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A Career in Geriatric Medicine Listen to the Audio
Introduction My name is Janet Lippett and I'm a geriatric specialist registrar working in the South Thames region. I'm currently in my fourth year of specialist training. I've been asked to give an overview of geriatric medicine and how to train to become a geriatrician. Background to Geriatric Medicine Geriatric medicine is not a new speciality although it has changed dramatically over the years. Back in Roman times there were units for the care of older people called “Gerocomia”. In the 16th century the poor elderly and infirm were looked after in the workhouses. These had infirmary beds which become filled with the chronically sick. The term geriatrics was coined by Nascher in 1907 and its literal translation is old physician. Modern day geriatrics has its origins in the workhouse wards of the West Middlesex Hospital. Just as nursing has its Florence Nightingale, geriatrics has its Marjorie Warren; as a newly qualified consultant in the 1930s she was working in the workhouse wards. She was appalled to find the elderly infirm residents with low morale, frustrated and helpless, confined to their beds, vacating them only when they died. Marjorie Warren with the aid of Trevor Howell started to care for these patients correcting treatable medical problems and rehabilitating them with exercises. To the surprise of the other clinicians at the hospital the elderly started to be discharged well and in fact better than when they were admitted. As the profile of geriatric medicine increased so did the plight of geriatric patients in other hospitals and the government began to invest in their care. Trevor Howell went onto conduct research into the physiology of normal ageing with the Chelsea Pensioners and the science of ageing or Gerontology was born. A Typical Day for a Geriatrician The speciality of geriatrics does vary throughout Europe and in fact the world. So for those not familiar with the British form of the speciality I thought it would be useful to outline a typical day or days. Day 1 Morning - post take ward round on the acute admissions unit reviewing elderly patients admitted overnight. You may take over the care of those who are frail elderly with complex medical and geriatric needs and offer advice regarding patients admitted with falls, acute confusion, stroke and other typical geriatric problems. This is followed by a ward round on the orthopaedic ward reviewing elderly patients with fractured neck of femurs who also have medical problems. Lunch time - research meeting over lunch, discussing research projects being carried out in the region. Afternoon - Outpatient's clinic. This may be either a general geriatric clinic seeing a wide range of problems such as Parkinson's Disease, cognitive impairment, stroke, ischaemic heart disease or a special interest clinic for example in falls. Day 2 Morning - ward round with team reviewing all current geriatric inpatients under your care. Again these may range from acutely ill patients with bronchopneumonia, to those with terminal cancer who are for palliative care to those with fractures who are rehabilitating. The ward round is followed by a multidisciplinary team meeting with the nurses, social worker, physiotherapists and occupational therapists. This involves discussing the patient's progress, setting goals and planning discharges. Lunch time - reviewing paper work for patients, who are being considered for nursing home placement, Afternoon - Meeting with the Day Hospital team and reviewing patients who attend. These are outpatients who visit a couple of times a week, they generally have multidisciplinary needs and see the doctor, nurse, physio and OT on each visit. Training In order to become a geriatrican you need first to complete a year as a house-officer (HO). This may change in the future with modernising medical careers; but at present this is followed by 2- 3 years as a Senior House Officer (SHO) during which you need to obtain your Membership of the Royal College of Physicians (MRCP). It is a good idea to do one geriatrics job as an SHO - to see if you like it and as its good general medicine experience anyway. The interviewers will also expect it when you apply for registrar jobs. Try to approach geriatric consultants in the region when you are training they can give you useful careers advice and it is useful to get your face known. Following this you can apply for registrar jobs, there are essentially three types:
You need to complete 5 years of training before you get a Completed Certificate of Specialist Training (CCST) and then you can apply for consultant jobs. The training within the five years is on the job with a monthly training day at ones of the hospitals in your region. You can train for pure geriatrics in just 4 years but most of us our dual trained in General Medicine (GIM) and geriatrics. The GIM part takes an extra year making 5 in total. Within the 5 years you need to have exposure to 21/2years of GIM, this isn't difficult as a lot of the jobs are combined. How Does GIM and Geriatrics Differ? Geriatrics is very different to GIM; I could send my HO to look after a 40-year with a myocardial infarction, but a 90-year-old, that takes more skill. You start them on the aspirin, a beta blocker, ACE inhibitor etc and they have a gastro-intestinal haemorrhage and such bad postural hypotension that they can't get out of bed, then they get pressure sores and pneumonia and so on and so forth. They aren't as robust as the young and have less physiological reserve. The skill is about applying the medicine appropriately for the individual patient. Aside from the acute medicine there is also all the rehabilitation side, which is very rewarding as you see patients improving. The role of the doctor is to optimise them medically so that the therapists can get the best out of them. This serves to maximise their quality of life and hopefully enable them to be discharged home independently. I think we also work better as a team; we involve the therapists a lot more, our discharge planning is always multidisciplinary; we don't just say that the patient is medically fit to go home they have to have completed their goals with the physio, OT etc. We treat the patient holistically and try to sort out all their problems rather than just the acute ones. We look at everything, including how they manage at home and their social support. We have an excellent working relationship with the other team members and you need to be a good communicator to bring the team together. It's quite a responsibility as ultimately you are responsible for the patient and you need to balance everyone's opinions. Yes, they could stay in hospital, but sometimes you need to accept the risks of sending people home. The Down Side There are some negative points as well, we often get very involved with the patients so its not a 9 to 5 job, I often find myself staying late to sort things out. The patient's relatives can be a problem too, it's rather like paediatrics in that respect, but we have the children of the patients and they have the parents. A good portion of my time is spent communicating with relatives, but they can be an excellent source of information about the patient so the conversation should always be a two way thing. Unfortunately they can be very demanding both in time and resources. Social services can't provide everything free of charge whereas relatives often feel they should. It also a very rewarding part of the job if you can reassure them and guide them through the minefield of locating a nursing home for example. You often find yourself doing things which aren't strictly medicine or a doctor's job, but its all part of the fun and makes the day interesting. Areas within Geriatric Medicine Within geriatrics there are numerous sub specialities you can develop. During your training you get exposure to them anyway but you can pursue one in particular if you have a special interest. These include
There is also ample opportunity for research if you are interested; we are encouraged to do some as part of our training. This could be in any area you like as the elderly suffer from most diseases. Post-graduate Qualifications Some of us do post graduation qualifications as well. I have just completed an MSc in Health Sciences; others do them in Gerontology or Law and Ethics. There is also a diploma in geriatric medicine. Personal Experience I think what inspired me to do geriatrics was some fantastic geriatric consultants when I was training. In fact, it started before that, I have also been interested in the science of ageing and did by intercalated BSc (half way through my medical training) in gerontology. I did a geriatric job as a HO and loved it, I was fortunate to work for a great boss. Following that I did geriatrics again as a SHO - it was a very busy job, with long hours but I loved it. Also all the geriatric registrars were happy and enthusiastic, the best of a bunch, hopefully I now inspire my juniors in the same way. I loved their methodical and through approach to the patients. I once remember a medical consultant saying to me that when you pick a career you have to think whether you can sit through a whole clinic of it. He was a diabetologist and I thought “a whole clinic of diabetic foot ulcers” - no thanks. Well, in geriatrics you don't have to sit through a whole clinic of anything. Each patient is different, one has a stroke, the next heart failure, the next PD and the next dementia, it's so varied. And to top it all the patients are generally lovely people with fascinating stories to tell about their lives. Perhaps that's why I stay late, too much chatting in the day. If I had the chance to choose my speciality again I'd definitely make the same decision. |
