Real-life story - Dr Hannah Skene
Choosing AIM as a career path
As a junior doctor, essentially, I was a good all-rounder who really enjoyed being on take, working on the Acute Medical Unit (AMU), and looking after the unwell patient. I liked that each on call and take was different – I was in regular contact with all the medical specialties and I could see the immediate effects of my assessment and treatment skills. There is the pattern recognition that comes from seeing the regular clinical presentations that form the core of every day, but then there are also the unusual situations that require a more thought and expertise. I still really enjoy that challenge and discussing ideas with colleagues.
I worked with some inspiring and brilliant general physicians who would make the point to get the basics right. I loved the way they knew so much about so many different specialties. They made acute medicine exciting and appealing to me and taught me some great principles for dealing with any presentation in an environment that can be both tough and rewarding. I also found the environment unique – the camaraderie amongst the staff who work in an AMU every day is motivating and certainly helped me to develop a real sense of team and multidisciplinary working. The AMU teams gave me the confidence that I would be good at this, and to see the AMU as a place that can really make a positive difference for patients and improve how a hospital operates and performs.
Acute Internal Medicine (AIM) was still in its infancy when I chose to specialise in it, but it was expanding and trusts were redesigning their acute care services around this new specialty. The chance to be part of this evolving specialty and have a say on how local services were developed was certainly attractive to me. At the time, some were keen to tell me that it was a risky choice of specialty, but now nearly 10 years on, I can certainly say that I have no regrets, and I’ve seen the sceptics realise the value of acute physicians and even tell me how jealous they are of the type of work we do.
Now, in 2015, AIM is one of the fastest growing UK specialties, with well-established and highly regarded training programmes across the UK, and there’s increasing interest in developing AIM internationally. That makes me feel intensely proud of the specialty.
When did you decide to train in AIM?
I knew I wasn’t a GP or a surgeon, and that I loved the variety of the acute take and the AMU environment. If AIM hadn’t come along at the right time I think I would have ended up in another of the acute care specialties. To me, AIM offered all the best bits of the medical and critical care specialties, in an environment which I found motivating and supportive.
What training do you have to do to get into AIM?
After completing the Foundation Programme, trainees can choose either Acute Care Common Stem (ACCS) or Core Medical Training (CMT), and they must complete the MRCP(UK). Higher specialty training in Acute Internal Medicine then begins at ST3 (specialty training year 3). Trainees will dual train in Acute Internal Medicine and General Internal Medicine in their higher specialty training years.
Do you work closely with other specailties?
Very much so – it’s one of the main attractions of the specialty. Almost all medical patients are admitted to hospital through an AMU. On a daily basis I speak to colleagues in many different medical specialties about my patients, and I really love that interaction and interface with the rest of the hospital. I also work hard at maintaining a good working relationship with our referrers (GPs and ED mainly, but sometimes other healthcare services) as it’s crucial that our patients are seen by the right person, in the right place, at the right time.
AMUs are often seen as the hub for secondary medical care and it’s great to have the interaction with the other specialties that comes with that position – it’s a very sociable specialty to be in.
Typical work pattern
Each department works differently, but acute medicine can be quite sessional which many people find attractive. There are days when I’ll work later into the evening when on call and I help to provide weekend cover, but the frequency of this varies between trusts. In compensation for working weekends and evenings I’ll get week days/afternoons off which suits me. I’m not aware of any trust where the consultant acute physician is resident in the hospital overnight.
I have a rolling 5 week rota, where I do a week of take, a week of ambulatory care, a week of enhanced care (Level 1 and 2), a week of research and Supporting Professional Activities (SPA), and then a week of prospective cover or leave.
My take weeks are when I am on the AMU daily, assessing and managing patients as they arrive, reviewing all the patients under my care on the AMU, coordinating their care and discharge home or to another specialty ward if needed. I do this in tandem with another consultant colleague so that we take it in turns to stay late to see patients as they arrive in the evenings.
Ambulatory care is a clinic type facility where I can see patients post discharge from the AMU for review, follow up results that are outstanding for AMU patients, see new referrals from GPs, discuss cases with GPs, and manage certain patient pathways such as DVTs and outpatient IV antibiotics.
Enhanced Care is an area on our AMU where we have Level 1 and Level 2 patients – so a variety of patients in need of monitoring, ventilatory and cardiovascular support, with increased nursing levels. It’s my chance to put my critical care skills to use, work closely with the intensive care team, and it adds to the variety of intensity of work that I do.
My week of research and SPA is my chance to attend meetings, deliver teaching, write articles and documents, focus on my own continuing professional development (CPD), analyse how the department is performing, and concentrate on the non-clinical aspects of my job such as strategy, service development and clinical governance.
Building in prospective cover to our rota means that it’s flexible, sustainable, and we don’t have to cancel any patient activity in order to take leave, so the service can keep delivering for our patients.
Opportunities for teaching, lecturing and research
Given that almost all junior doctors work on AMU at some stage, there are many opportunities to teach both undergraduates and postgraduates. With such high multi-disciplinarily team input, much of the training on AMUs can be multidisciplinary. I do a lot of teaching and trainee supervision that can be in the form of direct supervision on the ward, in a classroom, on courses or in a simulation centre. Again, having that broad skill set makes the acute physician a perfect choice to provide training.
Interest in the processes of acute care delivery is currently topical, with quality improvement science being embedded into departments’ daily activity. The data generated by AMUs is gaining a lot of interest nationally, at trust board level, and with local commissioners. Acute physicians use their data to measure against standards of care and influence commissioning decisions and care pathway development.
Common misconception and changes within the specialty
We are not on call all day every day. We are quite sessional in the way we work and good job plans mix a variety of work intensities into the rota. Being on call overnight and working into evenings and weekends is reflected in the overall hours of work, so that means time off during weekdays when everyone else is working, which I really like as it can make juggling family life much easier.
It is also a misconception to think that acute physicians never get to see what happens to their patients. Patients tend to stay on an AMU for no longer than 72 hours – but that is long enough for me to get the vast majority of patients directly home again, supervising the full admission from start to finish with as much continuity in care as possible. AMUs will often have follow up clinics where patients are seen once after their admission.
I’ve seen huge changes and advances in both the training and provision of acute medical care. The way hospitals admit and manage patients in specialist admissions units with dedicated allied healthcare professionals is all still relatively new. As the pressures on secondary healthcare provision rise, trusts are investing in innovative acute medical services to improve patient care and patient flow. Patients’ length of stay is now much shorter and increasing numbers of patients are being treated in an ambulatory-care setting. Patients are getting relevant specialty input earlier and we know that inpatient mortality levels fall when you have consultant acute physicians available on an AMU.
Advice and tips
Almost all trainees will work in acute medicine at some point, so even if it’s not your career choice take advantage of the opportunities offered by an AMU ie:
- lots of senior supervision
- a large variety of cases
- lots of practical skills training
- consolidating excellent history and examination skills
- seeing the results of your direct intervention
- developing your diagnostic and management skills
- the chance to work in a really vibrant and multidisciplinary environment
If you’re thinking about applying for AIM training, make sure you experience working in a few different AMUs with several different acute physicians, as they all work slightly differently. Talk to lots of people in the specialty so you have no unanswered questions. Finally try to get to an acute medicine conference - there are many available, but especially the Society for Acute Medicine ones will allow you to see what’s happening in the specialty and you’ll get to meet lots of like-minded individuals.
Acute physicians need to have excellent clinical acumen, with a solid grounding in all medical specialties, and need to know who to call when they don’t know the answer! Exemplary communication and people skills are vital given the vast number of patients, families and staff groups that they will meet and work with. Doctors who show compassion and genuine care for their patients and their journey through what is a complex healthcare system will do well in acute medicine. They obviously enjoy working on the AMU, have a good dose of common sense, value the full multidisciplinary team, and show enthusiasm and initiative to improve the way we do things. Acute medicine attracts individuals who can effectively lead a large multidisciplinary group through what are often large cultural shifts and changes in the drive to provide excellent care.
Ultimately, they are the doctors that I myself would want to be treated by.
Find out more by watching Dr Hannah Skene's video-cast.