Dr Adam Gordon is a Consultant and Honorary Associate Professor in Medicine of Older People at Nottingham University Hospitals NHS Trust. He is Deputy Honorary Secretary of the British Geriatrics Society and also edits this blog.
The report of the Future Hospital Commission, published last week, suggested we needed “a cadre of doctors with the knowledge and expertise necessary to diagnose, manage and coordinate continuing care for the increasing number of patients with multiple and complex conditions. This includes the expertise to manage older patients with frailty and dementia.”
The most evidence-based way to manage frail older people is Comprehensive Geriatric Assessment (CGA). CGA has consistently been shown in large meta-analyses and systematic reviews over the last 20 years to improve outcomes for older patients. These include – but are not limited to – decreased risk of cognitive decline and death, increased likelihood of functional independence and a lower probability of readmission to hospital.
Doctors don’t “do” CGA – it is delivered by a multidisciplinary team (MDT). It requires assessment across multiple domains (medical, psychological, environmental, social and functional), accompanied by case management and iteration of management plans. The role of doctors is to provide diagnosis and prognosis, to initiate medical treatments where necessary and to do so with consideration to the broader management plan agreed with the MDT.
If doctors are to do this they need first to understand how CGA works. They need teaching on the theory, supplemented by experiential learning that allows them to identify and develop the pre-requisite skills and attitudes. Doctors also need to develop sufficient expertise in the management of the conditions most common in frail older patients. This will enable them to populate their part of CGA – the medical part – with appropriate skill. They need to know about incontinence, cognitive impairment, falls, syncope and immobility as well as the pathological processes and diseases that drive these presentations.
We still cannot be sure that every medical school in the UK delivers dedicated teaching in these principles. Although national surveys of undergraduate teaching about geriatric medicine and ageing conducted in 2008 and 2013 had good response rates, there are 10 medical schools for which we have no data. Meanwhile, doctors can pass through foundation training – and through core medical training – without the guarantee of training under the supervision of a geriatrician.
The retort to these concerns – that frail older patients are everywhere and that doctors will therefore learn to deal with them by osmosis – is flawed. The challenge is not for doctors in training simply to be around older patients. The challenge is for them to develop the skills to manage them according to evidence-based principles.
So the British Geriatrics Society is calling for the following:
- every medical school in the UK should be able to identify where, in the curriculum, it teaches about Comprehensive Geriatric Assessment and where students gain experience of it in practice.
- every medical school should be able to map its teaching to the learning outcomes specified in the BGS recommended curriculum for medical undergraduates.
- all foundation programme doctors should undergo a period of dedicated training under the supervision of a consultant geriatrician.
- all core medical trainees should undergo a period of dedicated training under the supervision of a consultant geriatrician.
We’re working closely with the national bodies responsible for medical training to try to have these requirements accepted as essential. This is important stuff. If doctors fail to develop the appropriate knowledge, skills and attitudes, no amount of structural tinkering with the NHS will make us ready for the future.