Medical Specialties - Acute Medicine (17 Apr 2024)

SPEAKER_01 0:00

If you enjoy listening to career conversations, why not become a member of the Royal College of Physicians of Edinburgh? Our membership provides you with access to the RCPE educational portal, the live evening medical updates, and you have options to view the symposia both in person or online. If you would like to learn more about this, please go to the Royal College of Physicians of Edinburgh website. My name's Marilena Gianudi, and I am on the TNMC. And today I'm delighted to be joined by Dr. Jennifer Taylor, who is an acute medicine registrar at Holdale Hospital.

SPEAKER_00 0:50

Good morning, Jen. How are you? Good morning. Thank you very much for having me. I'm very happy to be talking about my favourite topic, which is acute medicine.

SPEAKER_01 0:59

Thank you for joining us. So the first question that I like to ask is why did you choose acute medicine?

SPEAKER_00 1:08

I think one thing about acute medicine that is often joked about in our conferences is that we struggle to explain to people what acute medicine is, particularly people who don't work in hospitals. So my family members, for example, they'll often say, But what do you actually look after? Because we can't connect it to an organ, for example. So when I was in medical school, it's not really a specialty that you're very aware of. And obviously it only really became a specialty in the early 2000s. So it was very much in its infancy when I was at medical school. So it certainly wasn't something I thought about at medical school or even in foundation training. And I thought about lots of different specialties, and actually perhaps me thinking about lots of different specialties was showing that I liked a little bit of everything and I liked to be a generalist. But I also really liked looking after unwell people in hospital. So to me, that really suggested I probably didn't really want to be a GP or wasn't suited for general practice. I wanted to be kind of more in a hospital environment. So I think in my FY2 year, I worked in an acute medicine department and was one of the consultants there that showed me that I probably had the skills to work in acute medicine and to have that kind of general overview of patients, which can be difficult and challenging. And I'm sure we all agree that as patients get more complex and they have multiple health problems, being able to have skills to look after lots of different things is really important. So I think I wanted to be able to do a little bit of everything and I also wanted to have a bit of variety in my day. And I also wanted to work in a hospital setting. So I think that's why acute medicine was right for me.

SPEAKER_01 2:45

And what is a typical day of an acute medic like? Because I think there's maybe common misconceptions that you know there are no clinics, or you know, there may be lots of practical skills elements, but what is it like for you or for people that you've worked with?

SPEAKER_00 3:01

Yeah, I think one thing to remember is that because acute medicine departments are really different, because not really confined by having to provide certain services, like for you with cardiology, there's always going to be calf labs, there's always going to be echoes and EP work in tertiary centres. Acute medicine departments are really different, and often that is down to the individual consultants and how they've decided that they need to structure or set up their service. And that can be dependent on even things like the local population. And for example, when I've been to a conference last week about hospital at home, so you know, there are some acute medics doing things like a hospital at home, and that might be with more of a frailer population. There's things like virtual wards which are now coming in. But a typical day for me in the department that I work now, and I think the misconception as well is that with acute medicine that you're always on a call and that therefore you'll only be doing the same on-call work that your kind of fellow GIM registrars are doing. And that's not really true. When I'm on a normal day, I'm not the medical reg on call. So typically I might do a ward round of my own patients on MAU, and obviously now that I'm more senior, do some post-take reviews that I've discussed with patients and see patients that have been on the unit for a couple of days. I might then support the junior doctors in the afternoon on the unit, or I might spend a day in the same-day emergency care. I find the days in same-day emergency care really fulfilling. I think STEC is a particular skill, and I really love working with the ACPs and the junior doctors who work there as well, and that's dependent on different units who staff same-day emergency care. And I often take referrals from GPs, I liaise with AE. I speak to the nurse in charge in STEC, I go through the list in AE and I see what we can do to help reduce that pressure in AE. I think with acute medicine, we spend more time in AE than other specialties, and we have to be honest about that. And those working relationships with A ⁇ E are really important. And actually, what we're seeing is that they're taking a lot of the risk on in the hospital with bed weights now, and we have to try and help spread that risk as much as we can and working collaboratively, you know, does this person really need to come in? Is there an alternative pathway that I'm aware of that the A and E SHO isn't? So I know that there's a virtual ward for respiratory, there's a virtual frailty ward, there's frailty STEC, there's medical STEC, or am I happy to take on doing some outpatient referrals to help get that patient home? Or even just a little bit extra knowledge about things like I think yesterday when I was on call, there were four patients in the waiting room, all with high blood pressure, that had been sent by the pharmacists and actually supporting the A and E SHOs through hypertension guidance and why these people didn't need to come in. You know, that was four people who otherwise might have ended up on the AMU. So I also sometimes go to the university because acute medicrars will have a specialist skill, and there's a list which is approved by the JRC PTB, and that can be very wide-ranging. And obviously, all of the new acute medicine registers do famous training and ultrasound training. So half of a day a week they'll be doing that. And then another half a day a week, I have time for specialist skill. So I use that to do my master's work. So my master's is in leadership and healthcare management. So that's something I hope to be able to use in my consultant career. But I've got colleagues who do positive care, who do infection work, and some people who do diabetes clinics. So the idea that we don't do clinics is not entirely true. And I also go to the VTE clinic. So we have a VTE follow-up clinic for patients in Nasdaq. So we see people at three months and we make decisions about anticoagulation. So there is opportunity to do some clinic work and long-term follow-up and decision making with patients about long-term plans for chronic conditions. So you can get quite skilled at VTE, and actually, the vast majority of patients are followed up by the acute medicine consultants and not really actually by hematology. So yeah, there is variety. I don't just go to A ⁇ E and Clark with the on-call registrar, and I think it's important that we try and promote that in acute medicine. Obviously, I do my on-calls like everyone else, but my normal days are spread across the department. And we're about to set up our virtual ward in Calderdale. So I'm hoping that I'll be involved in that too.

SPEAKER_01 7:20

And I think it's really good for people to actually understand what an acute medic does because you're right. Juniors coming through training will always be an acute medic on MAU and don't actually have exposure to anything that happens outside of that, which is why it's so important that you know we do get knowledge out there and even through, you know, things like podcasts, people get a bit more of an understanding of what it actually entails. I just want to go back slightly to what you mentioned about your special skill, because I know that's something quite unique to acute medicine. When do you have to choose it and how long do you train in that?

SPEAKER_00 7:55

Yeah, so when acute medicine was started and became a CCT in about 2009, I think it was, there was an idea that because ambulatory care wasn't as widespread as it is now, and certainly things like virtual wards, you know, that was really far into the future. So we were all very honest, and there was an idea that continual ward rounds on MAUs might be a bit much, you know, that decision fatigue every day. So they were kind of colloquially called sanity sessions. And at the beginning, they were really only focused on doing echo, medical education, and some like actual procedural skills, but it's massively expanded over the last 10, 15 years. And some of the specialist skills that are recommended are no longer there. So there are some consultants who did do things like endoscopy, but I think the realization now is that actually when you've got gastroenterology registrars struggling to get endoscopy training, that there isn't really a role or a value added for the acute medical unit for you to go and do endoscopy once a week. So the idea is about what you can do to add value on the acute medicine unit. So now that we're all starting at ST4 after IMT3, the first year is focused on attaining famous accreditation for the ultrasound skill. That's in the new curriculum that came out last year. So that's what the registrars are focused on. So basically about ST5, they'd be deciding what it is they want to do, but probably most of them might have an idea at ST4 and start exploring. The other thing also is that with acute medicine, there's opportunities to dual CCT with, for example, intensive care medicine. So I have colleagues who do acute and intensive care medicine. It's not very common. And actually the pathways and the consultant jobs are perhaps more established in some regions more than others. But actually, you know, adding intensive care skills to that generalism skill of acute medicine, it's like ultimate medical reg. You know, you come down and make that amazing MRCP diagnosis and then sweep them off to ITU and do all the stuff that you can do there. And then there's an opportunity to dual train with stroke as well. So from ST5, really, you'd be deciding and we're really clear in our region to our trainees that they must have a job plan that includes time for their specialist skills so that they can evidence that at ARCP. And if they do find something that they want to do that's not on the approved list, then people have applied and had things approved. So yeah, it's very flexible. And if you have a particular interest in headache, for example, then you might be able to run a headache clinic for mastec or diabetes, you can have that extra expertise on the medical floor. So it's really variable and I think it just adds value to the patient care that we're able to give on the acute medical unit.

SPEAKER_01 10:40

That's great. And you mentioned that there's a list of everything that's formally approved on the JRCTB website. Yeah. So I'll pop that in the show notes. I'll also pop a link to the famous courses on the show notes. So if whoever's interested can have a read in their own time. So thank you for that. In terms of advice to juniors, what advice would you give to, first of all, someone who definitely wants to do acute medicine as to what they need to kind of prepare for a career in that? And maybe for someone who like you was thinking about lots of different things and wasn't quite sure, or do I like lots of different things, or do I actually want to do something that incorporates a little bit of everything?

SPEAKER_00 11:22

Yeah. And you know, to be honest, I did have a training number initially in infectious diseases because to me that was, you know, infection is cross-body, it's broad-based. But I then decided to work in acute medicine for a year as a registrar out of training, and that helped me, obviously. And you know, years out of training are so common nowadays that lots of people will be working and doing low-come shifts in acute medicine units or the type of shifts that I see, you know, low-come SHOs working lots in AE, just cracking patients. And I don't think it's a very good reflection of what acute medicine consultants actually need to do. So I think you do really need to explore a job. For example, there are some places where you might work in STEC for the whole year and that might give you an idea. And then you can also have some of those procedural skills. I think the thing that makes someone good at doing acute medicine is someone who's just interested in lots of things and likes to read around lots of different topics who maybe you have to prepare yourself that you have to keep yourself up to date on lots of different areas. So I have to be aware of the new BTS guidance, but I also have to be aware of new ESC guidance and European Society of Endocrinology and British Geriatric Society guidance. So if you're reading around as much as you can, you know, there's resources on Twitter, journals, even just reading the BMJ every week will just give you an idea of keeping you up to date. I think the other thing that the new acute medicine curriculum is highlighted quite well is that to be good at acute medicine, you have to have an awareness of things like how do we make decisions at the beginning of the hospital admission that have a big effect further down the patient journey. So awareness of things like clinical decision making, clinical risk. So Professor Ben Lovell, who's an acute medicine consultant in London, does a clinical reasoning podcast that discusses specific clinical cases, not in a way to criticize, but in a way to explore the ideas about clinical decision making and risk. And that's really important in acute medicine because you know, when you're making that post-take war-drown diagnosis, that often sets quite a clear path for that patient. So understanding how you have a big role to play at the beginning of the hospital journey is important. I think if people are not clear or they are not definitely clear about acute medicine, then there's loads of resources for the Society for Acute Medicine. They have a take-aim fellowship where registrars kind of do visit conferences with medical students and core trainees to discuss acute medicine as a career. And I think over the last couple of years that's really helped with recruitment. And we are seeing kind of much more competition in recruitment in acute medicine now and as we are across the board. So I think showing that you're interested in lots of different specialties, showing that you read around, showing that you understand about decision making and that kind of I'm not going to say taking risks, but as in risk awareness and alternative pathways and showing how you understand about working across the hospital. So, you know, how do we work? One thing that they often say in our conferences is acute medicine at the heart of the hospital. So how does acute medicine have that interface between AE and the downstream wards and specialties? So, you know, how do we get the right patient in the right place, having the right treatment at the right time? And those kind of decisions are made early on at the front door and on the acute medicine unit. So when you're going to interview, if you really understand that process, I think that shows that you understand what it means to have that role as a trainee in acute medicine and as a consultant.

SPEAKER_01 15:00

And I just want to briefly touch on STEC, same-day emergency care, because I think for a lot of registrars, I actually really do love it.

SPEAKER_00 15:19

Yeah.

SPEAKER_01 15:20

I've spoken with other med regis who absolutely hate STEC, who feel that you know it's a very high-risk environment. And I think as regis, I can kind of see where that comes from. I do think it's only because I did find it uncomfortable to start with, and I just kind of pushed myself to keep going back that I kind of started enjoying it a lot more. And obviously because I made sure that, you know, I read up a lot more and I just felt a bit more confident in the decisions I was making. Because I do think that it's very different to, you know, having seen a patient on the ward for five days, having seen that they are gradually getting better, their bloods are gradually improving, and actually you're safe to go home. Yeah. And I know that's a very broad generalization, and you're probably cringing at what I'm saying. I could have my basic knowledge of same-day emergency care. But what skills do you think we need to effectively do our jobs on same-day emergency care? And how do you think we can get better at working on same-day emergency care? Yeah.

SPEAKER_00 16:16

So EstEC can be really interesting because again, I've worked in lots of different STEC units while I've been training. And actually, the one thing to think about as you go into the unit is what's the culture of this unit and what is the hospital asking this STEC to do? Because it can be very variable in different hospitals. So is this hospital staffing this STEC with lots of people? And essentially, people are arriving from triage direct in AE with a general medical presentation with, say, a new score less than five. So that you know could happen where someone just goes, Well, I came to triage and I've just been directed round. There's no clinical discussion and there's no prior clinical review by an A and E doctor before they come down to ASTEC, versus this patient has fully been assessed in AE by a clinician already, has already had X number of tests, a working diagnosis, and is just coming round to STEC to have a CTPA for you to review. Or this patient's come from general practice with a very specific question. So there are different patient streams in STEC, which means you can get a patient arrival from GP who's very different to what you expect. And you know, that can cause some frustration sometimes because you think this isn't what I was sold in adverted commas, or this chest pain that's come from triage is because he had a road traffic accident or something similar. So if you are allowing more undifferentiated patients to come through, you do have to accept that sometimes people will slip through the net that may not be appropriate for same-day emergency care and to try and not let that affect feelings of frustration. I think knowing what STEC is good at is important, and STEC is really not a replacement for specialist clinical review. So STEC is not a rapid access chest pain clinic. I don't have access to the correct functional testing that a patient might need. STEC's not a place to come for seven weeks in a row to have blood tests done, but those blood tests just being checked again and again, and nothing really brought forward from that. So understanding what STEC's good for will help you see the right patients there. I think getting support from colleagues, speaking to consultants in acute medicine about whether a patient is suitable, you know, there always should be a consultant who's able to give advice on STEC. And I don't think our GIM colleagues should feel that they should be taking on all the risk themselves. You know, consultant presence on STEC is really important, is something that many hospitals is trying to improve so that we can get the right patients into STEC. In terms of risk, I think one problem is a deferred responsibility that you sometimes see in STEC, which is when patients are just, well, you know, come back in a couple of days and we'll decide what to do then. It can be frustrating. And actually, you do need someone senior to really guide what's happening with that patient and you know, to make the decision at what point they need to be discharged from follow-up because STEC has now turned into, you know, there is lots of patients who do come very frequently and things like that, rather than just a one-off attendance. I think thinking about the common presentations that you're going to see in STEC, so feeling really comfortable with VTE. Obviously, there's quite clear nice guidance on VTE, but every hospital and trust will have their own VTE guidance, which is often reflective of the NICE guidance. Presentations like collapse or syncope is really common, palpitations, new AF, chest pain, obviously. Headache. A headache is a great one because making a positive diagnosis of a primary headache is very difficult, I think, for GIM registrars. And just doing the LP and saying, well, it's not a subarachnoid, but not being able to treat the underlying headache, I think causes frustration for registrars. Yeah, making decisions about who to LP with subarachnoid because obviously the guidance has changed quite recently. So that's something we had discussed at one of our training days as well. IAH is a good condition, and papilledema assessment is a very specific condition that often comes to STEC that GIM registrars sometimes have not seen much of. So I think generally some of those common presentations, which are the same presentations that you're probably going to be seeing on the on-call take as well, but just the environment's slightly different. But yeah, you've always got time and you've always got senior support, and no one's asking you to take risks that you're not comfortable with. But actually, there's lots of patients in STEC can be managed with a few attendances instead of kind of five or six days in the hospital bed, and that's a great thing, I think.

SPEAKER_01 20:52

So what skills do you think a doctor needs to be a good acute medical?

SPEAKER_00 21:00

Can you give me top three? Top three. I think curiosity and a willingness to learn about lots of different specialties throughout your career. I think I will have to say understanding your limitations because you really do need to know where specialist opinion is needed. And that is a difficult balance, and don't think I've got that right yet. And I'm sure there'll be times in my career where, you know, someone will come back to me and say, Well, actually, you sent this person home, but they needed to have XYZ investigation. They needed to come to my clinic for that. And you might not always get that right. But on the other end of the spectrum, I think it'd be really sad if every patient on the MAU had to have a specialist opinion before they went home, then the hospital would grind to a halt. So you have to find where you sit and where I am compared to another registrar, may be different, and that has to be okay. And we have to be accepting of where other colleagues feel. Their competencies and their risk taking is. I think the third one is probably just I don't want to say resilience because that's probably a bad word, and yeah, it's just but it can get tough in winter and it can get tough with bed weights, and we're not gonna pretend that they don't exist. And it sometimes feels in some hospitals we've been seeing on the news recently that there can be a whole two or three extra AMUs of patients in AE, and that is difficult. And I think innovative teamworking solutions for how we look after those patients will only come if you can work well in a team, and that might be a team, the consultants, registrars, your on-call team, your normal staff on AMU, your junior doctors and your ACPs and PAs, but also you have to work with AE as well. So teamworking across the hospital is really important and into the community as well. So as we start doing things like virtual wards, we need to be more aware as acute medics about what there is available in the community so that we're signposting patients to the correct resource. If we don't know what GPs can do and what they can provide, then we can't give the right advice. So you need to have good teamworking skills across primary and secondary care.

SPEAKER_01 23:15

And my last question, and if I'm putting you on the spot, then that's okay, you don't need to answer. But I like to ask if you have an interesting case that you could discuss, you know, stick to patients' confidentiality, but that can perhaps be, you know, a highlight of what your job entails.

SPEAKER_00 23:35

Yeah, I mean, there are some cases that stand out, obviously, where things didn't go as you planned. I think there was one case when I was working a couple of years ago and I was doing my intensive care placement, but I was also still doing my medical registrar on calls. And it was a patient that I saw on the ward, and then when they were then admitted to intensive care, I was looking after them there. So that was quite nice. And well, there were two patients. So one was a woman on the ward who'd was being treated for community-quirried pneumonia, but there was just something when we'd seen her overnight that wasn't quite right, and we ended up thinking about vasculitis and making that diagnosis, and I think that was just showing that awareness of you know, multi-system diseases. We'd noticed, you know, all her kidneys are off, and you know, she does have this rash as well, and it looks more like a pulmonary hemorrhage on the X-ray. So I think even though she was on a respiratory ward and she had been there for a week or so, the diagnosis hadn't been thought about. So, you know, getting that anchor sent off and getting the diagnosis meant that she could start the right treatment with the rheumatologist on intensive care, and she ended up being very poorly and she ended up with cerebrovasculitis as well. And there was another patient, a young man who came in, he was very anemic, it looked like he was hemolyzing, and suggested he had a kind of thrombotic microangropathy that was probably due to high blood pressure. So actually, just being able to pull together all of those odd blood test results, link it with the high blood pressure, thinking about things like HUS and TTP, and knowing that, right, this is the situation where I need to act malignant hypertension, I know what to do. You know, I've been reading these guidance, he definitely needs intensive care and having the confidence to be able to then go to the intensive care reg and say, this man's blood pressure's this. I've looked in his eyes, he's got this, he's hemolysing, this is due to accelerated hypertension. You know, this is the moment I've been training for. MRCP in practice. Yeah, yeah. And obviously that's a diagnosis that a lot of the medical registrars on call would be able to make as well. But I just thought those two diagnoses, things like vasculitis and like a multi-system problem that hypertension would cause, just felt like pulling everything all together and things that I had been reading about as well. And then being able to look after them in intensive care afterwards was quite nice as well.

SPEAKER_01 26:00

Except very rewarding as well. Yeah. Okay. Yeah, that makes me worry about all the people I see when I read Red Junkle, and I never think of those things. But that's fine. I won't dwell on that too much. Great. So, any final comments from your point of view for anyone listening to this podcast who may want to go into acute medicine?

SPEAKER_00 26:21

So I'd say obviously there's great resources out there. So there's the Take AIM team, the Society for Acute Medicine, they obviously have conferences, they have very good conference rates and discounts for junior doctors as well. The Take AIME reps are quite active on social media and Twitter and things like that. And I think, you know, just speak to acute medicine trainees and consultants in your own hospitals as well, and just try and find out what it is that they do on a daily basis. And you don't see the same consultants on AMU every single day, so they must be off doing other things. The only thing I would say is in a career in acute medicine, it can give you work-life balance and it can also give you really interesting cases, and it's constantly surprising. And it's a career where there's a lot of teamworking and opportunities to do things like managerial and service development and research increasingly now. So I would just speak to people and look at information and just understand what it is that we're doing every single day, and hopefully that will be attractive to people. That's great.

SPEAKER_01 27:23

Thank you so much, Shane. Thank you for you know all the resources that you've pointed out. I'll make sure they're all in the show notes. Thank you for your cases, thank you for your knowledge, and thank you for talking to us before you go back on call. Yes, thanks very much. Thanks for having me. And for anyone else who's maybe interested in another career, you can listen to our other podcast episodes on Career Conversations or for more clinical questions, you can go to our clinical conversations podcast page. Thank you for listening.