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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.

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