Acute Hospital Treatment Research Articles

Acute hospital medicine in Ireland — past, present and future

The twentieth century has seen enormous changes in the practice of medicine, and as it becomes ever more successful, demand for acute hospital treatment can only increase. For political reasons the growth of Ireland's hospital service has been erratic and poorly planned. There are, therefore, still Irish hospitals in which acute general medicine is practised without subspeciality support by a dwindling number of general physicians. These physicians and their medical units care for more than half of the 140 000 acute medical admissions/year to Irish hospitals. Most Irish general medical units are efficient with short length of stays compared with other specialities, and low levels of inappropriate admissions by international standards. However, fundamental problems have developed in Irish post-graduate medical education, which are presently seriously lowering morale throughout the profession. Although the number of hours worked has recently been decreased considerably, the proportion of hours spent doing nonmedical menial and clerical work has increased, with a corresponding decline in the number of hours spent in productive patient-related training. As a result, clinical training has become far less satisfying at every level: professional, educational and emotional. Despite the fact that manpower statistics predict an oversupply in the near future, young Irish physicians still continue to seek subspeciality training and show little interest in acute hospital medicine. A major cause of this paradox is the lack of general physician role models in Irish academic centres. The provision of medical service to the population at large is the medical problem of our age: it is undoubtedly true that in the past, many physicians acquired much of their skill by a process of trial and error, often at the expense of their patients. The challenge for the future will be how to recruit and train the next generation of general physicians safely and appropriately.

A comparison of three health status indicators.

Interest in health status indicators has produced measures of widely varying applicability. We were interested in the use of such indices to establish mean recovery curves for groups of similar patients undergoing acute hospital treatment. A longitudinal study relating resource usage to these recovery curves had been intended but there were difficulties in finding suitable indicators. Firstly, two published indicators relying on patient interviews were tested for consistency. Poor correlations were found among those scorers unfamiliar with the patients and it seems unlikely that these indicators could be used in a routine system. Different parts of the indices presented difficulties to the different professions involved in scoring, and a multidisciplinary approach may be needed in assessing full health. The indicators tested included no assessment of prognosis. Those parts of the indices which had produced significant correlations were retained in subsequent work and were supplemented by further measures designed to overcome the earlier difficulties. A new trial of this indicator was undertaken where staff, familiar with the patients, scored data recorded by the Problem Oriented Medical Record system. This produced improved correlations but some problems remain.