For he’s a jolly good fellow…

David Shipway is a final year registrar in geriatric medicine working at London’s Charing Cross and St Mary’s Hospitals, Imperial College NHS Trust. He is currently developing a new comprehensive surgical liaison service for patients undergoing gastrointestinal surgery.shutterstock_154668242

With population ageing, the number of oldest old undergoing surgery is increasing markedly. For anyone who’s recently been the medical registrar on-call, it will come as no surprise to hear that there is considerable unmet need on the surgical wards of the UK. But the experience of pioneers in this field has proved that reactive post-operative care is not enough: a proactive approach immediately following the decision to operate is needed to improve outcomes for older patients undergoing surgery.

Proactive care of the Older Surgical Patient (POPS)

Geriatric surgical-liaison is a nascent sub-specialty which is rapidly increasing in size and stature. The vanguard departments with dedicated services, such as POPS at Guy’s and St Thomas’ in London and SCOPES in Nottingham are extending their experience and we are seeing newer centres of peri-operative geriatric liaison emerging nationwide. I was fortunate to recently complete the Guy’s and St Thomas’ POPS fellowship. This fellowship is now in its second year, and after completing 12 months in position, it’s time to reflect a little on what this fellowship can deliver and why similar fellowships should be established nationwide.

Specialist Knowledge

First things first. Twelve months of surgical liaison has been a blast of nostalgia for wide-bore nasogastric tubes, iloprost infusions and high output stomas. Defrosting a bit of surgical knowledge gives you a smidgen of credibility on the surgical ward round. Understanding what’s normal and what isn’t helps with picking through the post-operative problems. Knowing the expected admission duration for a robotic cystectomy or TURP helps identify the outliers at the surgical board round, and knowing what’s likely to go surgically wrong tailors your pre-operative advice and planning.

Geriatric & General Internal Medicine

Though specialist surgical knowledge is invaluable, the real role of the geriatrician in surgical liaison is to bring geriatric and general medical skills to the surgical patient in the surgical setting.  All the gems of the geriatric ward can be found in surgery, but under the care of doctors who aren’t specifically trained to manage them. There is a palpable need for clinicians who can confidently handle delirium through to diabetes, by way of hyponatraemia and heart failure.

Leadership, research and the added extras

But doing a dedicated fellowship is not merely about practicing generic geriatric medicine on surgical wards. Under supervision and mentorship, a fellowship can provide an opportunity to develop your leadership style.

With the housekeeping of the ward no longer your direct responsibility, it is possible to turn your hand to the bigger picture: itself an important facet of consultancy. Throughout our training we are expected to engage with quality improvement projects many of which are driven by an acute ARCP requirement rather than direct interest and enthusiasm. It’s no surprise that these projects fail to create an impact or are lost to follow-up. A fellowship provides a specific opportunity and dedicated time to achieve these aims without the distractions of a gritty on-call rota and providing ward cover for stretched SHOs. In my case, we were able to establish and develop a system of twice-weekly MDT board rounds in urology. This was shown to significantly reduce inpatient length of stay for both older and younger urology patients. It is now standard practice and built in to the team timetable.

The Bottom line

This fellowship provided me with direct, yet supervised, experience of how to practically go about meaningful service improvement. Having time and opportunity to execute and develop these plans has provided a base of experience, which I intend to draw upon as a consultant. Since the fellowship involved ongoing, supervised clinical experience as a senior registrar, I was able to accredit the fellowship for training with the JRCPTB and PYA panels for both geriatric and general medicine. My OOP(E) hence became an OOP(T).

I would strongly recommend that fellow trainees apply for fellowship opportunities such as this to diversify their training, and also to experience something different.

Consultants looking to set up new services should also strongly consider applying for fellowship funding. The benefits of this may be two-fold: additional boots-on-the-ground to help design, execute, evolve and evaluate new services. Secondly, this would broaden the range of sub-speciality fellowships available and improve leadership training within geriatric medicine.

That could only be a good thing for the future of our speciality.

1 thought on “For he’s a jolly good fellow…

  1. sounds like a great project and ideal as a fellowship opportunity- as yet an under filled subspecialty. Is there a place for additional funding for fellowships that I am not aware of??? Would love to know.

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