Where

is the sharp end and how did we get here? Editor – The paper by Almond (Clin Med April 2007 pp 105–8) does not mention two challenges that acute medicine has to overcome: one organisational, and the other clinical and intellectual. The organisational one is that, though the Royal College of Physicians sees the role of acute medicine as one of improving the management of acutely sick patients, in practice these patients represent a small minority of today’s takes. Management therefore view the physicians ’ role as being to decide who needs to stay in hospital and to expedite the discharge of the rest. The clinical and intellectual challenge is the tendency, in my experience, for medicine on the acute medicine unit to be directed more towards ‘excluding ’ or managing a select few high-profile condi-tions, such as acute coronary syndrome or deep vein thrombosis, rather than actually establishing a diagnosis. There is therefore a tendency for patients to be discharged with the knowledge of what is not the matter, but not what actually is. While sometimes this may not cause any great harm, it is hardly good for our intellects or for the training of junior physicians. The best method of ensuring speedy and safe discharge is accurate diagnosis – a sentiment with which I hope all acute physicians would agree