Acute medicine: past, present, and future.

‘‘O ver the past few years there has been a growing realisation that there is a need for a senior medical presence in Medical Assessment and Admission units (MAUs). This has been manifest by the large number of appointments that have been made to MAUs at Consultant and other levels’’. A significant point in the development of acute medicine was marked on 3 July 2003. It was the day when the Specialist Training Authority recognised acute medicine as a subspecialty of general (internal) medicine (G(I)M) and subsequently trainees have been appointed to specialist registrar programmes for higher training in both G(I)M and acute medicine. The development of acute medicine however has a much longer history. There was a time when all physicians were expected to be competent in both the immediate and subsequent management of all common medical disorders, and thus were general physicians. However, fascination with the disorders of particular organ systems resulted in many clinicians developing more specific expertise and becoming ‘‘specialists’’. Formalisation of medical training in the 1970s defined specialty training, and facilitated the development of the physician with special interest in a particular specialty. With specialisation came the development of specialist societies and many physicians became more committed to their specialties than to the generalities of the acute intake. The creation of specialties within medicine should have raised concerns about the ability of specialists in one specialty to deliver the best care to patients suffering from the acute disorders of another specialty, but as the physicians involved in the acute intake practised general medicine as well as their specialty, it was assumed that acute medical care in all situations could still be delivered by all physicians. Acute medicine thus remained part of G(I)M and the Royal Colleges have always emphasised the importance of G(I)M in this regard. Gradually it became evident that specialist care of acute medical conditions yielded better outcomes than did nonspecialist care, but the organisation of healthcare provision in the UK made it virtually impossible to provide parallel specialist intakes in all fields of medicine, even in the largest hospitals, and thus most patients admitted acutely continue to come under the care of consultants not necessarily specialising in their presenting conditions. Furthermore, the concept of the physician as ‘‘consultant’’ has meant that the immediate delivery of the majority of acute medical care has been by doctors in training, with senior consultation. Despite this, there have always been physicians deeply interested in the management of medical emergencies, and educational events targeting this area are almost always over-subscribed. The direct involvement of consultant physicians in the process of the acute medical intake has increased over time, driven in part by the interest of some, but also the perceived inappropriateness by many, of the most seriously ill patients being managed for long periods of time by junior doctors without early consultant involvement. In many areas however, consultant physicians remained uninvolved in the immediate care and resuscitation of emergency admissions, and the quality of care of the acutely ill medical patient has been questioned in a number of forums, including the Journal of Accident and Emergency Medicine. In truth only the increased presence of appropriately trained consultant physicians at the front door of medicine could bring the quality change that was needed. From this background developed the subspecialty of acute medicine. A key development was the introduction of dedicated areas for the reception of emergency medical admissions. Traditionally emergency medical admissions had been admitted to the ward of the physician on call, but with the inexorable rise in the numbers of emergency admissions, ward based admissions were lost, with patients being admitted initially to any available medical bed, and later to virtually any bed in the hospital. The inefficiency of this process, with the admitting team spending almost as much time rushing from ward to ward as with their patients, had to be resolved. Medical admission units (MAUs) helped this resolution. MAUs however also provided a location for the practice of acute medicine, and those interested tended to gravitate towards them, while those not interested drifted away. This was true of both nursing and medical staff. There then evolved a number of new models of consultant involvement, starting with the duty consultant cancelling fixed commitments to do a formal post-take round, to cancelling commitments on part or all of the day of admission—physician of the day, to cancelling commitments for a prolonged period—physician of the week or part week. Ultimately came the development of the physician who had little or no inpatient bed holding other than on the MAU—the consultant physician in acute medicine. Subsequently, Trusts have found particularly attractive the ability of consultant physicians in acute medicine to use ambulatory care to provide the ‘‘bed equivalents’’ described by Derek Wanless in The Review of Health and Social Care in Wales. This entails the care of patients as outpatients, with early and frequent review, who would previously have been managed as inpatients. Ambulatory care is clearly an important aspect of acute medicine, and has helped cope with the problem of lack of capacity to accommodate emergency medical admissions. This is, however, only one aspect of the discipline and improving the quality of care of patients admitted as medical emergencies is equally important. The consultant physician in acute medicine provides expertise in the best initial care; as good as that of the appropriate specialist, but limited to a maximum of the first 48 hours of care, by which time triage to the appropriate specialty should have taken place. Acute medicine first caught the eye of the Royal Colleges in 1998 when the Scottish Colleges reported on The Future of General Medicine and Acute Medical Admissions. Subsequently a working party was set up by the Federation of Medical Royal Colleges, chaired by Professor Carol Black, to examine the role of the physician in acute medicine. This included representation from emergency medicine, both on the working party itself and among those giving evidence (Richard Hardern and Roger Evans) and reported in 2000. The conclusions of this working party seemed discouraging to those favouring the rapid development of acute medicine, 652 EDITORIALS