Chapter 9 Medicine
Introduction
• The prospect of undertaking a medical placement or rotation within an acute hospital trust can fill a student or band 5 (newly qualified or not) with either a sense of trepidation or excitement.
• Medicine tends to be a placement or rotation that is not considered by many students or graduates to be ‘desirable’, unlike outpatients, ITU or paediatrics for example.
• What is involved in working in medicine tends to be poorly understood by both students and graduates alike.
• Medicine is a diverse speciality where physiotherapy can really make a difference to patients’ independence and the overall quality of their lives.
• From a professional and developmental perspective medicine can provide an environment where fundamental knowledge and skills can be acquired which will be valuable and applicable to all other areas of physiotherapy practice, that are likely to be encountered throughout a professional career.
• The most likely location of a medical rotation is within an acute hospital trust, the size of which can be variable.
• It is realistic to say that a band 5 will be responsible for more than one medical ward, and students may also find that they have patients dispersed over a number of wards.
• Medical wards may encompass any number of beds from 20 upwards.
• There has been an increase in average age of the population in recent years and this poses increasing challenges for clinical staff working in the area of medicine when it comes to providing safe and effective management of their patients.
• There have been rising numbers of admissions and the associated demand for beds has often been accompanied by a reduction in the number of acute beds that are available as a result of efficiency cuts in budgets.
• Many of these changes have followed the introduction of government policies and it is these policies that have provided the drivers for the production of clinical guidelines (DOH 2010, NHS 2000, Reeves et al, 2003).
• The Department of Health white paper: ‘Equity and Excellence: Liberating the NHS’ (2010) outlines the future of the NHS, with Government recommendations suggesting reforms that are both challenging and far-reaching in terms of the cultural changes that they will bring about in the NHS (DOH 2010).
• The proposal is for the NHS to release up to £20 billion through efficiency savings, which will be reinvested to support improvements in quality of care, clinical outcomes and to provide a coherent, stable, enduring framework for quality and service improvement (DOH 2010).
• It is realistic to view the proposals as being the most significant and radical changes in the NHS in recent times that may change physiotherapy practice beyond recognition and will impact on the delivery of physiotherapy in the medicine setting (Dixon and Ham 2010).
Conditions encountered in medicine
• All patients will be under the care of a consultant-led medical team for the duration of their admission in hospital.
• The conditions and pathologies that will be encountered within the speciality of medicine either as a presenting condition (PC) or past medical history (PMH) are diverse.
• It is not possible to cover these in depth in this volume, therefore a list of examples is provided to indicate the variety of conditions and experiences associated with medicine (Table 9.1).
• It is essential to have some knowledge of the condition a patient is presenting with and/or the patient’s past medical history in order to perceive the patient holistically.
Table 9.1 Specialist areas of practice and common conditions associated with medicine
| Cardiology | |
| Respiratory | |
| Neurology | |
| Vascular | |
| Metabolic | |
| Urinary | |
| Oncology | |
| Cellulitis | |
| Falls |
The role of the physiotherapist and the multidisciplinary team (MDT)
• It is equally important to recognise the role of the physiotherapist during the patient’s period of hospital admission.
• The process by which a patient is referred into the physiotherapy service will vary, depending on the system of preference within an individual hospital.
• Some units may operate a ‘blanket referral’ policy, where every patient on a particular ward has their physiotherapy needs assessed.
• Other organisations may operate a ‘nurse-led’ referral system, resulting in the nursing staff being able to refer patients to the ward physiotherapy service on an as-required basis.
• Some may follow the more historical system where only members of the consultant team are able to complete a referral, i.e. house officer (HO), senior house officer (SHO), registrar (Reg), senior registrar (Sen Reg) or the consultant themselves.
• Alternatively a service may operate a mix and match of any of the above referral processes.
• MDT working is covered during the training of physiotherapy students in the university setting where it may seem to be a rather abstract concept in many instances.
• It is during placements or rotations that multiprofessional practice is placed into context.
• It is in clinical practice where MDT working can be seen to facilitate the efficient and effective management of patients, ensuring discharge from hospital occurs in the shortest possible time.
• During a medical placement/rotation the other members of the MDT that will come into contact with physiotherapists are; occupational therapists (OT), speech and language therapists (SALT), social workers (SW), dieticians, pharmacists, specialist nurses with an interest in chronic obstructive pulmonary disease, tissue viability, multiple sclerosis or Parkinson’s disease.
• In the author’s experience the use of a physiotherapy ward book can be an effective and informative method of keeping a record of the patients that have been referred into the service and can include specific information about when they have been seen or not and also highlight those that are deemed to be too ill for intervention.
• Ward books also offer an ‘at a glance’ view of the workload that includes the case mix, overall numbers of patients and levels of dependency.
• They can be found along with other medical records on the ward or in a designated physiotherapy area.
• Medical wards can be incredibly busy, therefore it is essential that ward physiotherapists remain aware of what patients are currently under their care, that they are confident when prioritising their workload, are clear about when patients were last seen and that they ensure timely intervention.
• If patients are not on the ward, as anticipated, the reason for this needs to be discovered, e.g. a patient may have been transferred to another ward or specialty, they may have been discharged or have self discharged or no longer require treatment, e.g. the patient has died.
Prioritisation
• With the rising pressure to provide efficient services in health and social care the assessment and subsequent prioritisation of the patient care is imperative to ensure that they receive appropriate physiotherapy intervention in a timely and appropriate manner, according to their care needs and also in relation to their discharge plan.
• The workload tends to be much more variable on a medical ward than, for example, the predictable flow of patients every 20 or 30 minutes as experienced by physiotherapists in the outpatient setting.
• It is important to be able to manage time effectively in order that patients are appropriately assessed, that the physiotherapy interventions are defined for their particular needs and delivered in the appropriate time frame on any particular day.
• To be able to achieve this it is essential that the physiotherapist is able to prioritise their workload; if this is not done the patients will not be managed in the most efficient manner and will spend longer in hospital, further increasing pressure on beds.
• Prioritisation is a skill that needs to be developed.
• The physiotherapist needs to have an in-depth understanding of the presenting condition (PC), PMH and the associated risks of not seeing a patient within a desired time frame, if they are to manage their patients effectively and efficiently.
• In some organisations there may be a generic in-patient prioritisation document or process that will have been designed to assist physiotherapists in being able to identify high, medium and low priority, which is the equivalent of the ‘must, should and could’ process used in many musculoskeletal outpatient departments.
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