Editorial

Much has been written in recent months about the challenges at the hospital’s front door; emergency departments and acute medical units have found themselves in the spotlight, while politicians and clinical leaders have debated where the causes for this crisis lie. As summer progresses and we continue to search for solutions, it is likely that some of the focus will shift from the emergency department to the processes of care which take place after a patient has been admitted. The Royal College of Physicians’ long awaited Future Hospital Commission report will be published later in the year; a key theme in this document is going to be the importance of continuity of care for patients in hospitals, ensuring the minimum numbers of patient transfers both within the hospital and between consultants. Inevitably this will open a key debate over the role of the ‘generalist’ in hospitals of the future. The last decade has seen a steady drift away from generalism, with increasing numbers of hospital clinicians retreating into their speciality enclaves, and withdrawing from the acute medical take. For some patients speciality-led care has been shown to be highly effective; however there remain significant numbers of patients whose problems cannot be neatly packaged into a single organ category. Acute physicians have taken on the management of this group of patients within the acute medical unit (AMU), but who should provide ongoing general medical care for patients who are transferred out of the Unit? A recent survey of members of the Society for Acute Medicine (SAM) has confirmed that the overwhelming majority of existing acute medicine consultants are accredited in General Internal Medicine (GIM), while a similar proportion of current acute medicine trainees expect to attain a certificate of completed training in GIM. Provided that hospitals can secure adequate numbers of new consultant appointments, acute physicians will be ideally placed to provide continuity of care for this patient group. The survey, which will soon be published on the SAM website, also indicates that most acute physicians would be happy to provide this service, as long as it was appropriately resourced and supported; furthermore a substantial proportion viewed a combination of GIM and acute medicine as their preferred model for their future job plan. Inevitably, staffing levels will be key to whether acute physicians can branch out of the AMU. There appears to be no lack of enthusiasm amongst hospitals to expand numbers of acute physicians, with vacancies being advertised on a weekly basis across the UK. However a shortage of doctors completing acute medicine training in 2013, due in part to curriculum changes in 2009, means that many of these posts are remaining unfilled. It is clear that much work clearly remains to be done on our acute medical units to ensure that we achieve the high standards which SAM has published. By the time this edition is published, data for the second Society for Acute Medicine Benchmarking Audit (’SAMBA 2013’) will already have been collected. Results of last year’s baseline audit are presented in this edition, and highlight a number of areas in which acute medical units needed to improve. Delays in the initial assessment of patients and consultant review are likely to have reflected the well recognised, and ongoing imbalance between demand and workforce; however it is encouraging to note that almost all patients underwent appropriate observations to enable calculation of an early warning score. Access to investigations for pulmonary embolism and upper gastrointestinal bleeding also appeared to be constrained to a greater degree than CT scan for suspected stroke, which may reflect the relative priorities often afforded to these conditions. It should be noted that the data were collected on a Wednesday – weekend access to investigations remains an even greater challenge in many centres. Those who are regular users of Twitter and other social media will no doubt be aware of their increasing range of medical uses. In the third of a triad of articles which this journal has published on sepsis, Luke McMenemin and colleagues have highlighted how Twitter might be used in future to help disseminate and identify innovative medical solutions to common clinical challenges. Delays in the publication of traditional written media mean that broad implementation sometimes lags behind the innovation; as a consequence, there may be a tendency to ‘reinvent the wheel’ rather than learning from others’ experience. Twitter clearly has its limitations – the 140 character limit is a tough ask for even the most succinct of writers – but with an increasing numbers of users, perhaps the time has come for more acute physicians to take the plunge!