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!