Welcome to the older people’s ward. My name is Dr Sean Ninan.
I hope you enjoy your time on the ward. You will certainly learn lots. By the end of your time here you will see patients with classic geriatric syndromes, sepsis, malignancy, acute kidney injury, neurological disorders and much more. We will teach you to become very good at assessing patients with delirium, falls, blackouts, immobility, Parkinson’s disease, dementia as well as general medicine topics like sepsis, acute kidney injury and acute coronary syndromes. You will learn what frailty really means and what it means to perform comprehensive geriatric assessment. I expect you to learn about these topics because you will be looking after patients with these problems, but wherever possible, we will try to tailor learning to your chosen career, whether that is general medicine or general practice. If you are going to be a surgeon, obstetrician or something else, then bear with us! It is still important that you learn about geriatric medicine in order to provide a good quality of service, and hopefully you will still enjoy it, and take some of what you have learned into your future career. I also hope that we can convince some of you along the way to join us in geriatric medicine in the future.
In the patient list for the admissions unit – “acopia.”
In the nurse’s voice “Can you give her some lorazepam please?”
In the junior doctor’s tone “Another one admitted with falls. Nothing wrong with them.”
In the referral letter – “This lady has no (insert your own specialty here) -ological issues. Please could you take over her care”
Some healthcare workers do not enjoy dealing with older people. Part of me can understand why. It’s hard. Frail older patients place a lot of demands on staff. They need help washing and dressing. They need help with eating. They need help going to the toilet. They call out. They call out again. About the same thing you just reassured them about. And they don’t tell you what’s wrong with them. They come in “off legs” or confused, the same presentation hiding a multitude of diagnoses – from constipation to cord compression.
Dr Sean Ninan is a registrar in Geriatric and General (Internal) Medicine in the Yorkshire Deanery. He blogs at Senior Moments and tweets at @sean9n and @gerisreg
I’m a big fan of Pharrell Williams. My housemates endured “Frontin” on repeat in the summer of 2003. That debut Justin album was dope. The Snoop and Jay-Z collaborations super fly. I love the man, but I’ve never heard him quite like this.
“It might seem crazy what I’m about to say Less is more can often be the best way”
These are words that sing directly to the heart of a geriatrician. In a “parody” of “Happy” by Pharrell, the Choosing Wisely campaign offers us great lines such as
“Antibiotics for a cold will do nothing but make you ill A routine screen for many things is often overkill”
You really should check out the whole video, full of people of all ages grooving here
The Choosing Wisely campaign originated in America from the American Board of Internal Medicine Foundation. They estimated that up to 30% of care delivered in America is duplicative or unnecessary and may not result in improved health. In response they worked with specialty societies to come up with “Things Providers and Patients should question” And now, as reported in the BMJ, they want to spread their campaign worldwide. Continue reading →
Be good to older people. Many of your patients will be frail and vulnerable. Much of society may view them as a burden. You should not. These are mothers, fathers, husbands and wives. They have been on this planet two or three times as long as you have and many of them will have rich tales to tell. It is your job to look after them as well as you can, with empathy and kindness.
Be part of the team. Physiotherapists, occupational therapists, other allied health professionals and experienced nurses will know things that you don’t know – both day to day information, and nuggets of clinical wisdom. Introduce yourself to them, ask about progress, and feed back relevant information. You are now working in a multidisciplinary team.
Older people are really complicated. Acute coronary syndrome (to give just one example) will rarely be treated in a standardised fashion on an elderly ward. Some patients may be suitable for all the drugs on an ‘ACS protocol’. Others may not be suitable for more than one (or even none). Far more will be in between. Look at what your seniors are doing, and ask them why. Remember there is very little black and white in geriatric medicine and different doctors may do different things. Think about their reasoning and decide what kind of doctor you will be.
Dr Sean Ninan is a registrar in Geriatric and General (Internal) Medicine in the Yorkshire Deanery. Here he reflects on a recent report from the Royal College of Physicians on the role of the Medical Registrar and how it it compares with his personal experience.
I was on call a few weeks ago and was shadowed by some keen medical students. It was a busy day and I spent most of the day in the resuscitation area of the Emergency Department. There was a handful of patients with COPD and type 2 respiratory failure requiring non-invasive ventilation, a couple of patients with pneumonias and severe sepsis, one who was peri-arrest with anterior T wave inversion and one with S1Q3T3 on their ECG who had a massive pulmonary embolism, and a young man with ischaemic extremities, pleuritic chest pain and a butterfly rash…
The students loved it. They found it fascinating, exciting, intimidating and then…
“I could never be the Med Reg”
It has always been so, yet increasingly trainees seem to be put off by acute specialties and the burden of the general medical take at a time when acute services are under increasing strain.
Dr Sean Ninan is a Specialist Registrar in General (Internal) Medicine and Geriatric Medicine working in the Yorkshire deanery, UK.
When I was 20 I travelled round India, a wonderful beguiling country with some of the worst administration I have ever encountered, much of it unchanged from systems introduced during the Empire.
I have fond memories of the trip but there were many frustrating experiences too. Taking out money from the bank, for example, was particularly painful.
You enter, make your way to reception and explain that you would like to take out some money. They ask you to take a ticket, and you wait in the queue. After some time, patiently waiting you reach the front of the queue.
The medical student had come to join me in transient ischaemic attack (TIA) clinic. I had taught him about diagnosis, differential diagnosis, investigations and management. We had just seen an interesting patient with recurrent stereotyped symptoms of tingling down one sided, preceded by a funny feeling in her head and usually accompanied by clouding of consciousness and sleepiness afterwards. I explained to him why I thought these were complex partial seizures.
“It must be so frustrating doing a clinic where half the patients haven’t even had a TIA,” he said. He had previously sat in a respiratory clinic where many breathless patients had been referred who didn’t even have lung disease.
Why geriatric medicine? It’s a question I am asked often, often by people who are surprised I have chosen the specialty, or perhaps assume I would prefer to do something else.
I remember being asked my career intentions by a fellow candidate sitting MRCP paces whilst we were waiting for our exam. His reply when I told him:
“Oh. Did you choose that?”
The contempt in his voice was barely disguised. I replied that yes, of course I had chosen geriatric medicine as my number one career choice and outlined the reasons why. I politely asked him what his future path entailed. He wanted to be a neurologist and launched into a passionate speech about his subspecialist interest, where many patients were sadly misdiagnosed – tinnitus. It is still ringing in my ears.
I have enjoyed my first year as a registrar. I’ve enjoyed the greater responsibility, the chance to lead others, the chance to pursue more closely my chosen specialty as well as other interests within medicine such as teaching and writing. I don’t read as widely as I used to because some of these other “work interests” eat into my spare time.
Recently, I was given a book called “Philosophy for Life And Other Dangerous Situations” by Jules Evans, which has got me reflecting. The author had suffered from what might be termed “a nervous breakdown” or, more accurately, social anxiety, depression and post traumatic stress disorder. He discovered a cognitive behavioural therapy (CBT) self help group and realised that it had similarities to what he knew of ancient Greek Philosophy, particularly of Socrates. In his book, he looks at ancient philosophers and how ordinary people can use philosophy to improve their lives. I’ve only read the first couple of chapters so far but I can’t help thinking how much useful advice there is for doctors.