Volume 12, Issue 2, Pages 65 – 124 (2013)

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.