Acute Medicine

 

 

Section 1: Information about the writer

Dr Mohammed Ali Homaida

ST4 Acute Medicine

Western General Hospital – South East Scotland Denary

 

Section 2: Scope of Practice in the UK:

Acute Medicine concerned with the assessment, diagnosis and management of adults presenting to secondary care with acute medical illness.

It encompacses :

1. The prompt practical management of acute presentation of medical illness
2. Medical patients management in an in-patient setting
3. Maximise safe, effective care in the community where feasible (Ambulatory)
4. Leadership skills within an acute medical unit
5. The care of patients requiring more intensive levels of care than would be generally managed in a medical ward.  HDU and ITU .

Acute Medicine is NOT Emergency Medicine however It is very closely related to the Emergency Medicine except we don’t see the Padeiatric and Gynacology bit . We spend many hours in the Accident and Emergency (ED doctors are our friends).

Most common presentations are:

• Respiratory ( COPD , Asthma , Pneumonia )
• GIT  ( Mainly bleeds , Exacerbation of IBD  )
• CVS – Chest pains investigation
• Neuro ( Strokes , Subarachnoid Hemorrhage , Seizures )
• Sepsis ( wherever the source )
• Swollen Joints , Arthritis , Cellulites
• Falls ( elderly medicine )
• Toxicology ( Alcohol , substance misuse )

Typical day

Registrar – Differs a lot fro hospital to hospital. mainly senior reviews in MAU , ward round , specialty clinics . different specialty wards , nights , on call  . Can range from simple canola to more a team leader of a CPR . From simple drug kardex filling to the most senior medical decision maker in the hospital.

A Myth: Acute medicine registrar is not always on call . He works in the area where people usually on call but not on call. On calls are distressing, but MAU is not.

A Fact : Acute Medicine registrar is the most known registrar in the hospital        (especially upon juniors) as most opportunities in teaching and education for junior staff will be in the MAU. Your name will be in most of the assessments for junior medical staff as the assessor.

As a registrars you will do variable procedures ranging from a canula through tranvenous pacemaker to a central line. It mainly depends on where you work .

Consultant : Most of the consultants will be concerned about the flow through MAU ( I,.e number of admissions and discharges ).

• Senior reviews and ward round in the MAU ( medical admission unit )
• Meetings with hospital managers (assessing flow, discharges, obstacles, incidents and how to improve the flow)
• ITU medical referrals
• GP medical referrals
• Senior role in Medical HDU
• Ambulatory care. ( Acute Medical Discharges follow up )
• Teaching and research

Specialty Clinic ( depends on special interests ) e.g. : stroke clinics , TIA clinics , respiratory clinics , Acute neurology clinics , rapid access chest pain clinics . Infectious disease clinics. Diabetes clinics . most of acute physicians will plan to implement a high symptoms based specialty clinic as a backup to specialties . ( e.g. Headache clinics, first seizure clinics , rapid access chest pain clinics ,  dizziness and collapses clinics , acute neurology , TIA and stroke clinics  )

Procedures (endoscopy lists, bronchospoy list, echo lists .. etc).

 

Section 3: Type of training/ Route to training

Enter either through CMT program or ACCs program .

CT grade level ( 2 years in CMT or three in ACCS )  – mainly clerking new patients, ambulatory care clinics and performing procedures like LP and  fluid paracentetsis.

Speciality Training level :

ST3-ST5 – More senior role,

Senior review of clerked patients in MAU, Registrar in medical HDU,.

Rotation through cardiology, Respiratory and Elderly medicine as a registrar (4 month each) ,

Rotation in the ITU (6 month as a senior house officer).

6 month free (training needs) to be rotated through the specialty of choice ( e.g. – GI if special interest in endoscopy , Cardiology if special interest is echo ) .

1 year in District general Hospital as Acute Medicine ( usual ST3 ) .

ST6 and ST7 – Mainly Management, back to acute medicine (MAU – as a consultant level (6 month),

More free time for Research and Audits,

More free time for teaching and medical education.

More free time for special interest.

 

Section 4: Sub-Specialties

All trainees Must develop special interest or procedure during training. You must decide in first 3 years . You will gain a CCT with special interest in it.

It can be either:

1. Procedure :

Some will choose Echocardiogram , Endoscopy , Bronchoscope . Most of procedures has different levels of competencies . Minimal level is required in each procedure to gain a certificate ( to be included in your CCT – Acute medicine with special interest in …  ) .

2. Specialty (the most rewarding)
3. ITU (need at least extra 3 years in training – minimum but may be longer , need to apply for ITU training separately , save 2 in ITU training as Acute medicine is part of ITU training ) .
4. Stroke (extra 1 year in training)
5. Medical Education (need master degree within training )
6. Research (need Out of program time) –
7. Toxicology (degree)

Other specialties does not need extra time in training most of them will need a  degree within training ( can be managed online or distant learning within training period )

Section 5: Application Process

Oriel system – very much like every specialty  ( link)

Section 6: Requirements To Get Into Training (Person Specification)

1. ALS
2. MRCP
3. CMT competency ( either through official CMT training or though pararelel training pathway – Certificate C )

 

Section 7: Important CV/Portfolio Perks (How To Achieve Them)

(applicable to junior doctors)

1. Post graduate certificate
2. Acute Medicine courses (IMPACT  – Acute Medicine Updates , Procedure courses ) ( very recommended )
3. experience in MAU ( not essential but unlikely you will get training without it )
4. experience in ITU ( not necessarily , preferable  )
5. Audit ( one with a competition of the cycle , almost necessarily , specially in Acute Medicine )
6. Teach the Teacher Course ( very preferable )
7. Presentation and Posters ( not necessarily )

Easy to get the specialty with above. Your chances are guaranteed if done well in interview with the above

To achieve them : during your experience in UK try to attend one or two Acute Medicine updates ( check RCP website ) , Make sure ALS done and do IMPACT course ( check IMPACT website ) . Do a procedure course (Check denary website you are working with). Make sure you get experience in MAU (90 % of the jobs in NHS as junior medical doctor have it). and try to attach to the ITU ( at least 4 month – not very difficult if agreed with the hospital and almost essential in CMT training ) . Do an Audit ( if not already required in CMT ) . Make sure you finish your MRCP on time (full diploma) as this will help you to build your C.V smoothly  . Postgraduate certificate may be the most difficult, Please don’t attempt before the MRCP. I mention it because it really boost your chances but not essential and many doctors got the training without it .

 

Section 8: The Interview

3 stations :

1.Portfolio

2.Ethics and Communication

3.Clinical Senario

 

Section 9: Competition Ratio

Very variable for acute medicine (usually 3 to 1 . Fill rate is 80 percent) For recent data http://www.st3recruitment.org.uk/specialties/acute-internal-medicine

 

Section 10: Offers and Visa Issues and HEE

Offers: Usually through the Oriel System (very easy to use )

Visa is through the HEE and HES

 

Section 11: Specialty Exams

Specialty exam in Acute Medicine: best time to take is within the first 2 years of training ( i.e. ST3 and ST4 ) , Materials ( On examination and Pastest , Recent guidelines , ALS and Impact courses )

 

Section 12: Speciality Courses

Variable , Usually training will be directed toward your subspecialty ( eg people with subspecialty of stroke will likely do Neuroimaging courses , Thrombolysis courses ,… etc .

 

Section 13: Rotations

Variable – as above. TPD ( training program directors )  are usually very helpful. Usually will need to go at least for 2 years in District general Hospital ( it may be away from the city you live in )

 

Section 14: Ranking of Deaneries

TBC

 

Section 15: Wages / Take Home Cash

Depends on your experiences. Recent change to contract may change the salary . In Scotland it is banded as band A. It means the salary with start from 36000 basic and 50% banding. to summarize . Take to home cash usually between 3000 as a start to 4500 (depend on previous experience) . ALOT of Locum opportunities in Acute Medicine. (in Scotland it is usually from 60 to 70 pound per hour for ST3 and above . 100 to 120 pound per hour for consultant ) . Introduction of new locum cap in England may affect those rates.

 

Section 16: MTI

See MTI section : embeded ink

 

Section 17: Experience of Sudanese Doctors (Personal Experience)

I enjoyed working in the MAU before I got my training number. I worked for more than 2 years in Acute Medicine department in James cook hospital. It was difficult at the beginning as I did not have that much experience as a registrar when I started. The hospital was busy and the pressure was high. However with time I really started to like being in the MAU. the main reason behind that is the variability . I never get bored . You don’t know your next patient will be someone with haemoptysis who may end up having Wegners or a man with alcoholic hepatitis with encephalopathy who may need Ascetic tap. I became addicted to the rush of adrenaline in my brain after seeing that patient in Ambulatory care who had a skin rash who I said it is HSP who has just has his skin biopsy results back which confirmed my suspicion. I like to see my patients improving in front of my eyes and I feel the power when I discharge them. There is a big myth that it is stressful. Unfortunately this came from the fact that MAU is always related to being on call . On call shifts are very stressful at times and most of the time you will find yourself doing stuff that you don’t enjoy. However, being away from the hassle of bleeps in the MAU will definitely change everyone experience in the Acute Medicine.

From Sudan point of view : Acute Medline is a totally new specialty  . It is not defined as a specialty in Sudan per se (as well as the Emergency Medicine, ITU and many other specialties) , But definitely you can work as a specialist in Sudan if you have a special interest . If you are thinking in coming back early to Sudan get away from subspecialty like Toxicology for example. Respiratory or a Procedure like endoscopy .will be more useful. .

In the Gulf: Acute Medicine It is very well recognized now in Qatar, UAE and Saudi Arabia. You can work directly as a consultant in Acute Medicine if you have 2 experience in Uk after CCT with a very competitive salary.

As part of your training in other Specialties (Acute Medicine , Gastroenterology, Respiratory, Renal, Endocrinology, Infectious Disease and Elderly medicine you will get raining in the General Internal Medicine . It is by itself a specialty and you will get CCT for both your main specialty and the GIM . there are some specialties that lack this privilege .

This is one of the few growing specialties and new Consultant posts are currently being made available at a rate that surpasses any of the other medical specialties, so career prospects are good for competent candidates

The other thing it has an excellent appointablility . It is very unlikely that you will not find a consultant post as already there are many vacancies.

I will highly recommend taking one of the Take AIM conferences (link below) . It will tell you exactly the pros and cons and what you expect and what to do.

If someone asked me my satisfaction percentage for this specialty I would say 100 Percent

 

Pros and Cons of working in this specialty ( RCP Edinburgh )

Pros

• Highly varied caseload ensuring you are kept on your toes and thinking on your feet – no two days are the same, and you are constantly testing all your medical (and sometimes surgical) knowledge and experience
• Immense satisfaction from meeting acutely unwell patients at their most medically unstable and emotionally/psychologically distressed and seeing immediate positive impact from your actions
• Working with a large multi-disciplinary team (MDT) with constant opportunities to teach and learn
• Good support from other clinical and diagnostic specialties.
• Opportunity to develop and shape a new specialty, and apply and develop skills in leadership, management and education

Cons

• Heavy, unpredictable and growing workload
• Highly pressurised environment as we are often caught between conflicting needs of the Accident and Emergency (A&E) Department and other specialties, and under intense management scrutiny
• The impact of hospital bed shortages is felt here the most.
• Rapid team turnover
• Lack of patient continuity means often missing out discovering final diagnoses in complex cases or the satisfaction of seeing a patient eventually discharged
• Less experienced junior staff and the movement towards a Consultant-present workforce are likely to result in heavier out-of-hours responsibilities – expect Consultant overnight working in the near future

 

Section 18: Important Links and Websites

Acute Medicine Updates will be found in corresponding royal college . you will need to fill in the teaching bit by teach the teacher course

Society of Acute Medicine http://www.acutemedicine.org.uk/

Royal college of physician  Edinburghhttps://www.rcpe.ac.uk/

Royal college of physician Londonhttps://www.rcplondon.ac.uk/

Royal college of physician Glasgow https://rcpsg.ac.uk/

Impact course website http://www.impactmedical.org/

Take AIM  http://takeaim.org.uk/

ALS course    https://www.resus.org.uk/

Hammersmith Acute Medicine course http://www.hammersmithmedicine.com/Acute-Medicine-Courses

Very recommended Acute Radiology course http://radiologymasterclass.co.uk/tutorials/ct/ct_acute_brain/ct_brain_start

Teach the Teacher course http://www.medicalinterviewsuk.co.uk/teach-the-teacher-course.html ( not the only one )

Oriel System ( for application ) https://www.oriel.nhs.uk/Web/Account/LandingPage

Deadlines for Application  http://www.st3recruitment.org.uk/