Acute Medicine is a new specialty in UK which acts as buffer zone between Hospitals and Emergency Medicine Department


Acute Medicine is a new specialty in UK
which acts as buffer zone between Hospitals
and Emergency Medicine Department

UK plans to have one thousand Acute Medicine
Specialists by 2018 - Dr. Fraz Mir

From our correspondent

LAHORE: Acute Medicine is a new specialty in UK. It acts as a buffer zone between hospitals and emergency medicine department. It was established as a separate entity in 2003 and by 2018 the government wishes to have one thousand trained Acute Medicine specialists in UK. This was stated by Dr. Fraz Arif Mir Associate International Director South Asia of Royal College of Physicians London. He was making a presentation on “Acute Medicine- an aging specialty in modern healthcare” at Azra Naheed Medical College, Lahore on October 9th 2014 during his recent visit to Pakistan. The meeting was very well attended by faculty members of AZNMC, some senior Fellows and Members of RCP London besides medical students.

Dr. Fraz Mir

In his introductory remarks Dr. Fraz Mir referred to the reluctance of the West to interact with Pakistani physicians and Pakistan. I have received tremendous warmth in Pakistan and I wish that my colleagues in UK should come here and experience this warmth. Due to lack of interaction between us, you have suffered, patients in Pakistan have suffered and we in UK have suffered as well because we used to learn from you. It is a disaster for all of us and let us join hands to reverse this trend in the coming months. Patient care and quality of care in Pakistan is very dear to the Royal Colleges, he remarked.

Picture on left shows Prof. M. Akbar Chaudhary along with Prof. Mahmood Ali Malik presenting
a certificate to Dr. Fraz Mir after his presentation on Acute Medicine at AZNMC while on right
Dr. Fraz Mir is presenting a memento to Prof. Akbar Chaudhary
on behalf of Royal College of Physicians London.

Speaking about Acute Medicine, what it is and how it is run in UK, Dr. Fraz Mir said that we do not have general physicians and people have to be trained in organ based medicine like cardiology etc., but first they do medicine. At present there is a huge gap in general medicine. Acute medicine physician deals with immediate and early seventy two hours of care of the patient. In general medical clinics we have acute medicine unit and we run ambulatory care where we have medical assessment units. Ambulatory care has links with the primary care physicians so that less and less number of patients comes to the hospitals. Other special interests of acute medicine physicians will include teaching, training and research, IHD, cardiac arrhythmias, DVT, diabetic complications, cerebrovascular diseases like stroke, COPD, Asthma, Sepsis, acute infections etc. but they are not emergency physicians but general physicians. Emergency Physicians see all sorts of patients including surgery. General Medicine is a subspecialty of general internal medicine. Critical care and emergency medicine are included but it is similar to general medicine. So far there has been increasing subspecialty or organ based medical disciplines. The General Medicine specialists do not exist any more and we do not see them. In UK the government has decided for four hours target and within this time the patient coming to the emergency must be attended to. Once when one of the war veterans spent forty two hours waiting to be seen in the trolley, there was lot of adverse publicity in the media and the patient described it as the worst experience than the blitz itself. Since then waiting time for the patients in emergency has been reduced and it aims at disposal of patients within four hours. Acute medicine aims at making it work for the patients. All emergency departments, Dr. Fraz Mir said should have senior consultant level physicians to look after the patients.

Tracing the history Dr. Fraz Mir said that general medicine started as a specialty in 1993 but it was in 2003 that acute medicine was formally established and from 2003-2010 we have four hundred fifty Acute Medicine specialists. Giving a pictorial journey of acute medicine, Dr. Fraz Mir said that when the patient comes to the emergency department, it is seen by triage nurse who does basic investigations and refer the patients to different hospital areas. Surgeons do not see patients without CT scan. It is the elderly frail patients who come to the physicians. Acute Medicine Unit has High Dependency Unit (HDU), monitoring facilities, nurse lead facilities. Acute physician have one hundred to hundred fifty beds and the senior leader takes ward round twice daily. The unit has dedicated area for high dependency and the target it that the patient is out of the hospital within four hours and referred to ambulatory care services. These patients have access to allied healthcare professionals like physiotherapists who continue to see them in their homes. Some of these patients are senile and elderly. Ambulatory emergency care aims at delivering same day emergency care. It works as a rapid exit clinic. In UK DVT patients are seen by the nurses, they assess the risk of anticoagulation. Patients come daily, take their medicines and go home. Most of these patients suffering from DVT, atrial tachycardia, heart failure, syncope, low risk GI bleeds, pleural effusion are not admitted. There are facilities for rapid elderly care assessment. They are all taken care and they go home. The aim is to keep people out of the hospitals. Establishment of these acute care units has resulted in 6% reduction in mortality, reduction in hospital stay, 40-60% reduction in admission rate. Patients in UK, Dr. Fraz Mir opined wish to be treated at home rather than at the hospital. Giving details of training in acute medicine, Dr. Fraz Mir said that fresh medical graduates complete their Foundation Year One and Two and then continue. They commence their medical training working at Senior House Officer Level for two to three years and pass their MRCP examination. They see directly observed procedures. Then doctors are certified to be trained. The consultants as well as the patients also watch them working. There are case based discussions. Every trainee has to get referrals from four consultants with whom they have worked. It is a confidential report. Then the authorities get feed back from all those with whom you have worked from doctors to junior staff how you see patients. It is a complete feedback and it happens with every trainee in UK every year. It is now with the committee which is looking at revalidation. As regards specialists training, doctors have to work for three to seven years depending upon the requirements of the specialty concerned and it is only after successful completion of this training period that one becomes a specialist.


Associate International Director South Asia of Royal College of Physicians London Dr. Fraz Mir during
his recent visit to Pakistan also made a presentation on Acute Medicine at AZNMC on October 9th 2014.
Picture taken on the occasion shows Dr. Fraz Mir, Prof. M. Akbar Chaudhry and
Prof. Shahid Mahmood speaking on the occasion.

 As regards specialty skills in acute medicine, one can get training in Echo, GI, opt for Diploma or Masters, select a specialty of interest or go for Research. E learning is also very good. There is lot of variety but diagnosis is the most interesting and challenging part, he remarked. Acute medicine has its own pros and cons. While it offers higher job satisfaction and well respected role in the hospital, all specialists do what they are good at but it also requires hard work and it can be stressful. Australia and New Zealand has also started acute medicine units. In fact acute medicine is still evolving and the future is uncertain. Almost 20-25% of positions of Trainees and faculty positions are vacant at present. More people are now coming to general medicine by gong away from early sub-specialization. Patients are living longer and there is more liaisons with primary care and research. Acute medicine takes care of the local needs and protects patients from the excesses of private medicine and sub specialization. Patients are at the mercy of acute care physicians and not sub-specialists. A patient after diagnosis of myocardial infarction should be treated by a cardiologist but general physicians needs to be trained to diagnose it. At present in many cases patients are being exploited by the private health sector, Dr. Fraz Mir remarked.

Responding to a question during the discussion he said that Cambridge University is a federation of thirty colleges and the training and examination are all governed by the university. It was also pointed out that while in UK patients wish to go home and wish to be treated at home, in Pakistan, even after being discharged patients wish to remain in the hospital and try to extend their hospital stay on one pretext or the other. For becoming a specialist in UK, one has to work for two yeas after MBBS, then work at SHO level and qualify MRCP examination. It is followed by four to five years training before one is certified as a specialist. Medical Training Initiative scheme offered opportunities to many international medical graduates to come to UK and complete their postgraduate training. In some countries, it is mandatory for their doctors to spend last one year of their postgraduate training overseas in UK, Australia or Singapore before they become consultants. They work at Registrar level for two years and then they go back to their own country after getting a certificate so that there is no brain drain. If they wish to come back to UK, they have to apply for visa again from their own country and then they can come.

Participating in the discussion Prof. Mahmood Ali Malik one of the senior most Fellows of Royal College of Physicians London in Pakistan said that concepts keep on changing. Majority of the doctors in teaching hospitals used to be general physicians and they used to spend one to two years in different specialty of their interest. Then came the sub specialization and general physicians were out of the market. However, now they are coming back as there is no substitute for General Physicians. They are required and they are going to become more important, Prof. Mahmood Ali Malik remarked.

Earlier Prof. M. Akbar Chaudhry Principal Azra Naheed Medical College introduced the guest speaker Dr. Fraz Mir and thanked him for his visit to AZNMC and his presentation on acute medicine which he opined, was very informative and interesting.

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