Adam Gordon and Adrian Blundell are Consultants and Honorary Associate Professors in Medicine of Older People at Nottingham University Hospitals NHS Trust. They write here about a programme of work to better understand how UK medical schools teach about ageing, undertaken on behalf of the British Geriatrics Society.
Let’s not beat around the bush here. Older patients make up the lion’s share of work for the National Health Service – as they do for the health services of all developed, and many developing, economies. Most doctors currently in practice will spend the bulk of their career dealing with older patients. Many of those older patients will have frailty, or physical dependency, or multiple medical conditions. Many will have all three.
Older people with frailty should be cared for by doctors who are expert – they deserve no less. These experts should be skilled in managing common medical presentations – heart attacks, strokes, pneumonia, gastrointestinal haemorrhage, urinary retention and so on – but to really meet the needs of the frailest older patients, those with the high levels of dependency, they need to be even more expert.
They need to understand how to deal with medical complexity, how to conduct an assessment across multiple domains (medical, psychological, functional, social and environmental), how to establish a problem list taking account of multiple problems, how to work with a multidisciplinary team and how to do all of this whilst supporting and empowering a very vulnerable person who finds themself in the midst of intensive and detailed medical assessment.
Undergraduate medical education has traditionally been good at teaching doctors how to manage medical problems classified by system. It has been less good at teaching them how to make sense of the situation when multiple systems start to go wrong all at once. Effective core teaching in geriatric medicine is one way to address this deficiency.
When we surveyed how undergraduates in the UK were taught about geriatric medicine in 2008, we identified a number of deficiencies. Not enough medical schools taught about the basic sciences of ageing (which we loosely termed, for the purposes of the study, biogerontology and social gerontology). There were critical deficiencies – from a patient safety perspective – in teaching about elder abuse and pressure sores. The British Geriatrics Society sent these results to the deans of all UK medical schools at the time.
A lot has happened since 2008. Ageing has become a hot topic in the collective psyche of the medical profession, the healthcare services within which we work and the public that we serve. The Francis Report, Future Hospitals Commission, Hospitals on the Edge and Future Shape of Training Review have all highlighted the central importance of effective responses to older patients with frailty and dependency as part of a functioning healthcare service.
Against this background, we set out to understand whether the change in zeitgeist had been reflected in better undergraduate teaching about ageing and geriatric medicine.
As a first stage in this process, we had to establish what it was reasonable to expect undergraduates to know. In 2008 we produced a recommended undergraduate curriculum in ageing derived from the then available curricula of the American, Australasian and UK geriatrics societies, and the recommended curriculum of the International Association of Geriatrics and Gerontology. To ensure that this remained current and applicable to UK practice, we undertook a mapping exercise to compare this to the existing statutory guidance for undergraduate training – the third version of Tomorrow’s Doctors. The mapping exercise, published in Age and Ageing, identified an important deficiency. It told us that we needed to include learning outcomes about research in older patients with frailty. We did this – the resulting curriculum can be found here.
We then went on to conduct, as before, a national survey of undergraduate teaching in ageing and geriatric medicine – which took place in 2013. The results, published in Age and Ageing, demonstrated some improvements. Medical schools had got better at teaching about the basic sciences of ageing and they relied less on informal teaching methods than they had at the previous iteration. Worryingly, though, only 68% of schools taught about elder abuse and the median total amount of teaching devoted to core topics in ageing was 55 hours….out of a five year course!
This is not good enough. A health service which is fit for purpose needs for doctors to develop and hone core skills in these important areas. Doctors who don’t know about pressure sores, or elder abuse, or who can’t communicate effectively with a multidisciplinary team, are not ready for practice. Regulators and medical schools need to do more to ensure that they are better equipped – or risk failing the patients that need them most.