A day in the life of an acute medic

I’m a consultant in acute medicine, which means I care for adults who become acutely unwell and need urgent medical attention.  It’s different from emergency medicine, we are looking after adults who need tests and treatment after their emergency department assessment, either on our ward (acute medicine unit) or via our clinic (ambulatory emergency care). It’s a bit like being a GP in a hospital, I will meet people who have a huge variety of medical (and non-medical needs). You may wonder why I combine this work with my role here at Macmillan as I’m not a cancer doctor but nearly 15% of people who are admitted as an emergency to hospital in the UK will have cancer as one of their diagnoses. I work with my colleagues in cancer care (oncologists, cancer nurse specialists in acute oncology) and other specialists (palliative care, surgery, geriatrics) to care for acutely unwell people with cancer and bring those experiences into Macmillan as a National Clinical Advisor in the Centre of Clinical Expertise. 

Although there isn’t a typical day, I’ll talk about some of the people I meet with cancer in my day-to-day work 

Some of my clinical shifts are based in the emergency department seeing patients emergency medicine doctors have referred for ongoing investigations and care. Just last week I met a man in his late 60s who had been feeling increasingly breathless over the last weeks. He had tried to get an appointment with his GP but struggled with the electronic form they used as he only had very basic ability to read and write. So he, like many people in my corner of inner city north London, had come to the ED (emergency department). His oxygen levels were slightly low, so he had a chest X-ray which suggested he had either a pneumonia or a cancer. He was sent for a CT scan of his chest and that showed he had advanced (metastatic) lung cancer. In the middle of a very busy ED with people waiting many hours for a hospital bed I had to explain to him and his partner that he had incurable cancer and would need to stay in hospital. Up to 25% of cancers in UK are diagnosed as an emergency. These cancers are often incurable at diagnosis and in are diagnosed in people who are adversely impacted by health inequities such as deprivation, high rates of smoking related lung disease and lack of health literacy.

On other days I am busy on our inpatient ward (the acute medical unit) seeing people who are at the start of an inpatient stay. On any given day two or three of the patients on my ward will be in hospital due to the effects of a cancer or the cancer treatment. I meet people like Susan* who has progressive incurable rectal cancer, we have met two or three times in the last 18 months during emergency admission with infections after chemotherapy, dehydration from vomiting when her cancer progressed and now when she had become very confused at home. She and her husband have had chance to talk about her wishes for her end-of-life care with a community palliative care team and she has said she would like to die at home. However, when she became suddenly more confused and agitated it wasn’t possible to get the social care support she needed at home quickly enough, so she is back in the hospital. It is hugely frustrating for her (and for me) when we can’t get the support needed for palliative care at home. As funding for community based social care, district nursing and specialist palliative care is reducing rather than increasing this is likely to be a more common situation. 

The last part of my work, and the part I am most proud of, is the work I do in our ambulatory care clinic (sometimes called SDEC, same day emergency care). This is a type of clinic where we provide complex diagnostic testing and treatment for acute medical illness without people having to stay in a hospital bed. We will do our very best to get people the tests and specialist expertise they need on the same day they come to hospital. For people with cancer this is a game changer- they can avoid the ED and spend more time at home. Recently, I saw a patient with incurable breast cancer who had become unwell with a fever. Instead of going to the ED she came to the ambulatory clinic and had a full work-up, with bloods, chest X-ray and tests for viral/bacterial infection. I discussed her with our infectious diseases’ doctors (as she was just back from a holiday in Thailand) and decided she could have treatment with oral antibiotics at home. I called her oncologist at another hospital, and they arranged to see her next week to ensure that the fever had improved before her next planned treatment. She went home at 6pm in time for her daughter’s bedtime. In old ways of working she would have waited in ED for hours and then stayed in a hospital bed away from family so it’s really satisfying to work in this way for me and my patients. 

As Macmillan’s strategy moves to focus on improving the care of people with cancer who are most impacted by health inequities, cancer and multiple long-term conditions, and variation in the quality of treatment and care they receive I hope that some of these stories from acute care will become increasingly rare.