Hospitalists and consultant physicians in acute medicine.

and Bournemouth in the UK2 describe new approaches to the hospital care of acutely ill patients. Although from historically different systems of health care, each addresses familiar concerns. Baudendistel and Wachter1 consider the development and evaluation of the relatively new specialty of the hospitalist, who is identified by the place of practice rather than by expertise with diseases of a particular organ or system. Armitage and Raza2 describe and evaluate their experience following the appointment of a consultant physician in acute medicine in a district general hospital. In the USA, responsibility for primary care lies variously with a family physician, a paediatrician or a general internist, who refer patients to specialist colleagues. Primary care doctors also undertake inpatient care, although increasingly they transfer that responsibility to a hospitalist, thus coming closer to UK practice, where the general practitioner (family physician) refers to a consultant for both inpatient and other specialist care. American primary care physicians once spent half their time providing inpatient care. But changing conditions have encouraged the development of a new inpatient practice, based chiefly on the needs of acutely ill patients. In the UK, where most specialist practice integrates outpatient and inpatient work, other influences have provoked a similar response. The common factor is the need to ensure that acutely ill patients are attended by physicians who are skilled and experienced in the assessment and management of acute medical disorders. Separation of acute internal medicine from medical specialty practice seems to have been accepted in the American system described. UK physicians have been reluctant to follow this route. This largely stems from a conviction that hospital medical practice is grounded in experience in general internal medicine (G(I)M). Moreover, most general practitioners wish to be able to refer patients to general physicians as well as specialists. In the UK, G(I)M encompasses acute medicine and the inpatient and outpatient care of patients with multiple disorders or ill-defined conditions. Although it is usual for a general physician also to have a specialty, the converse does not always apply and physicians in a number of specialties do not practise acute medicine3. Specialisation to the exclusion of acute work increases the workload of physicians who shoulder these duties, often to the detriment of their specialty work and other responsibilities. The consequences are particularly pronounced in the UK, for the plain reason that there are far fewer consultant physicians in relation to population compared with the US and other developed countries. Even among physicians who regularly undertake acute work, there are many who would willingly reduce or even relinquish this duty. Other familiar factors compound the problem: each year there are more emergency admissions, fewer hospital beds, fewer experienced junior staff, as well as shorter junior doctors’ hours resulting from the EC directive. In the UK, many consultant physicians are in a sense hospitalists who practise acute medicine within G(I)M, and have a specialty3. But their on-take work for unselected acutely ill medical patients is intermittent – though often burdensomely frequent – and until recently it was uncommon for acute work to be the continuing predominant activity of a physician. In 1996, the RCP proposed that studies be conducted to evaluate the role of an acute physician, a physician who would specialise in the first 24 hours of acute care4. Such a physician would also provide support to a medical assessment or admissions unit, assign patients to appropriate specialties, teach and train, co-ordinate the use of guidelines and protocols, and provide an outpatient department (OPD) service for follow-up of some patients from the acute take. A Scottish Intercollegiate Working Party5 endorsed the proposal. Before evaluative studies could be set up, trusts proceeded to appoint acute care physicians (ACPs). They have diverse job descriptions and come (as do hospitalists) from various clinical backgrounds. Some work as general physicians with a specialty, with time allocated to work in the medical assessment unit. They may have on-call commitments. Some have jobs with regular working hours based in the medical assessment/admissions unit, with outpatient sessions. Teaching and research rarely appear in the job descriptions. A working party report of the Federation of n EDITORIALS