrealistic. We do know from several sources that doctors are working 14-16 sessions per week and close to a 60 hour week. We know that consultation times in outpatient departments have been pared to the bone. We know that clinical governance in all its guises will place further demands on consultants. If we do not state our requirements now for an expansion in the number of consultants we will never achieve improvements.

[1] Forgacs I. Caring for and about acute general medicine. BMJ 1999;318:73-4. (9 January.)

[2] Alberti KGMM, Bell J, Goodman M, London D, Wales J, Ward JD. Consultant physicians working for patients. Part I: a blueprint for effective hospital practice. J R Coll Physicians Lond 1998;32:suppl.

K G M M Alberti President J D Ward Vice president Royal College of Physicians of London, London NW1 4LE

Specialists should not be expected to practise general medicine

EDITOR--Forgacs says that there is a pressing need to evaluate the quality of emergency medical care and the demands it makes on those who deliver it.[1]

I retired from the NHS almost seven years ago. My official title was consultant physician and gastroenterologist, and throughout my career as a consultant I took my turn on the on-take rota. However, I stopped seeing general medical patients in outpatients many years ago and over time felt increasingly insecure regarding my non-gastro-enterological inpatients. I can only hope that, largely owing to the input of a succession of very well informed medical registrars, the general medical patients who were admitted in my name received better than average care.

I am saying nothing new when I suggest that with the need for specialists to know more and more they cannot do justice to the general field where over time they will inevitably know less and less. It is unrealistic to believe otherwise.

It is unfair to specialist consultants and to their patients to continue to expect the former to practise general medicine, and to admit such patients as part of their on-call responsibilities. There are alternative approaches.

[1] Forgacs I. Caring for and about acute general medicine. BMJ 1999;318:73-4. (9 January.)

KFR Schiller Emeritus consultant The Mill, Cuddesdon, Oxford OX44 9HQ

Imaginative solutions are required

EDITOR--I disagree with Forgacs's comments relating to partial shifts.[1] The Royal College of Physicians's survey revealed general dissatisfaction with partial shifts, but the survey was carried out in 1997 and reflects the period before this, when many partial shifts were in their infancy.[2] My own experience of a partial shift was much more positive, with the morale of both junior and senior doctors remaining high despite typically large numbers of admissions. Importantly, our partial shift had been in place for several years and was implemented and subsequently adjusted with input from consultants and juniors. Support for the view that partial shifts, like good wine, can improve with age comes from a recent study by Kapur.[3]

Forgacs cites a frequent criticism of partial shifts, that they reduce continuity and consequently the quality of care. True continuity of care would require an individual or team of doctors to provide cover 24 hours a day, 365 days a year. Currently, under the traditional rota system, patients are looked after by a small number of junior doctors for about 70% of the time. These doctors are unlikely to have met or discussed most patients before taking over their care. Consequently, I question whether continuity of care has ever existed. Would a system involving defined periods of care with structured hand-over not be better?

Despite the good intentions behind "continuity of care" our reluctance to abandon this mythical concept is limiting our ability to deliver acute medical care in the most efficient way. Only by ridding ourselves of the "continuity of care albatross" can doctors meet the challenge of providing a high quality acute medical service while coping with the changes outlined by Forgacs. Imaginative solutions, including partial shifts, should be considered when the long overdue national audit of emergency medical care finally takes place.