11.3 A Day in the Life of a Doctor
Presented by: Iain Wilkinson, Stephen Collins and Georgie Gill
Contributors: Dr Emily McIntosh, Dr Alex Rollings, Dr Jonty Sterne, Dr George Turner and Dr Hsu Yadana
Learning Outcomes:
Knowledge
- To develop an understanding of the different types of doctor in a hospital setting who are likely to come into contact with an elderly patient
- Recognise that doctors in elderly care focus on each patient as a whole due to the complex nature of multimorbidity, rather than breaking patients’ care down into separate single-organ systems
- Consider the difference between age, multimorbidity and frailty, and how patient management is affected depending on each of these.
Skills:
- Improve our skills in terms of assessing the acutely unwell older patient, and appreciating the importance of a comprehensive geriatric assessment in achieving the best possible outcomes for them.
- Know what signs to look for in an older patient that should alert us to make appropriate onward referrals to other specialist teams within the hospital (eg. Orthopaedics, Frailty Day Assessment, Orthogeriatrics, Medicine etc).
Attitudes:
- Reinforce the difference between age and frailty, and help healthcare professionals to realise that decisions relating to treatment should not be made purely on a patient’s age alone.
- Challenge the stereotype held by some that doctors of all specialties can do the job of those working in elderly care medicine, and instead show the highly specialised and targeted nature of our work in caring for our elderly population.
- Gain an appreciation of how the demographic in healthcare is changing, and how people are living longer and more elderly patients are coming into our hospitals
- Help junior doctors see how enjoyable and rewarding geriatric medicine is, and how it is a brilliant option for their work in the future!
Social Media:
- Word of Mouth’ Podcast Episode – “When Words Fail Us”, presented by Michael Rosen and featuring Dr Kathryn Mannix (BBC Sounds)
Research from Alzheimer’s Society shows that day trips are one of the most regular activities for people living with the condition and their carers. In comparison to other visitor attractions, people living with dementia view heritage sites as ‘safe’ and familiar spaces.
The National Trust is setting up dementia friendly spaces cafes, tours and social events. Some sites such as the Back to Backs in Birmingham are delivering reminiscence experience sessions, and Wimpole in Cambridge hosts a Farming memories group for famers and agricultural workers living with dementia to meet up.
These sessions emerged following work by Page, Innes and Cutler- ‘Developing Dementia-Friendly Tourism Destinations: An Exploratory Analysis’ (2015).
Show Notes
Foundation Programme: a two-year programme for newly graduated doctors, consisting of six rotations, each lasting four months. These different jobs can take place in either acute or community settings.
Registrar: a doctor who is receiving advanced training in a particular hospital specialty. Also known as a specialty registrar (SpR). Once they complete full medical training in their chosen area, they can then become a consultant.
Clinical Fellow: a doctor who works for a period of time in teaching, research or specialist clinical care. They undertake research in order to develop the science of medicine and can be any grade of doctor.
Escalation plan: a discussion that takes place to provide the opportunity for patients, doctors and nurses to come to an agreement on a patient’s overall plan of care. One recent example of this is the ReSPECT form (Recommended Summary Plan for Emergency Care and Treatment) which has been introduced in the UK.
A little bit about doctors in the NHS:
- There is an ongoing shortage of doctors in our part of the world. In the UK today, there are only 3.03 doctors per 1000 people in the population (the EU average is 3.7 doctors/1000 people).
- The ongoing coronavirus pandemic continues to affect doctors’ career intentions and the medical workforce. In 2021, 23% of doctors said they were planning to leave the profession, up from 19% in 2020
- There has been an unprecedented increase in the number of students accepted into UK medical schools, with the number of students commencing in 2021/22 up 21% compared with 2020/21.
When the NHS was founded in 1948, around 48% of people died before the age of 65. Now, that figure is around 12%. The ‘oldest old’ (over 85) are the fastest growing age demographic.
- By 2030, around 1 in 5 of the population will be over 65 and life expectancy at 65 is projected to be 88 for men and 91 for women.
- The term geriatrics comes from the Greek word, geron meaning ‘old man’ and iatros meaning ‘healer’. At its core, Geriatrics requires comprehensive assessment of older people living with illness or long term conditions which affect their daily lives.
- There are currently 65 approved specialties which doctors in the UK can choose to train up in. Geriatric medicine is a fantastic option, but it is just one from a very long list!
So where is Jean Now?
We met Jean in our series 11 Introduction episode.
In the last two episodes we met the Paramedics who attended her at home and conveyed her to hospital.
We then met the nurses who care for her throughout her time at the hospital.
Who are the Doctors Jean meets?
The Emergency Department Doctor:
Alex would be the first doctor that Jean would meet in hospital. He would take a history from Jean, perform a clinical examination, review her blood results and X-ray imaging, start her on medication if needed (eg antibiotics, pain relief) and refer her to the most appropriate team for her ongoing care
The Orthopaedic registrar:
Jonty would be contacted if imaging done in ED had shown that Jean had an acute bony injury. Thankfully Jean did not sustain any fractures from her fall but if she had, Jonty would assess her and decide whether or not to manage her surgically, and if she was for surgery would take over her care. A significant number of the operations he does are for hip fractures in the elderly.
The Geriatrician:
Emily would be the consultant who assesses Jean on the post-take ward round the morning after Jean arrives in ED. She would create a management plan and admit Jean to the most appropriate medical ward. If Jean had been suitable for safe one-day turnaround, Emily could have brought her up to the Frailty Day Assessment Unit for a full CGA.
The FY1 working on the ward:
George would perform clinical jobs for Jean when she arrives on the ward for her period of inpatient rehab. He would request blood tests and review results, prescribe IV fluids, assess her if she became clinically unstable and maintain regular communication with Jean’s family at home.
The geriatric clinical fellow:
Hsu would perform daily clinical reviews of Jean throughout her stay in the hospital. She is responsible for daily assessment and reviews of older patients on the wards as they undergo their rehabilitation with the hospital MDT.
This would involve ensuring that Jean’s AKI and chest infection are resolving, requesting any examinations needing done, establishing a cause for her fall, starting new treatments if appropriate, speaking to members of other medical specialties, and devising a daily plan for Jean’s management to help guide the rest of the ward MDT in their own work.
Curriculum Mapping
NHS Key Skills Framework
Core
Communicate with people on a range of matters.
Develop a culture that improves quality
Health and Wellbeing
Plan, deliver and evaluate care to meet people’s health and wellbeing needs.
Plan, deliver and evaluate interventions and/or treatments.
Foundation Curriculum Year One
1.3 Mental capacity
– Recognises the potentially vulnerable patient.
– Manages situations where safeguarding concerns may exist.
2.6 Communicates clearly in a variety of settings
– Works effectively within the healthcare team for the benefit of patient care
– Makes clear, concise and timely written and oral referrals to other healthcare professionals within the hospital
2.7 Works effectively as a team member
– Acts as a member of the multidisciplinary professional team by supporting, respecting and being receptive to the views of other healthcare professionals
– Works effectively with others towards a common goal e.g. accepts instructions and allocation of tasks from seniors at handovers and multidisciplinary team meetings
3.18 Recognises and works within the limits of personal competence
Recognises and works within limits of competency
Uses clinical guidelines and protocols, care pathways and bundles
Foundation Curriculum Year Two
1.2 Delivers patient centred care and maintains trust
Discusses management options with patients and responds to their ideas, concerns and expectations
2.6 Communicates clearly in a variety of settings
Demonstrates ability to make referrals across boundaries / through networks of care (primary, secondary, tertiary)
2.7 Works effectively as a team member
Anticipates and identifies problems for the next clinical team/shift and takes pre-emptive action where required
3.10 Recognises, assesses and manages patients with long term conditions
Encourages and assists patients to make realistic decisions about their care and helps them to construct and review advance/long-term care plans
3.11 Obtains history, performs clinical examination, formulates discharge planning
– Anticipates clinical evolution and starts planning discharge and ongoing care from the time of admission
– Liaises and communicates with the patient, family and carers and supporting teams to arrange appropriate follow up
3.17 Manages palliative and end of life care
– Discusses the patients’ needs and preferences regarding care in the last days of life, including preferred place of care and death, treatment escalation plans, do not attempt cardiopulmonary resuscitation (DNACPR) decisions
GP Training Curriculum
Fitness to practice
– Recognise personal attitudes to the elderly, to the processes of growing old, becoming frail and to dying
– Recognise your attitudes to the use of intensive or invasive tests and treatments and the use of limited healthcare resources in the care of the elderly
– Be aware of these broader factors in order to counter personal biases that are unhelpful to the care of the elderly
Communication and consultation
Have appropriate communication skills for counselling, teaching and treating patients, their families and carers, recognising the difficulties of communicating with older patients including the slower tempo, possible unreliability or having to rely on the evidence of third parties
Making decisions
– Recognise the importance of a problem-based approach, taking in the ‘big picture’, rather than a disease-based approach to the care of older people, who often have complex physical, psychological and social problems
Clinical management
– Understand the management of the conditions and problems commonly associated with old age, such as Parkinson’s disease, falls, gait disorders, stroke, confusion, dementia and cancer
– Know how to access support services for older patients, e.g. podiatry, visual and hearing aids, immobility and walking aids, meals on wheels, home care services
Managing medical complexity
Understand how co-morbidity will influence the management of existing disease and delay the early recognition of adverse clinical patterns
Core Medical Trainee
Common competencies:
Managing patient conditions and promoting patient self-care
Define the role of rehabilitation services and the multi-disciplinary team to facilitate long-term care
Management and NHS Structure
Understand the structure and function of healthcare systems as they apply to your specialty
Geriatric medicine competencies:
– Recognise when specialist geriatric medicine opinion is indicated
– Recognise importance of multi-disciplinary assessment
– Rationalise individual drug regimens to avoid unnecessary polypharmacy
– Contribute to discussions on decisions not to resuscitate with patient, carers, family and colleagues appropriately, and sensitively ensuring patients interests are paramount
– Recognise the often multi-factorial causes for clinical presentation in the elderly and outline preventative approaches
– Recognise that older patients often present with multiple problems (e.g. falls and confusion, immobility and incontinence)
Internal Medicine Training Curriculum
Generic CiP 2:
Able to deal with ethical and legal issues related to clinical practice
Generic CiP3:
Communicates effectively and is able to share decision making, while maintaining appropriate situational awareness, professional behaviour and professional judgement
Geriatrics and Higher Specialty Training Curriculum
- Comprehensive geriatric assessment
– Recognise that good health includes both physical and mental wellbeing and social, sexual and spiritual aspects
– Models and concepts of frailty
- Diagnosis and management of acute illness
– The emergency presentations and acute medical conditions which occur in older people including the associated underlying Biology of Ageing
– The non-specific acute presentations seen in older patients
- Diagnosis and management of chronic disease and disability
– The major chronic illnesses and disabling conditions seen in older people
– Principles of rehabilitation
- Rehabilitation and Multidisciplinary Team Working
– Principles of rehabilitation and comprehensive assessment
– Roles and expertise of different members of interdisciplinary team
- Falls
– Causes of and risk factors for falls
– Consequences and impact of falls
- Community practice including Continuing, Respite and Intermediate Care
– Frailty
– End of Life Care including advanced care planning
- Orthogeriatrics
– Surgical and anaesthetic issues and understanding of postoperative care and complications (including pain control and tissue viability)
- Care of older people living with frailty
– Clinical presentation of frail older people
– Advocacy for frail older people
Resources and other useful information
The Foundation Programme Curriculum 2021- https://foundationprogramme.nhs.uk/curriculum/new-uk-foundation-programme-curriculum-2021/
Doctors’ titles explained, BMA, October 2021- https://www.bma.org.uk/advice-and-support/international-doctors/life-and-work-in-the-uk/toolkit-for-doctors-new-to-the-uk/doctors-titles-explained
Treatment Escalation Plans, Torbay and South Devon NHS Foundation Trust, 2022- https://www.torbayandsouthdevon.nhs.uk/uploads/25236.pdf
The ReSPECT Process, Resuscitation Council UK- https://www.resus.org.uk/respect
The State of Medical Education and Practice in the UK 2021, The General Medical Council (GMC)- https://www.gmc-uk.org/about/what-we-do-and-why/data-and-research/the-state-of-medical-education-and-practice-in-the-uk
GMC approved postgraduate curricula: List of specialties and sub-specialties, The GMC- https://www.gmc-uk.org/education/standards-guidance-and-curricula/curricula
NHS Medical Staffing Analysis, BMA- https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/nhs-medical-staffing-data-analysis
Oliver D, Burns E. Geriatric medicine and geriatricians in the UK. How they relate to acute and general internal medicine and what the future might hold?. Future Hosp J. 2016;3(1):49-54. doi:10.7861/futurehosp.3-1-49- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465863/
‘Our Purpose’, British Geriatric Society- https://www.bgs.org.uk/about/our-purpose