With the advent of Modernising Medical Careers, most medical specialities secured their trainees the option to relinquish General (Internal) Medicine – G(I)M. Cardiology, gastroenterology, endocrinology, respiratory and rheumatology registrars can opt out to undergo speciality-only training, or specify that only 2 out of the 5 years will include acute G(I)M take.
Geriatrics is now the odd one out. Most geriatric trainees undergo 5 year rotations with very few having speciality-only periods of training.
Is there too much G(I)M?
I think so. If you are geriatric specialist trainee, you can look forward to 5 years of hard labour on nights and the dreaded medical registrar on-call rota. The positive side of being involved with GIM and the acute take is that, with the ageing population, the average medical take has ‘aged’ considerably and as the medical registrar on-call, a large proportion of the workload is dealing with older patients. This is the bread and butter of geriatrics. In medicine, clinical exposure and experience is a fundamental necessity and in the era of the European Working Time Directive (EWTD) and partial shifts one could argue that more training and on-call experience can only be a good thing.
However, on the flip side of the coin, EWTD and partial shifts also mean fractured training and a lack of continuity of care. Post-take rounds are usually rushed affairs with very little feed-back or follow-up of interesting patients. The traditional grand teaching post-take rounds are now extinct. Medical registrar on-call is service provision with very little to gain in terms of training. In some hospitals, the acute team may not even present the patients they clerked during the day or night shift. In others, the med reg on call triages the bleeps/referrals whilst ‘running the take’.
Many would also argue that Geriatrics = G(I)M. The complexity of frail older patients ensure that there is a wide variety of exposure to all elements of medicine from haematology to neurology to neurosurgery. So a ward round on the geriatric ward is mostly composed of general internal medicine training. So why is there a need to top this up with the Acute on-call GIM experience for 4-to 5 years? Is there a marked difference between the two?
Is this affecting our morale and recruitment?
Again, I tend to think “yes”. Being medical registrar on call is stressful, disruptive and probably life-shortening. It is certainly not viewed in a positive light by trainees.
Considering the range of specialities available and, in particular the shorter length of G(I)M training in other specialities, it is perhaps unsurprising that many “natural geriatricians” now seek out other specialties.
• Shorten the training: Is there a need for Geriatrics to be a 5 Year programme or can we emulate acute medicine and convert into a 3 year Geriatric/GIM training with an extra year to further sub-specialise in stroke, orthogeriatrics, incontinence, community, rehabilitation, memory or research?
• Speciality only training years: 2 years G(I)M and 3 years geriatric training with no acute on-calls.
• Recognise that G(I)M=Geriatrics: Lighten the requirements of case-numbers, outpatient sessions and recognise that time spent on geriatrics wards and training days are, actually, G(I)M training as well. We do not require as much “non-specialty” exposure as other registrars in rheumatology, cardiology or gastroenterology.
• Recognise that Geriatrics=G(I)M: We could adopt a bold and radical strategy. Why not make geriatric training the equivalent of GP training and shorten it to just 3 years! This would be a radical solution but will go someway to attracting trainees and will appeal to even GP trainee applicants who may be put off by the long length of training required for a career in hospital medicine.
What are your views or thoughts?
I find that I think differently about this depending on whether I approach it from the evangelical or pragmatic perspective.
From an evangelical angle I think that we ought, as geriatricians, be seeking out frail older patients and delivering the best possible care to them – wherever they are. As you point out in your blog entry, there are a lot of frail older patients on the acute take. Do they not deserve to be sought out and looked after by geriatricians? Ought we not to be recruiting the type of doctors to our specialty who are happy to endure a few sleepless nights and stressful afternoons to find those patients with advanced frailty and complex comorbidities who most need our help?
From a pragmatic angle, I have – in the recent past – supervised many trainees who seem to flourish in the role of foundation doctor, or core medical trainee, in a specialist service for frail older people. Talented, wise, dedicated to providing a high quality service to the most vulnerable in society. They are instinctively drawn to our specialty and yet put off by the lifestyle implications of joining the specialty with the most substantial commitment to the acute medical take.
Geriatrics encompasses much of G(I)M but it also encompasses so much more. No other group of general physicians learns about comprehensive multimodal assessment in the way that we do. No other group of doctors understands frailty as we do. We know about and understand bio- and socio-gerontology. We learn about and know about rehabilitation driven by goals set to encompass broader definitions of health, rather than the narrow world of illness that defines the work of most physicians. We will lose these specialist aspects of geriatrics if we allow ourselves to be lulled into the view – that other physicians hold – that we are just general physicians.
So the solution, I think, is to level the playing field. 66% of acute hospital inpatients are over the age of 65. A growing number are frail. Geriatricians can’t provide care to all. Other doctors have to learn how to look after this core constituency. So it is now time for the “-ologists” to be made to re-engage with the acute take and to use it as an opportunity to learn not just general internal medicine but some of the additional skills that make geriatricians special. This way they can serve their patients better and the bright young things who would be natural geriatricians will realise that an obligation to the take is just part of being a physician. There is no “easy ride”, so they might as well get on and choose the thing that they most enjoy doing, and are best at. For many, this will be geriatric medicine.
Também jamais quer mais saber dessa dieta sofrida. http://jeremy1999ad.blogs4funny.com/let-us-explore-the-ins-and-outs-of-this-concept-to-truly-understand-how-fitness-health-and-spirituality-intertwine-to-create-a-well-rounded-life-1