Consultants prelims

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<ul><li> 1. Gastroenterology1 Description of the specialty and clinical needs of patientsThe specialty of gastroenterology and hepatology cares for patients with both benign andmalignant disorders of the gastrointestinal (GI) tract and liver. The specialty encompasses awide range of conditions from common disorders to highly complex problems andspecialised procedures such as endoscopic resection of cancers and transplantation.Common problems include change in bowel habit, indigestion, irritable bowel syndrome,inflammatory bowel disease, cancers of the GI tract, gastro-oesophageal reflux disease, chronicviral hepatitis and, in recent years, hepatic steatohepatitis and the rising burden of alcoholic liverdisease. Gastroenterologists also see patients with a variety of general medical problems,particularly anaemia and weight loss. Much of the work, particularly to exclude organic diseasein symptomatic patients and to provide rapid diagnosis and treatment for patients with suspectedGI cancer, is based in outpatients. The investigations required often include endoscopy andimaging. An acute and emergency inpatient service is needed for common problems such asgastrointestinal haemorrhage, acute inflammatory bowel disease, decompensated liver disease(particularly due to alcohol), other forms of liver failure and abdominal pain.Gastroenterology departments have an essential role in the implementation of the two-weekreferral strategy for improving the diagnosis and treatment of GI cancers. Several departmentshave combined to form multidisciplinary teams (MDTs) in order to provide the critical mass ofspecialists needed to meet the guidelines of the Department of Healths (DH) Clinical OutcomesGroup (COG) for the provision of specialist services.1Tertiary referral units may receive patients with complex hepatobiliary disease and complexnutritional problems that require total parenteral nutrition, as well as those who need complexnon-malignant GI surgery and complex therapeutic endoscopy. Patients who requiretransplantation of the liver and small intestine are referred to the small number of units thatundertake organ transplantation.2 Organisation of the service and patterns of referralRapid changes in referral patterns due to the implementation of primary care-basedcommissioning have led to multiple sources of referral to gastrointestinal services, which maybe shared between providers based in primary care and secondary care. Closer working betweenhospital specialists and GPs with a special interest should improve patient flows.Most symptomatic patients are looked after by their GP, and most problems are resolved bydiscussion, primary care-initiated investigation, advice and medical treatment. Nonetheless,there has been a continuing steady increase in outpatient and inpatient work for gastro-enterologists, particularly in relation to alcoholic liver disease and the increasing numbers ofcancers of the GI tract that occur in an aging population.140</li></ul><p> 2. 2 Specialty GastroenterologyThe increasing acuteness of medical admissions has meant that gastroenterologists have hadto reorganise their work in order to be able to take part in a daily triage of patients withemergency gastroenterology problems and to provide more time for ward referrals andemergency and unplanned endoscopy. These changes are an inevitable consequence of areduced inpatient bed pool. The inpatient casemix usually comprises patients with cancer,severe alcoholic liver disease and inflammatory bowel disease.Close liaison with colleagues in surgery, radiology, pathology and oncology facilitates thetreatment of different forms of GI disease. Combined outpatient clinics undoubtedly improvemanagement, and the weekly cancer MDT meetings are a useful forum for discussing allcomplex cases. Meetings with radiologists and pathologists should take place at least once aweek and can be combined with formal training sessions for trainees.Many units have established posts for specialist nurses working in inflammatory bowel disease,liver disease, disorders of bowel function and nutritional support and for those working asendoscopists. Larger departments will often employ consultant GI nurses, and GPs with specialinterests (GPSIs) will often carry out sessions in the hospital unit.3 Working with patients: patient-centred carePatient choice and involving patients in decisions about their treatmentMuch of the outpatient work in gastroenterology relates to the management of chronicconditions such as chronic liver disease and inflammatory bowel disease. Success depends on agood working relationship with the patient, whereby the patient has a full understanding of andparticipates in the management of his or her condition and it is clear where responsibility liesin patient care among the specialist, patient and GP. Inflammatory bowel disease is one examplein which patients will often initiate a change in their treatment in the face of a relapse of theirdisease, usually in close liaison with the specialist team or GP, or both. Patients are representedon the joint gastroenterology/hepatology committee of the Royal College of Physicians (RCP)and, through the National Association for Colitis and Crohns Disease (NACC), are involved inthe generation of standards of care for patients with inflammatory bowel disease. Similarly,patients have been involved in setting standards for nutritional support through Patients onIntravenous and Nasogastric Nutrition Therapy (PINNT) a core group of the BritishAssociation for Parenteral &amp; Enteral Nutrition (BAPEN). The British Society forGastroenterology (BSG) Endoscopy Section has devised comprehensive information leaflets forall patients undergoing endoscopy. The British Liver Trust and CORE the main GI charity also produce many helpful documents for patients. All of the charitable bodies have excellentinteractive websites, as does the BSG, whose website has a dedicated patient information area.Opportunities for education and promoting self careSpecialist GI nurses can expand the opportunities for patient education through discussion,leaflets and CD-ROMs and by directing patients to interactive websites.Many opportunities for improved patient care are available, including clear guidelines for theprimary-care management of patients with peptic ulcer and non-ulcer dyspepsia. Locally141 3. Consultant physicians working with patientsagreed referral protocols enhance care pathways for patients with suspected cancer, iron-deficiency anaemia and suspected liver disease. New guidelines on all of these conditions havebeen commissioned and produced by the BSG in the last five years. Targeted outpatient clinicsand joint medical and surgical assessment and management are increasingly being developed inall areas of the specialty. Other major advances have been made in diagnostic and therapeuticendoscopy, particularly by the implementation of the global rating scale for endoscopy unitsand the introduction of new techniques such as narrow-band and confocal endoscopy,endoscopic ultrasound, capsule endoscopy and radiology, and computer tomographiccolography. Some invasive diagnostic procedures such as endoscopic retrograde cannulation ofthe pancreas are being replaced by magnetic resonance imaging techniques. All of thesedevelopments need to be underpinned by first-class teaching and training.The introduction of new biological treatments for inflammatory bowel disease and betterantiviral treatments for chronic viral hepatitis, the identification of patterns of inheritance ofgenes that predispose to inflammatory bowel disease and the introduction of endoscopicmucosal resection are all remarkable examples of progress.4 Interspecialty and interdisciplinary liaisonMultidisciplinary teams and working with other specialistsThe practice of gastroenterology involves many specialties and perhaps a greater overlap betweenmedical and surgical practice than for any other specialty. For this reason, well-organised MDTworking is essential. This is coordinated through MDT meetings, and facilitating close liaisonwith tertiary referral centres is an integral part of the management of complex GI problems eg complex liver disease, pancreatic cancer, liver or small bowel transplantation and complexnutritional problems that often require home parenteral nutrition. Specialist nurses in nutrition,stoma care, GI oncology, general gastroenterology and management of the treatment of viralhepatitis play an increasingly valuable role in improving the quality of service, communicationand liaison between disciplines within the team. Hospital and community dieticians are vitalmembers of the GI team.Working with GP specialistsThe development of GPSIs and other primary care practitioners with an interest ingastroenterology has been a major advance during the last five years. Nationally, primary carespecialists have been closely involved in the production of guidelines by the National Institutefor Health and Clinical Excellence (NICE). Locally, GPSIs have helped to develop guidelines forthe shared care of patients with chronic gastrointestinal conditions and have also worked closelywith hospital-based gastroenterologists to develop networks, to supervise Clinical Assessment,Treatment and Support Centres (CATS), to determine the relevance of protocols for Chooseand Book referrals, and to ensure the more efficient use of direct-access endoscopy services.These developments have significantly shortened waiting times for the diagnosis of patientswith alarm symptoms.142 4. 2 Specialty Gastroenterology5 Delivering a high-quality serviceCharacteristics of a high-quality serviceCare for patients with GI symptoms should be timely, patient focused and consultant based.Although most patient care takes place in the outpatient department, this should be supported,in ideal circumstances, by a combined medical and surgical inpatient unit that provides senior-level expertise for the management of inpatients with GI emergencies 24 hours a day, seven daysof the week. A high-quality service will:qhave properly timetabled audit and clinical governance meetingsqfulfil the Joint Advisory Group on GI Endoscopys requirements for Endoscopyqhave sufficient time for staff development and appraisalqprovide consultant input at a high level into clinical managementqfacilitate research and academic interests where appropriateqimplement national and local guidelines on patient management.Consultants will also work closely with colleagues in other trusts to provide clinical networksto ensure that patients receive the highest quality of care. The BSG has produced a documenton care standards for patients with GI disorders2 and recommendations on out-of-hours care.3Resources required for a high-quality serviceSpecialised facilitiesSpecialised facilities are described clearly in the BSGs working party report of 2001 (Provision ofendoscopy-related services in district general hospitals4) and the 2006 report.5 Specialised facilitiesinclude a diagnostic and therapeutic endoscopy unit; facilities for parenteral nutrition; andoperative, anaesthetic and intensive therapy unit (ITU) support and interventional radiology intertiary referral units such as regional liver centres, which may or may not offer transplantation.There must be arrangements to support close collaboration with colleagues in oncology.Workforce requirements: clinical and support staffWorkforce requirements are considered in detail later in this chapter. Those that relate toendoscopy services are detailed in the BSG working party report.4 Adequate secretarial supportfor every consultant is essential. The complex working pattern of specialists and consultantsnecessitates that each has their own office. Communication is central to the safe managementof patients, and good information technology (IT) is necessary for auditing standards ofpractice within the department. Computer terminals should be present at all workstations andin endoscopy rooms and offices. In most gastroenterology departments, specialist nurses inendoscopy, cancer and palliative care are fully integrated into the management structure.Quality standards and measures of the quality of specialist servicesSpecialist society guidelinesIn 2006, the BSG produced a quality standards document backed up by data gathered over aone-year period.2 This provides information on all aspects of gastroenterological practice and143 5. Consultant physicians working with patientshow this can be improved. The BSG provides guidelines for the highest standards of care in allareas of clinical practice in gastroenterology. These have been published by Gut and areavailable on the BSGs website ( Clinical work of consultantsContribution made to acute medicineMost gastroenterologists are general physicians with a specialist interest in gastroenterology(85%). They therefore commit a major part of their time to the management of patients withgeneral medical problems as part of their unselected acute medical take, ward work andoutpatient work.The range of clinical commitments includes inpatient and outpatient services in generalmedicine, gastroenterology and hepatology; a specialist diagnostic and therapeutic endoscopyservice; and facilities for nutritional support. Gastroenterology is characterised by high-volumeand frequent inpatient and outpatient consultations, several sessions per week in diagnostic andtherapeutic endoscopy and the inpatient care of patients within acute medicine and thespecialty. Regular collaborative meetings are held to discuss clinical problems. Other tasksinclude contributions to the teaching and appraisal of medical staff and the teaching of medicalstudents, continuing professional development (CPD), clinical audit, clinical research,administration, commissioning and service management.Since the last edition of this document, significant demands have been added to the workexpected to be delivered by consultant gastroenterologists. Acute medicine has become moreonerous, with many hospitals running a daily triage service to specialist departments. Thesupervision and training of junior doctors is more prescriptive and occupies more time.Specialist cancer services may have been localised to fewer units, but the extra time required forMDTs and to dealing with two-week cancer referrals in general hospitals is a considerableworkload. Since the last edition, the DH has introduced fixed maximum waiting times foroutpatients, diagnosis and treatment, and endoscopy. These policy changes have had aconsiderable impact on the day-to-day work of gastroenterologists, who now have to devote asignificant amount of time to service redesign and commissioning. In addition, consultant jobplans and limitations on hours are having a detrimental effect on the provision of out-of-hoursGI emergency care.Direct clinical careThis section describes the work of a consultant physician providing a service in acute generalmedicine and...</p>