Acute medicine

Considering a career in acute medicine? Suresh Chandran makes a compelling case for this stimulating subspecialty

The past decade has seen dramatic changes in the provision of hospital medicine. One of the most important changes has been a new subspecialty-acute medicine. The speed of change and the considerable regional variation in enthusiasm for this concept has led to some confusion and misconceptions about training.

What's good about acute medicine?

• Wide spectrum of cases

• Excellent opportunity to hone the practical skills needed for managing acute medical emergencies

• Ability to learn an additional skill such as echocardiography, endoscopy, ultrasonography, or bronchoscopy

• Opportunities to develop fast track clinics (acute medical, rapid access chest pain, deep vein thromboses, and pulmonary emboli)

• Opportunities for research, developing patient pathways, and being involved in teaching

• Because it is a new and expanding specialty, increasing number of national training numbers (NTNs) will become available.

What do consultants in acute medicine do?

According to Mair Edmunds, medical director at University Hospitals Coventry and Warwickshire NHS Trust, the role of an acute medicine consultant involves:

• Maintaining seamless quality of patient care

• Clinical risk management as the interface between primary and secondary care

• A major educational role at all levels from undergraduate to postgraduate training

Most consultants in acute medicine have trained in other fields. In June 1999 in Southampton, Chris Roseveare, who originally trained in gastroenterology and general internal medicine, was one of the first UK consultants in acute medicine to be appointed. "I could see a clear need for trained clinicians to provide more hands on care as part of the general medical take," he told me. "I had always enjoyed my on-call days, and could not see myself spending the rest of my career in an outpatient clinic" (box 1).

Seven years on, Dr Roseveare still maintains two weekly endoscopy sessions, but has committed himself to a career as a consultant in acute medicine, directing training in acute medicine in Wessex and becoming treasurer of the Society for Acute Medicine. "When I started people told me I would burn out by the age of 40, but I still don't see this happening. It's horses for courses; provided you are happy in your work and appropriately supported by colleagues and your employer, I see this as a truly viable long term career choice."

Tempted to train?

A four year training programme using a competence based curriculum was approved in 2002. This aimed to provide the trainee with the necessary skills and competences to play a lead role in acute medicine.

In addition to experience in general internal medicine, trainees in acute medicine are expected to:

• Develop a specific practical skill such as echocardiography, abdominal ultrasonography, upper gastrointestinal endoscopy, or bronchoscopy
• Gain experience in a critical care setting including either the intensive care unit or the high dependency unit
• Gain experience of managerial roles in acute medical units.

There are more than 80 national training numbers in the United Kingdom, and the first certificate of completion of training has been awarded. Deaneries are being encouraged to provide more training places.

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No time to waste

What does the future hold?

When asked his view about the future, Dr Mike Jones, president of the Society for Acute Medicine said, "Acute medicine will continue to grow. The service requires good acute physicians at the front door (box 2). The physicians' royal colleges are very supportive of the specialty and Modernising Medical Careers (www.mmc.nhs.uk/pages/home) recognise that this area will require further development. The society is truly multidisciplinary and the membership continues to grow. The new curriculum will be presented to the Postgraduate Medical and Education Training Board in the near future and this should provide a very firm basis for acute medicine to become a very significant part of acute care in the health service."

Under the Modernising Medical Careers agenda, a run through structure for acute medicine has been proposed from August 2007 onwards. After selection during foundation year 2, trainees who complete their assessments in a satisfactory manner would not have to undergo a further selection process and would be expected to achieve a certificate of completion of training after a further five years of training.

Cut and thrust

Acute medicine provides an expanding range of opportunities for the prospective trainee. As one of the first specialist registrars to be appointed to an acute medicine training rotation, I would strongly recommend this field to anyone who is committed to a career in hospital medicine who enjoys the cut and thrust of the acute medical take. I strongly believe that this is the specialty of the future.