The ‘F’ Word – and Many Other Things

Picture1Kit Byatt is a consultant geriatrician and general physician in Hereford in 2001, with wide interests both within geriatric medicine and outside it. He wrote this piece having been challenged by a recently-published Age UK report, presented by Professor Adam Gordon at the recent BGS Spring Conference.  

For those of you who, like myself, hadn’t read Ipsos MORI’s report for Age UK, Understanding the Lives of Older People Living With Frailty, A Qualitative Investigation, there is much food for thought within.  Luckily for me, this intellectual nourishment was presented in a highly palatable form at the BGS Spring Meeting.

Its findings were discussed alongside a new joint piece of market research, to be be published soon by Age UK and the BGS, looking at older people’s views on the word “frailty” itself and associated terminology. Although the final presentation in the last session on the final day of the conference (and with the audience attrition rate increasing by the minute as train deadlines loomed), I found it increasingly compelling and thought-provoking.

Its central focus was the massive effect on patients of the language we use in describing them and their conditions.  Specifically, the fact that patients never use the word ‘frail’ to describe themselves, and object to having it used about them.  Extensive investigation using ethnographic methods clearly showed the force of older people’s views about this.  They used positive and aspirational language to describe their condition.  The word cloud we were shown summed it up – definitely better Ipsos MORI than memento mori!

The point was made during the presentation that ‘comprehensive geriatric assessment’ was not a very user-friendly term.  A member of the audience mentioned that she described the process as being akin to an ‘MOT’ with her patients, and this went down well.  I have used similar motoring metaphors with patients, with equal success.

I have sometimes referred to patients’ hospital admissions for acute medical problems as ‘roadside rescue’, ’60,000 mile services’ – or an ‘oil change’ after a red cell transfusion.   It may sound clichéd, but the patients get it, and it generally makes them smile – one of my personal aims with each patient I see.

All this got me thinking: surely we can capitalize on this rich vein, and find a suitable alternative nomenclature based on the familiar acronym?

Initially I came up with ‘meticulous overall tune-up’.  More or less a perfect word-for-word adaptation into everyday language.  Not bad, but surely we can do better?  I mulled over words such as management, masterly, methodical, medical, mindful and modern.  I considered objective, opportune, optimal/optimise(d), orderly, overall, and I tried out team, test, thoroughly, tool, and transformation.

In the end I decided that ‘multidisciplinary optimisation tool’ was better, although I still thought there was mileage in ‘maximizing outcomes through thoroughness’, ‘medical (or multidisciplinary) optimisation tool’ and ‘multi-domain overview and treatment’ remain contenders.  Perhaps we need an Age UK focus group to work through the possibilities?

Let’s develop the ‘knotty nomenclature’ theme a little.  Over the 35 year course of my career, the arguments have flown back and forth about what we should call our specialty.  I have for a long time favoured either ‘complex medicine’, or ‘advanced medicine’.  In the latter case, advanced can apply to both the patient and the medicine.  We are the last bastions of general medicine in secondary care, not only not deterred by the complexities of co-morbidity, but most of us see it as an active clinical and intellectual challenge.  I know the Shape of Training hopes to make all doctors general physicians in a couple of years, amongst their specialty training.  This totally seems to miss the point that a good general physician is someone who has had a lot of experience seeing a wide variety of medical (and other) problems in a wide variety of patients, from a wide variety of backgrounds.  The signal to noise ratio in ‘the muddy bottom of the pool of clinical practice’ (as Prof Peter Millard used to describe geriatric medicine) is much smaller than in textbooks or clinical exams.  We don’t develop our clinical antennae overnight!

On reflection, why not conflate the two and have ‘Advanced and Complex Medicine’ (adding ‘in Older People’ if you like).  I’ll leave it to you to tweak it and come up with a fancy acronym, but who wouldn’t want to be seen by a specialist in ‘advanced and complex medicine?’  I think people having an organ (or two) fixed in mere -ologists’ clinics would be jealous of our clientele, and actively seeking us out to get a bit of the action!

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