There have been many changes in recent years. The patients are older with more frailty, multiple comorbidities and a mixture of social and medical issues. These patients are often described as ‘complex’, making them sound as if they are something special. The reality is that they are now the norm and everybody should be able to deal with the norm. These problems are recognised by Royal College of Physicians in Hospitals on the Edge? The time for action (2012);
‘All hospital inpatients deserve to receive safe, high-quality, sustainable care centered around their needs and delivered in an appropriate setting by respectful, compassionate, expert health professionals. Yet it is increasingly clear that our hospitals are struggling to cope with the challenge of an ageing population and increasing hospital admissions.’
In most specialties, training has moved in an opposite direction to the needs of patients becoming more specialised and less able to deal with the norm. There is a rigid curriculum, set by the respective Royal College, to define the skills required for obtaining a certificate in training in a particular specialism. The typical inpatient does not have a single diagnosis or problem and, because of their frailty, is likely to develop further problems while being an inpatient. Therefore, by definition, dealing holistically with the patients in that specialty, if they have more than one thing wrong or develop new additional problems, the patient will be outside that specialist ability to manage them.
Even problems clearly defined in some surgical specialties curriculums are not being dealt with on the wards. These deficiencies extend to fluid management and the management of common postoperative conditions including chest infections, DVT and pulmonary emboli, retention of urine and delirium. I would also include pain relief in this list, surely the most basic of surgical competencies.
This has now gone beyond training and has become a cultural shift. Many specialties now don’t consider it their job to manage these problems listed above. In my experience this has now become so pronounced that surgical trainees are asking my F1’s advice about cases. Are we really to believe surgical skills are at a level where advice is being asked of the most junior person on the medical team?
In addition, the curriculum is being used as an excuse for not taking over a patient or necessarily managing them. How many times have I heard, even when the diagnosis is surgical, ‘there is no surgical intervention so please leave the patient under medical care’? To my shock I have heard doctors say ‘I am not medically trained’ when confronted with a relatively simple medical problem. These concerns about the care of elderly surgical patients have been well documented NCEPOD; An Age Old Problem. A review of the care received by elderly patients undergoing surgery (2010) but it appears with little translation into improving care.
When I started in COTE I remember my consultant telling me he was fed up with putting in urinary catheters for confused patients in retention post operatively. I have had the same problem happen twice since starting to write this article in two different specialties – it doesn’t look as if things have changed! The most basic skill of history taking and examination has not been done.
While it is stipulated that surgical specialties should be managing the dying patient they now require help to identify who is dying in the first place. This poses a great risk for the patient and visiting clinician asked to see the patient. The referral often reports a long list of surgical problems with some medical details followed by ‘please advise about medical optimization’. By suddenly being involved at the 11th hour, the risk in not seeing the decline in the patient prior to this, inappropriate treatment and investigations can be instigated. Neither has a rapport with the family developed and the unfortunate family will get mixed message about their loved ones care.
Dementia, delirium and the assessment of capacity is another area where concern has to be raised. The diagnosis, assessment and treatment of delirium seem to be out of the reach of some specialties. Despite delirium being common and is a poor prognostic indicator. The understanding of consent in a patient with confusion seems to be unknown to some specialties.
It is interesting how medicine has moved into the void left by other specialties while they remain fairly stagnant in their adaptation to the changing demographics. In psychiatry the inability to look after a drip or IV antibiotics has not changed in many years. However, medical specialties are expected to look after more confused and demented patients with behavioral problems. Having heard a senior nurse on our ward report that mental health can deal with the dementia and medicine with the end of life care it seems this cultural shift has taken hold at many levels.
The Comprehensive Geriatric Assessment (CGA) is the corner stone of looking after the older adult in Geriatric medicine. There are many examples of the use of this evidence-based tool by COTE teams in innovative ways. But how many specialties outside COTE have used and developed the CGA themselves with out the Geriatrician involved?
I now see medical specialties developing their own specialisms with a drift towards the problems outlined above.
I can’t say for sure that people will agree with these points but those I have spoken to seem to share the same experiences. What does this mean for the future? An open recognition of the problems is a good starting point. The issues then have to be tackled all levels.
For trainees the question is no longer what specialty should I do? The question is do I want a to be a practitioner who can look after my patients or do I want to only look after a small part of their care? While individual Royal Colleges write the curriculum for their own specialty perhaps it is time COTE defined what skills other Royal College’s should have. After all looking after the norm is everyone’s business.
If geriatric medicine embraces these changes the issues are complex. Geriatric medicine must not loose sight of its own goals. Geriatric medicine will need to plan the workforce carefully not only to fill vacant posts in COTE but the void in other specialties. This will be difficult because the void is not yet quantified.
The financial cost has to be addressed. It seems, at present, Geriatric medicine is in addition to established resources in a specialty already allocated to manage the patient. This seems a costly duplication of resources. If the current specialties are not looking after the patients they won’t need resources previously allocated to do so. It would be better to move funds and training numbers from other specialties to COTE. This is cost neutral. Also if your role is to manage the patient from admission to discharge then your salary should reflect that responsibility in contrast to those who don’t. Urgent planning and action is required.
If specialties don’t want to adopt a holistic approach to care of their patients then the future seems uncertain for them. Why spend so much time and money training a person who is a technician? This might seem farfetched but who would have expected nurses to be doing endoscopy, operations and seeing patients in outpatients a few years ago? We could train people to do operations at less than half the cost and time.
Specialties must be able to look after the patients under their care from admission to discharge. Can the GMC, that regulates medical practice and has the curricula published on its web site, really ignore this problem? The individual Royal Colleges will need to change curricula and competencies to encompass holistic care needs. Systems to make sure this actually happens is also required perhaps by specialist COTE teams to assess departments in hospitals. Limitations on practice with consequences for NHS and private work also need to be considered.
Pressures in the NHS are well documented with a focus on the front door but emphasis to tackle them falling on the medical specialties especially Geriatric medicine. Very little is said about the issues mentioned above but they certainly contribute to the pressures. As the Royal College of Physicians reports says “The time for action” is here!
Well written article!!
For someone who was trained in COTE in Wales and recently moved to Singapore for overseas experience, I can say that the above seems to be a global problem. Not just surgical specialists, even medical specialists have difficulties managing an older person.( which I have encountered in the NHS too)
The COTE teams here, routinely get referrals “for take over” from these medical specialities– “delirium, falls, functional decline etc.” The worrying aspect is that these referrals are passed on to the COTE teams on the same day the patient gets admitted. ( someone with a hyponatremia or sepsis will indeed be delirious and experience functional decline– but to pass it onto COTE means those junior Doctors lose out in learning to manage the older person)
Also there is also a nursing element of managing these older persons on a surgical ward– ” Recognising delirium, avoiding catheters, restraints, pain control etc””
Nurses are swamped with mindless documentation and hence good nursing care is lost somewhere!!
Therefore the training across the globe needs to focus on these general skills or as Dr James mentions here, train more geriatricians and reward them for their holistic care!!
I am surprised by the comments made by Dr Anthony James. With the elderly population on increase the complexity of management of these pt has changed. I do remember the days when in a DGH the A& E department was lead by a Orthopaedic Consultant and there were no Ortho Geriatricians. Things have moved on since then.
Every patient admitted to a hospital deserves a highest standard of care. I agree with him about the holistic approach. It may mean multidisciplinary approach.
In the past we only had Physicians in the hospital. Now we have Acute medical physician, Chest Physician, Nephrologist, Neurologist, Rheumatologist, oncologist ,Ortho geriatrician ect. Hospital at Night concept was introduced almost 10 years ago and number of doctors on call fell drastically. This has definitely effected patient care. The on call team is usually a medical FY1, a medical registrar and a Consultant. It is difficult for them to be in two places in case of emergencies and would not be aware of the surgical management of the patient. The medical issues not resolved during night may unfortunately go unnoticed until the following day.
The surgical specialist curriculum in UK is the most comprehensive and is envy of the world. It has been copied by various countries. It covers all aspects of patient management. Following a rigorous competitive selection process and a seven to eight years of training one manages to become a surgeon. It takes a particular person with right attitude, aptitude and dexterity to train as Surgeon. The training has evolved according to the needs and now surgeons specialise in a particular field like physicians do. Gone are the days when every surgeon would undertake most of the surgeries. Now we have Upper GI surgeons, Lower GI surgeons, Breast Surgeons, vascular surgeons, Urologist, Hip surgeons and Knee surgeons ect. They do exceptional jobs and provide highest standard of care for their patients. I am not sure if the author has stepped in to operating theatre recently to see the complexity of the process from pre opt preparation ,briefing ,operative procedure , debriefing and post opt management plan taking place. Facia iliac block and ERAS protocol has become standard practice in surgery. This has reduced narcotic related complications specially in elderly patients. Most of the hospitals now have guidelines and protocols for pain management.
It is mandatory (even a Legal requirement) to have a full time Ortho geriatrician in a hospital admitting elderly patients with Fracture Neck of Femur in England. Wales hasn’t caught up with that concept yet. These patients may have dementia, delirium with multiple comorbidities, requiring fall assessment, bone health assessment mini mental scores ect are better served under Ortho geriatrician. They may require pre operative optimization and post operative physician input .It requires multidisciplinary approach with input from various other specialties. Fluid management, pain control are basic concepts but still should be carried out vehemently and diligently otherwise it can tip the balance other way. Various studies and our own personnel experience has shown having a full time Ortho Geriatrician reduces complications, reduces bed days , increases early discharges and ultimately reduces Mortality. Shortage of beds, Doctors, nurses operating time does effect care provided to our patients. With increasing number Physician associates trained in the country the burden on physicians will decrease and hopefully they will not become a dying breed. The number of times I have come across patients admitted under Orthopaedics for social reasons because there is no Geriatric service available. The ultimate goal of all of us is to have safe environment to provide highest standard of care for our patients.
Consultant Orthopaedic surgeon