James Fisher is an St5 in Geriatric and General Internal Medicine currently working at Northumbria Healthcare NHS Foundation Trust. He has an interest in medical education, is the co-founder of the Association of Elderly Medicine Education (aeme.org.uk) and tweets at @drjimbofish.
I remember as a medical student attaching myself to a ward round with a busy senior physician. We had just reviewed a patient, an elderly lady, who had been chatting away happily to the consultant. The clinical details of the case have long since faded from my memory but I do vividly recall that as we walked away from the bedside, the clinician said to me: “Well, unfortunately she is clearly dying”. This hit me like a train. The idea that the patient I had just seen, who seemed so full of life, was dying, had never even entered my head.
Over time I came to realise that experience and training enables a clinician to sift through the wide-ranging assortment of clinical information that a patient interaction provides, to process it and to reach a conclusion such as this. Yet at the time this appeared shrouded in mystique.
I’ve been wondering whether frailty might carry a similar air of mystery. Like dying, defining it can be tricky – there’s no international consensus on how to identify it for a start. Sometimes, as a foundation doctor, patients who appeared ‘well’ to me were labelled frail by a more erudite colleague for reasons unbeknownst and undeclared. On reflection, I think that many juniors’ understanding of ‘frailty’ is that the term is simply an adjective that depicts someone who perhaps looks a bit thin, most likely has grey hair, and is recumbent in a hospital bed. Yet we know that frailty is far more complex, for a start, as described in a previous blog article, you don’t even need to be thin to be frail.
I think as geriatricians we need to be more proactive about teaching on frailty. We need to drive the agenda so that frailty is no longer perceived as just an inevitability of ageing, described using an adjective employed here and there, but as a clinical constellation that, once spotted, prompts the doctor to think: “This old person is vulnerable and needs Comprehensive Geriatric Assessment”.
So how might we go about doing this? First things first, I’m certain there are people out there far wiser than I with ideas to share on this topic. I’m very keen to generate some further discussion – those of you who are Twitter-literate, please feel free to get Tweeting and discussing! For now, here are four thoughts I had on the subject:
1) Emphasising that ‘being around’ old people is not enough…
Assuming that juniors who come into contact with old people will learn how to look after them properly is flawed. We geriatricians know that simply being in close proximity to frail patients does not imply that learning about frailty will take place. We also know that exposure to teaching on topics such as frailty is not guaranteed, both at undergraduate and postgraduate levels. The BGS’s ‘call to arms’, in response to this learning gap, cites the need to formalise undergraduate curriculum content on topics such as frailty, and to bring all Foundation and Core Medical Training doctors under the wing of a geriatrician for a period of dedicated training.
2) Acknowledging that simply ‘knowing’ is not enough…
Teaching on the theory is one thing, but this doesn’t guarantee that the learner will go away and translate this into practice. Theory-based learning on frailty needs to be complemented with co-ordinated clinical exposure. A critical component to teaching on frailty is arming the learner with the skills to manage a frail patient once they have been identified. Furthermore, addressing learners’ attitudes to elderly, frail patients is vital to drive progress, but hugely challenging. Crafting learning outcomes that adequately address attitudes requires careful consideration; working out how these can be assessed and how attitudinal change can be measured adds further complexity. Perhaps peppering teaching on frailty with involvement of patients and the public is one approach – patients have the potential to be far more powerful teachers than we do!
3) Innovate, stimulate, educate?
In the decade or so since I was at medical school the methods by which junior doctors and students learn have changed dramatically. In a digitally-connected world, with a staggering amount of information available at the click of a mouse, clinically relevant online medical updates may be a way by which junior learners can be reached, enthused and taught. With that in mind, short, focussed video podcasts, known as MiniGEMs (Geriatric E-learning Modules) have recently been described in the BGS newsletter. These are hosted on YouTube and are freely accessible to all. Is there anyone out there reading this who would like to take on the challenge of summarising frailty for juniors in a snappy, six minute video? If so, get in touch!
4) Making the implicit explicit
Thinking back to example I gave at the start – we need to ‘show our working’ to junior colleagues. Verbalising to the medical student on the ward round that a patient is “clearly frail” leaves the student scratching their head and wondering exactly how this conclusion was reached. Instead, we need to guide junior colleagues through the thought processes and clinical reasoning underpinning this conclusion – making the implicit explicit.
Perhaps junior doctors with a deeper understanding of what frailty is may be more likely to recognise that these patients are walking a physiological tight-rope. Maybe those who are armed with this understanding will be less inclined to employ pejorative phrases such as “the failed discharge” or “acopia” and “frailty” might start appearing in more clerkings…
This week’s series of blogs on the subject of frailty is to mark the launch of new guidance, Fit for Frailty, for recognising the condition of frailty and to increase understanding of the strategies available for managing it.