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The Acute Model

Besides studying patient safety and watching all five seasons of The Wire, my other major goal for my London sabbatical was to understand the way the Brits organize hospital care. Mirroring the U.S. hospitalist movement, a new field—called “acute medicine”— emerged about 15 years ago and became the country’s fastest growing specialty.

But there is a key difference: acute physicians are hospitalists working inside a smaller box, the acute medical unit. While the young field has enjoyed some striking successes, I recently spoke at its national conference and challenged acute physicians to be a bit more ambitious—to put a little more of the “disruptive” in their disruptive innovation.

To understand the different evolutionary paths of the U.S. and UK’s systems of hospital care, it’s important to understand the primordial seas from which hospitalists and acute physicians emerged. Whereas the U.S. hospitalist model has all-but-replaced a system in which the primary care physician was expected to be the physician-of-record in the hospital, the UK never had such a system. Instead, general practitioners in Britain have always confined their work to the outpatient world; patients in need of hospital care have been handed off to different physicians since the days of Alexander Fleming. But the traditional model has been for those physicians to be subspecialists, with patients admitted to wards run by consultants: the GI ward, the endocrine ward, the geriatrics ward, and so on.

There are clearly certain diseases—acute MI and stroke come to mind—in which such narrow, specialty-focused wards deliver better outcomes of care. But for the vast majority of hospitalized patients, who are rarely cooperative enough to have just one thing wrong with them, the requirement to pigeonhole patients into a specialty unit is problematic. A 2002 American study found that when patients happened to be cared for by the “wrong” specialist (the cardiology service, say, taking care of an asthma patient), both lengths of stay and mortality rates spiked.

It’s not just that patients usually have multiple things wrong with them. It’s that a system of many geographic subspecialty wards creates square peg/round hole problems up the wazoo. The ED needs to admit the GI bleeder, but the GI ward is full. Well, she has a remote history of COPD, so let’s put her on the pulmonary ward. Or, just hold her in the ED for a few more hours—a bed on GI should open up soon. You get the picture. What sounds like a perfectly sensible idea (who can argue against having patients cared for by the relevant specialist?) rapidly spirals into a chaotic, inefficient, and sometimes even dangerous mess. And so it was in the UK in the late 1990s.

It was at about that time, 1998 as I recall, that the Royal College of Physicians asked me to come over to describe this newfangled American hospitalist thing. This illustrates a key difference between the two countries: whereas the hospitalist movement in the U.S. grew without any major policy changes and with the begrudging support of professional societies like the ACP (at least in the early days), in the UK—with its centralized control of training slots and the overall organization of care—it was critical to get the Royal College, and ultimately the whole National Health Service, on board. It took a few more years, but then it happened.

In 2004, the Royal College issued a white paper entitled “Acute Medicine: Making it Work for Patients. A Blueprint for Organisation and Training,” which was a critical boost for the field. But this and other key reports didn’t limit their endorsement to a new specialty; they also promoted a newplace: the Acute Medical Unit.

The idea behind the AMU was to defer the subspecialty ward decision for 2 to 3 days while patients were both acutely sick (or “acutely unwell,” as they say here) and often relatively undifferentiated. In other words, rather than being admitted directly to the subspecialty ward from the ED or the clinic, patients would go to the AMU for 48-72 hours, where a new “generalist-specialist” was needed to oversee care. The acute physician was born.

I chose Imperial College London for my sabbatical because Charles Vincent, the top patient safety expert in the UK, is here. But I got lucky, since the leader of acute medicine, Derek Bell, also happens to be on Imperial’s faculty. Derek is a lively Scotsman (he commutes back to his home in Edinburgh each weekend, which would be like working in New York while living in Boston) with the kind of charisma and fortitude one needs to launch a new specialty and survive the inevitable arrows in the back. In the late 1990s, Derek and several colleagues began a path that closely resembles the one we took in launching the hospitalist field: defining the specialty, forming a specialty society (the Society for Acute Medicine, SAM), doing the research (which has shown improved outcomes, shorter lengths of hospital stay, and improved patient satisfaction), and creating a core curriculum.

AMUs—and with them the field of acute medicine—were destined to expand, but the growth of the units and the specialty were turbocharged by a national policy launched in 2005. In typical fashion, the NHS decided that the best way to deal with the problems of ED overcrowding and long door-to-floor times was with a rule. The “Four-Hour Rule” requires that all patients leave the ED (either to go home or be admitted) within four hours of arrival. As you can imagine, one consequence of this new standard (which is vigorously enforced) was that it created a need to grow the AMU to accommodate patients who required more time in the ED but could no longer stay there. My UCSF colleague Ellen Weber has written about some of the unintended consequences of the rule. One consequence that waspredictable was to make the acute physician, previously merely essential, now completely indispensable.

There are some important differences between Acute Medicine in the UK and Hospital Medicine in the US. Acute physicians largely limit their work to the AMU, meaning they have the benefit of a geographic unit (all their patients are in one place) but a far narrower reach than hospitalists: the 50% of patients who require hospital stays longer than 48 to 72 hours must be handed off to one of the subspecialty wards, a handoff that hospitalist systems avoid. The feel of an AMU (Derek has been nice enough to take me on rounds) is a morph of a U.S. step-down unit, an ED observation ward, and a full-on emergency department. The pace is brisk, the volumes high, and the transitions frequent—with dozens of new admissions and discharges (either home or to other units) every day. The number of acute physicians, while growing rapidly, remains far below that of hospitalists: while virtually every hospital in England has an AMU and acute physicians, the average group size is 3, and most programs cover only weekday daytimes. In contrast, most U.S. hospitalist groups have at least 10 physicians and some (including my own) have as many as 50, providing 24/7/365 coverage not only for sick medical patients but for many patients on other services (“co-management”).

Workforce constraints have been partly responsible for the limited growth of acute physicians. When the hospitalist field launched, there was a huge reservoir of general internists (and later, general pediatricians) ready to assume the new role, and the transition was as straightforward as saying “OK, I’m a hospitalist.” While hospitalists can now participate in fellowships and even obtain recognition of their focused practice via the new ABIM pathway, neither of these are requirements to join the field.

On the other hand, there are vanishingly few general internists in the UK. After a couple of foundational residency years, internal medicine types either shunt into GP training programs—which train exclusively for an outpatient role—or mixed IM/subspecialty programs. So the founders of acute medicine, all subspecialists qualified in other fields (Derek is a pulmonary/critical care physician), needed to establish a training pathway and a specialty designation, which they did successfully in 2003. While this training and certification requirement undoubtedly limits the field’s size, the field’s thought leaders (many of whom I met at least week’s annual SAM conference) are reluctant to lower the bar to entry. “We need to do rigorous specialty training to be credible with other specialists,” one told me. “I’d be reluctant to shorten it.”

Of course, he has a point. Because someone can self-declare as a hospitalist—and just as easily abandon the field for other types of generalist practice or to pursue a fellowship—our field has thousands of tire kickers, individuals who are hospitalists only as a way station for another destination. This comes at a cost, in terms of the specialty’s professionalism and its status in the eyes of others.

While acute physicians have embraced safety and quality work more than most UK physicians, I find that they still tend to think of it more in terms of the care of the patient in front of them than as system leaders. This is partly a symptom of something I’ve discussed before: the general passivity of UK physicians regarding their ability to influence the system (“Oh, the managers are in charge of that,” or “I’ll just wait for another NHS rule.”) In my closing address at last week’s conference, I urged the field to grab this area and run with it. One of the most important decisions we made in the early years of hospital medicine was to embrace the “two patients” mantra, namely, “I have two sick patients: the person in the bed and the system I work in. My job is to fix both.” While the landscape in the UK is very different than that of the US (with far more bureaucratic inertia to overcome), I still believe that acute physicians would do well to be—and be seen as—the MD leaders in systems improvement.

I also encouraged the acute physicians to carefully challenge the boundaries of their 48-72 hour AMU cage. Right now, they’re limited in their ability to do so by both workforce constraints (there aren’t enough trained acute physicians to expand their mission very much) and predictable political friction points with their subspecialty colleagues. And it may well be that, for some patients, transfer to a subspecialty service might be the best path. But for others, eliminating the need for a handoff and taking charge of the discharge transition seem like positive steps for patients, the NHS, and the acute medicine field.

I’m grateful to Derek Bell and his colleagues for giving me an opportunity to explore their exciting new field from the inside. Being at the SAM conference reminded me of the early days of our hospitalist field: seasoned and visionary leaders who had seen opportunity when others hadn’t, surrounded by hundreds of younger physicians excited to be part of something new, dynamic, and important. I look forward to seeing where the field goes in the coming years.

Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His posts appear semi-regularly on THCB and on his own blog, Wachter’s World.

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Elma
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