IT’S A widely known fact that, on the whole, people in the UK are living longer. Average life expectancy is expected to reach 90 by 2015, a good seven years longer than in 1997. The knock-on effects of this are many, from a steadily increasing state pension retirement age to the need to overhaul the funding of elderly care and consider improvements in end-of-life care.
An ageing population presents unique challenges for the NHS and could present the specialty of geriatric medicine with a unique opportunity to grow.
Geriatric medicine is defined as the branch of medicine concerned with the clinical, preventive, remedial and social aspects of illness in older people. It is the largest specialty within the Royal College of Physicians (RCP) and involves close interdisciplinary working with nurses, therapists, pharmacists, dieticians, social workers and many other health professionals including GPs, old age psychiatrists and many hospital clinical specialists.
While it may not be viewed as the most glamorous of the medical specialties, the fact is that almost two thirds of general and acute hospital beds are in use by people aged 65 and older and 43 per cent of NHS spend is on this group. Geriatrics is said to be enjoyable, stimulating and rewarding and there is some argument that given the growth of this patient group, geriatric medicine should be a compulsory part of the medical school curriculum.
Entry and training
The British Geriatric Society (BGS) recommend that doctors who are interested in a career in geriatric medicine gain experience either during F1/F2 on a general medical ward or apply for an F2 taster experience. They advise medical students to look at their choice of elective and ensure it offers relevant exposure to the specialty.
The BGS describes the personal qualities of a geriatrician as someone who:
• enjoys acute medicine and a variety of the medical specialties
• likes to sort out multiple and complex medical problems and is prepared to engage strongly with the social care sector
• is a good listener and communicator
• likes to enthuse others and lead by example
• would enjoy the challenge of practising a high standard of care for older people and has a down-to-earth, approachable personality
The Society also has a trainees group which offers opportunities for networking and provides experience in the governance of medicine.
Upon completion of F2, doctors undertake seven years of specialty training. This involves a two-year broad specialty programme (ST1 and ST2) in one of three types of training scheme, either Core Medical Training (CMT), Basic Neurosciences Training (BNT) or Acute Care Common Stem (ACCS). All three types of training programme can lead on to specialist training in geriatrics but the majority of doctors tend to do CMT.
ST3-ST7 involves competitive application to a five year specialty training programme in geriatric medicine leading to a CCT (Certificate Completion Training) in geriatric medicine. Competency in Level 2 Acute & Internal Medicine will also be achieved during this time which allows doctors to practise as a consultant physician managing an unselected acute medical intake in addition to specialty work.
Flexible training is above average in geriatrics and there are opportunities for those looking to work part-time. The specialty also offers limitless opportunities for clinical and laboratory research – one year of research can be undertaken during ST3-ST7 and counts towards the award of CCT without prolonging the specialty training programme.
Most geriatricians are based in acute general hospitals, caring for patients admitted via the emergency units with acute illness. In addition to acute and emergency care, geriatricians are involved in rehabilitation and an increasing number work within community based services. The majority of geriatricians also play a significant role in the acute care of adults of all ages admitted via the medical take.
Presentations of illness in old age are often non-specific and the RCP describes how geriatricians focus on falls, immobility, incontinence and confusion as well as adverse drug reactions. They see a broad range of illnesses, particularly stroke, heart disease, infections, diabetes, delirium and the dementias. Some geriatricians deal with the whole range of geriatric problems, particularly those who spend time working in the community. Others specialise in areas such as orthopaedic geriatrics, stroke, falls and syncope, cerebral ageing and Parkinsonism.
Many geriatricians are on call for all adult medical emergency admissions with opportunities to be involved in private practice, with the work often orientated towards subspecialty interests. There are opportunities to be involved in private practice, with the work often geared towards subspecialty interests. It also takes the hospital doctor into the community more than most other specialties.
Geriatric medicine is a large and growing specialty which combines intellectual challenge with human interest and deals with the whole person and their family, as well as diseases. It offers a varied and rewarding medical career.
Q&A Dr Suzy Hope, ST4 in geriatric medicine
• What attracted you to geriatric medicine?
My earliest shortlist was between GP or hospital medicine, but I realised I still loved hospital medicine. It was then a quick process of elimination that brought me to geriatrics. I’d done a lot of work as a healthcare assistant and loved the company of older people. The main thing that drives me is to try to help make people feel better, and this often requires more than just giving someone a pill – especially in the case of older people where there is also frequently more than one thing going on.
• What do you enjoy most about the job?
It is hugely varied, both in terms of the patients’ conditions and in the training opportunities and responsibilities. Having to use basic communication skills and common sense keeps you grounded and is very satisfying. Sitting down to solve problems as part of a team is hugely rewarding. I like that our opinion as geriatricians is valued by other specialties and also enjoy advocating for patients and their families. Most geriatrics registrars do general internal medicine as well, which means we are on the medical registrar on call rota, which adds extra variety and experience to the mix.
• Are there any downsides?
Clinic appointments aren’t always long enough. When there are staff shortages on the wards and bed pressures, it can sometimes feel like fire-fighting rather than being able to sort things out as much as one would like. But there’s always the option of bringing them back to an outpatient clinic which is useful for follow-up.
• What do you find most challenging?
When I started, it was challenging being off the ward a lot due to other responsibilities and training, which means having to “let go” of the day-to-day medical running of the ward. With staffing shortages and juniors being moved at short notice to cover other wards the continuity of care can feel threatened at times. I do miss not knowing the patients as well as I would like to, but the challenges of putting together and using all the accrued information at the ward round or MDT is satisfying.
• What is your most memorable experience so far?
So many! Usually they revolve around patients’ characters, whether they’re stroking consultants’ beards whilst giving the rest of the team a cheeky wink, playing the mouth organ for us or getting all the patients around a dining table rather than eating at their bedsides.
• What advice would you give to a final year or FY trainee considering geriatric medicine?
If you like taking the time to talk to people, and enjoy detective work and sometimes complex general medicine, do it! Get as much general medical experience as possible. It’s now pretty much compulsory to do audits from an early stage, so talk to a geriatrician to get some good ideas and guidance. And then ask if they can help you submit it to a geriatrics-related conference.