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A. GENERAL INTRODUCTION

1. The practice of modern Geriatric Medicine in the United Kingdom is more developed than in many other countries. It is changing with developing government social and medical policy. Geriatric services usually include acute care with some responsibilities for rehabilitation, continuing and community care, outpatient and specialty services some of which are described further in this document. Acute care is usually provided in major multi-specialty acute hospitals. Although Geriatric Medicine is predominantly concerned with the care of older people, many geriatricians work with younger adults especially for acute care. The United Kingdom is a world leader in the specialty, which expanded after the Second World War when the National Health Service incorporated responsibility for workhouse infirmaries. This document describes the training for future specialists in Geriatric Medicine and also for General Practitioners.
2. Geriatric Medicine is the second largest United Kingdom medical specialty after anaesthetics. There are lots of training and career opportunities for trained geriatricians. Currently there are about 591 trainees specialising in Geriatric Medicine and there are over 1000 consultants in Geriatric Medicine in the United Kingdom. There has been an expansion in consultant and trainee numbers following the reduction of doctors’ hours related to the European Working Time Directive and the increasing involvement of geriatricians in hospital acute medical rotas and developments in specialist services such as stroke and intermediate care.
3. The necessary expertise of a consultant in the specialty is continuing to change and expand.
4. As with other subspecialties within Internal Medicine as a whole, a broad training in medical specialties is essential. In the United Kingdom the majority of consultants have a responsibility for acute younger adult medicine alongside their specific responsibility for older people.
5. Specific expertise is required in the multiprofessional/multidisciplinary health care practice, in epidemiology and the measurement of population need, and in certain areas of interspecialty liaison, particularly psychiatry, orthopaedics, other surgical specialties and primary health care (See Good Practice Guide Sections C, D and E).
6. The consultant must have skill and experience in the management of patients and deployment of resources in different care settings, including acute care, assessment and rehabilitation, continuing care, day hospital care and management in the community.
7. He or she is required to have a firm grasp of the complex administrative/managerial implications of a population-based specialty in order to determine resources and advise Health and Commissioning Authorities. Many Geriatricians have management appointments as clinical or medical directors.
8. Physicians in Geriatric Medicine may have a specialist interest, such as stroke medicine, orthopaedic liaison, falls, incontinence, Parkinson’s disease, community care or other medical specialty areas such as gastroenterology, cardiology or diabetes.
9. Geriatric Medicine is proud of its record in auditing the quality of care it offers under the close observation of the Healthcare Commission. This and other aspects of practice development require research skills, irrespective of whether or not a consultant occupies a post in a teaching or academic institution.
10. Many Geriatricians are involved in other areas of practice such as research and teaching and education. Geriatricians are often Royal College or Clinical Tutors or Directors of Education, Undergraduate Deans or Postgraduate Deans with a major time commitment to education. Many Geriatricians hold academic appointments as Clinical Lecturers, Senior Lecturers or Professors.

B. TRAINING ISSUES

1. Responsibility for Training Programmes

1.1 The policies and quality assurance for undergraduate and the first year of foundation training are the overall responsibility of the General Medical Council. Post registration training after the end of the first year of the foundation programme is the responsibility of the Postgraduate Medical Education and Training Board. Training programmes are regularly inspected by postgraduate deans and PMETB supported by Royal Colleges. PMETB also has responsibility for issue of Certificates of Completion of Training (CCT) and Certificate of Entry to the Specialist Register (CESR), which enable entry on to the Specialist Register of the General Medical Council (GMC).

2. Undergraduate and Foundation Training And Overseas Trainees

2.1 Undergraduate training in Geriatric Medicine takes place routinely in UK medical schools often with a formal attachment to a Department of Geriatric Medicine. Many foundation programmes for newly qualified doctors include a period of experience attached to a Department of Geriatric Medicine. Though it is possible to attempt Part 1 of the Membership of the Royal College of Physicians examination (MRCP) Postgraduate Deans will not approve study leave for relevant courses during foundation training. Doctors coming from overseas for training may enter training at the F2 level but if entering after the start of Specialist Training (ST1) will not be able to acquire a CCT unless the posts overseas were prospectively approved for specialty training by PMETB. They will be able to apply for a Certificate of Entry to the Specialist Register (CESR) after satisfactory production of a portfolio and references as required by PMETB but this will not allow practise in other European Countries as an accredited specialist in Geriatric Medicine.

3. General Practice Vocational Training

3.1 Geriatric Medicine is one of the recommended specialties for doctors training to become a General Practitioner as part of a training rotation, which lasts for 3 years including 1 year as a Registrar in General Practice

3.2 The emphasis for the attachment in Geriatric Medicine should be:

a. Competency in recognising and managing common general medical emergencies
b. Familiarity with the common syndromes in older people e.g. falls, confusion, poor mobility, incontinence and failure to cope
b. Learning about supportive systems in the community for older people
c. Communication with primary care and social services
d. Outpatient management of common medical conditions such as diabetes, arthritis, dementia and Parkinson’s Disease

3.3 Ideally the trainee should be supervised by a consultant with an interest in community aspects of care of older people.

3.4 Those GP trainees who wish to demonstrate additional expertise or interest in Geriatric medicine can also sit the examinations for one of the Diplomas in Geriatric Medicine (DGM) set by either the Royal College of Physicians of London or the Royal College of Physicians and Surgeons of Glasgow.

3.5 Further information on vocational training is available from the Royal College of General Practitioners.

4. Post-foundation Training for Specialists In Geriatric Medicine

4.1 In order to train in Geriatric Medicine it is currently necessary during the 2 year Foundation Programme post qualification to apply for run-through training in the medical specialties via the national web-based Medical Training Application Scheme (MTAS) though this scheme is under review. Trainees (post foundation from 1.8.07 will be called specialty registrars (StRs)) will be selected for specialty training (including General Practice) after a competitive short listing of national electronic web-based applications via MTAS followed by a structured interview usually composed of three stations including an assessment of the applicant’s portfolio of experience, a brief conventional interview and either a presentation or an assessed discussion of a case scenario. Successful applicants will be given a national training number (NTN). Academic trainees will also be given a NTN with the suffix (A). Doctors can also apply for fixed term specialist training appointments (FTSTAs) which are one year fixed-term appointments. These posts may count as contributing to run-through specialty training if a doctor is subsequently appointed to run-through training and then receives a NTN. Locum posts approved for training (LATs) will also count towards training if a doctor later acquires a NTN in the specialty. StRs can take time out of programme (up to 1 year can count towards training) to further their research experience (OOPR), take up overseas training or other clinical training (OOPT). Trainees can also apply for a career break (OOPC).

4.2 Most doctors entering Geriatric Medicine will after foundation training undertake two years of Core Medical Training (CMT) in a selection of medical specialties (usually rotating every 4 months through 6 different medical specialties). However some trainees may enter from Acute Care Common Stem Training (ACCST), which is for those planning to enter Anaesthetics with a particular interest in Intensive Care, Accident and Emergency Medicine or Acute Medicine. During this period the trainee should acquire the competencies of Acute Medicine Level 1 enabling the doctor to practise supervised by a consultant when on the acute medical take. During CMT/ACCST trainees will apply for their choice of specialties. They will be expected to have passed Part 1 MRCP and may have an advantage if they have passed the MRCP Part 2 including the Practical Assessment of Clinical Examination Skills (PACES) at the time of application to specialty training.

4.3 The British Geriatrics Society has recently published a pamphlet “A Career in Geriatric Medicine” which further outlines the career steps to become a Geriatrician. This can be downloaded from the British Geriatrics Society (BGS) website (www.bgs.org.uk), or ordered from the BGS office.

4.4 (As a result of difficulties encountered during the application process for post-foundation training in 2007, there is on-going debate about how this process should be managed . It is likely therefore that further changes will be introduced before the definitive format is finally agreed.)

5. Specialist Training In Geriatric Medicine

5.1 General Issues
Specialist Training (ST) is key to ensuring that a doctor is able to provide a quality specialist service. The view of the Specialist Advisory Committee (SAC) in Geriatric Medicine is that considerable flexibility, breadth of experience and academic opportunities are essential, while sustaining the required standards and appropriate levels of competition. An updated version of the criteria and curricula for Registrar training in ‘Geriatric Medicine’ and ‘Acute Medicine’ are available on the Joint Royal College Physicians Training Board (JRCPTB) website (1-2).

5.2 Appointment to ST occurs on the basis of competition. All trainees will be expected to obtain the competencies of the curricula of Geriatric Medicine and Acute Medicine Level 2 combined with the Generic Curriculum (to be completed by all trainees in the medical specialties). This combined training will require a minimum of seven years of clinical experience including the 2 years of CMT/ACCST. No retrospective recognition of non-approved training posts either in the UK or abroad is permitted for acquisition of a CCT. (Such posts many only be recognised if specific approval is sought from PMETB in advance of taking them up. Guidance: PMETB approval of out of programme experience)

5.3 In formal training programmes for a CCT, training, which covers all aspects of the specialty should be provided both in teaching and district general hospitals as well as in the community. It is the responsibility of the PMETB to lay down the criteria for specialist training, and to work with the deaneries to select and approve the providers of training and to ensure that the training programmes meet the standards required.

5.4 It is possible to get on the Specialist Register by combining training, qualifications and experience both in the UK and abroad by the “Article 14” route. Details can be found on the PMETB website.
In order to be approved under article 14 doctors will be expected to have acquired the competencies of the newly appointed consultant geriatrician and covered all the areas within the Generic and Geriatric Medicine curricula.

6. Curriculum
6.1 Trainees must acquire the knowledge base, skills and attitudes required for specialised medical practice as laid out in the curricula (1-2). Providers of training should offer training in all aspects of Geriatric Medicine including acute care, out patients, assessment and rehabilitation, continuing care, and management in the community. Special Interest experience in Stroke Medicine, Parkinson’s Disease, Orthogeriatrics, Old Age Psychiatry, Continence and Palliative Care is also crucial. Generic skills in education, communication, management and team-working are an essential part of trainee learning and development.

6.2 Trainees should learn the skills required to supervise, teach and train others. They should develop an understanding of quality assurance, audit, clinical effectiveness and research methods as specified in the Generic Curriculum.

6.3 It is possible to obtain a CCT in Acute Medicine level 3 or Stroke Medicine or obtain research or Special Interest experience within the 5 year training programme by using one year of “out of programme” experience. This must be approved in advance by the deanery and PMETB. Trainees will be expected to be making very good progress with the targets and assessments of the Geriatric Medicine, Acute Medicine and Generic curricula to be allowed to take a year out of programme (detail is provide in the new guide to Speciality Training-“The Gold Guide”.

7. Organisation of Training

7.1 Introduction
On appointment, the Programme Director (who is responsible for the Geriatric Medicine training programme on behalf of the Postgraduate Dean) or the Regional Specialty Adviser (who is the Royal Colleges of Physicians appointee with responsibility for training) should provide the trainee appointed to a training programme in Geriatric Medicine with information on training in the region, ideally in the form of an induction handbook. This should include:

• advice on how to enrol with the JRCPTB;
• outline of possible rotations;
• outline of training posts and rotational dates;
• outline of the role of educational supervisors, research mentors and the appraisal system;
• outline of annual assessment review ( Record of Inservice Training Assessments (RITA) or the “Annual Review of Competence Progression” ARCP for new trainees from August 2007) process;
• outline of the procedure for out of programme experience;
• structure of the Regional Specialty Training Committee with names of members and trainee representative;
• relationship of Regional Training Committee with Postgraduate Dean, BGS Training Committee and SAC; and
• application form for the BGS.

Individual units should provide a local induction programme.

7.2 Training Programmes
Registrar training should be provided within structured training programmes comprising posts approved for specialist training. The curriculum in Geriatric Medicine has to be converted into deliverable training programmes, which are sufficiently flexible to meet the individual educational needs of the trainees. The full range of training and teaching methods should be employed, including self directed learning and practice-based education. The majority of training should be integrated with clinical experience. Structured departmental education programmes should be provided and facilities should include office space, library and internet access.

7.2.1 Trainees should be provided with a weekly timetable clearly identifying two sessions of protected time for audit, research, study and personal development. Attendance at regional and national meetings and courses will be encouraged and monitored with explicit standards for expected attendance rates. All trainees should have a research mentor/adviser, whom they should meet regularly throughout their training for help and advice with research training and experience.

7.2.2 The regional Specialty Training Committee (STC) should ensure that the programmes provided have a predominance of training and education over service provision, and that they comply with PMETB requirements. Trainees must be adequately supervised by a named educational supervisor. All training programmes and posts are subject to regular inspection by PMETB and the deanery through speciality schools.

7.3 Appraisal
Shortly after joining a Unit (Hospital), the educational supervisor should meet with the trainee to develop a Personal Educational Plan and sign a Training Agreement, which outlines the training needs of the Specialist Registrar (SpR) (renamed as Specialty Registrar (StR) for trainees commencing training from 1.8.07 onwards) and how these are going to be met during the attachment. Subsequently, appraisal should take place at least every three months.

7.3.1 Appraisal is a planned review of a trainee’s progress by the trainee and the educational supervisor, and should be a confidential, non-threatening two-way dialogue in which the trainee takes the lead. The following should be discussed:

• generic skills;
• particular strengths of the trainees, some of which may not have been apparent to them;
• areas that could be improved in a trainee’s performance;
• reasons for any identified weaknesses in a trainee’s performance, particularly whether these include external issues such as deficits in the training programme, or problems specific to the trainees;
• specific objectives set at the start of the training period. This is assisted if a written training agreement is drawn up at the start of a trainee’s attachment to a Unit;
• research: trainees should be encouraged to do research and should be provided with adequate support and/or advised where specialist advice can be accessed;
• career progress as a whole, taking into account the trainee’s personal and professional progress;
• aims and objectives for the next stage of training; and
• date of the next appraisal meeting.

7.3.2 Trainees must ensure that their Training Record (logbook or eportfolio) is kept up-to-date, and the appraisal meeting is a useful time to remind them to do so.

7.4 Assessment
Throughout the training programme there will be different assessments covering each aspect of the curriculum. Trainees will be expected to pass the MRCP Parts 1 & 2 and PACES by the end of the first year post CMT/ACCST (ST3). Other assessments include mini-CEXs (mini -Clinical Examination), Case-based Discussions (CbD), Acute Care Assessment Tool assessments (ACAT), Directly Observed Procedural Skills (DOPS) (this is for acute medicine and special interest skills only), Multi-source feedback by colleagues in different disciplines (MSF), Patient Survey Questionnaire (PSQ) and a Knowledge Based Assessment (KBA) 200 multiple choice questionnaire of specialist knowledge usually attempted during the 4th or 5th years of specialty training (ST4/5). These will need to be successfully completed to cover all aspects of the curriculum prior to completion. Trainees should have a valid advanced life support (ALS) certificate throughout training.

7.4.1 Each year a formal report on progress is completed by the educational supervisor for the annual review of training progress (RITA or ARCP ), which is organised by the deanery. Each Registrar is interviewed to establish their progress and make recommendations for training for the next year. The interview panel normally includes the Programme Director (Regional Specialist Adviser), a representative from the deanery, a representative of the Regional Adviser of the Royal College of Physicians and another educational supervisor. A RITA C (to be called Outcome 1 for trainees starting after July 2007) can be awarded if progress is satisfactory, RITA D (Outcome 2 for new trainees) if specific training targets need to be met, and a RITA E (Outcome 3) if the registrar needs to repeat some aspects of training, which may extend the date when they will obtain their Certificate of Completion of Training (CCT). Under the new system release from the training programme is called Outcome 4 and where incomplete evidence is presented Outcome 5 which may lead to the need for remedial training. A RITA F (Outcome 8 for new trainees) is awarded if the registrar has adequately completed a time of out of programme experience.

7.4.2 About 12-18 months before the completion of training date each Registrar will have a special annual review called a Penultimate Year Assessment. At this review there is also an external assessor present at the meeting who represents the SAC. Mandatory training targets can be set at the Penultimate Year Assessment. Within three months of the date the Registrar is expected to obtain their CCT there will be a further review to ensure all training targets have or will shortly be met. Following this review if successful a RITA G (Outcome 6 for new trainees) will be awarded which is supplied to the JRCPTB and then on to PMETB who will usually then award the CCT.

7.5 Regional Education Programmes
Regions should run a regular specialty education programme for all Registrars in that region if necessary as a day or half day release. The content should include the knowledge elements of the specialty and generic curricula e.g. Clinical Governance and the trainees should have input into its planning. Active participation by the Registrars rather than passive learning should be encouraged. Other doctors receiving specialist training in the specialty should also be encouraged to attend. In addition trainees will take study leave to attend management, teaching, research methodology and other appropriate courses provided by Deaneries, Royal Colleges and other educational providers.

7.6 Special Interest Training
STCs should organise structured training in stroke, old age psychiatry, palliative care, continence, community/intermediate care and orthogeriatrics for all Registrars. In some instances this will necessitate blocks of specific experience. In others it may be provided on a sessional basis. A trainee who wishes to add an official accreditation of competence in Stroke or Acute Medicine to CCT level will have to undertake subspecialty training for an out of programme year in an approved post and satisfactorily complete the required assessments. This can either be an additional training year or for trainees who are making good progress with Geriatric Medicine Training it can replace one of the main programme training years. This is provided the trainee has not already undertaken other time out of programme (e.g. in research) which the trainee also wishes to count towards their training time and the training has the prior approval of the deanery and PMETB. Training posts in Stroke and Acute Medicine will be advertised in open competition.

7.7 Educational Supervisors
Educational supervisors who are appointed by deaneries are required to provide clinical supervision, appraisal, and guidance on career progress. It is essential that they are adequately supported in this role by ensuring that they have protected time and resources to meet their responsibilities. It is also crucial that they have access to and funding for attendance at courses in “Training for Trainers”, which include instruction in appraisal and feedback, teaching techniques, methods of evaluation and interviewing and counselling skills. It is recommended that each educational supervisor of Speciality Registrars spends about 1 hour per week formally teaching, appraising and assessing their trainee.

8. Evaluation, Monitoring and Quality Issues
It is essential that the planners, developers and providers of training supported by the SAC undertake regular quality control to ensure that the aims and objectives of ST are being met and to monitor the quality of training and education being provided. In addition quality assurance of training programmes, training hospitals and trainers is undertaken by PMETB.

C: ADVICE AND SOURCES OF INFORMATION
1. The Regional Postgraduate Dean, Regional STC and Programme Director provide advice and guidance on all aspects of training. There are regional trainee representatives who can give advice. JCHMT/JRCPTB publish Newsletters on a regular basis. The British Geriatrics Society also organises conferences, which are a valuable source of information for both trainees and trainers. The booklet published in 1998 “A Guide to Specialist Registrar Training” (Orange Book), by the Department of Health is orderable from the Department on their publications section of their website, covers all aspects of the specialist registrar grade from entry to exit and applies to all specialties (3). This has been replaced by A Guide to Postgraduate Specialty Training in the UK ("The Gold Guide") for trainees commencing specialty training from 1.8.07. There are some recent updates (click here for an example). There are useful websites such as this one and those of the Royal Colleges of Physicians (London, Edinburgh and Glasgow), the Joint Royal College Physicians Training Board and the department of health. Useful journals are Age and Ageing, CME Geriatric Medicine and other gerontological journals e.g. Journal of the American Geriatrics Society and other relevant specialty journals especially those in rehabilitation.

D. REFERENCES

1. Joint Royal College of Physicians Training Board. Geriatric Medicine (December 2006) (http://www.jrcptb.org.uk/geriat/curr_geriatric.pdf) and Generic Curriculum (December 2006) (http://www.jrcptb.org.uk/curr_generic.pdf).

2. Joint Committee on Higher Medical Training. Acute Medicine (December 2006) (http://www.jrcptb.org.uk/curr_acutemedicine.pdf)

3. A Guide to Specialist Registrar Training. Department of Health (February 1998). (http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006614)

4. A Guide to Postgraduate Specialty Training in the UK ("The Gold Guide")
(http://www.mmc.nhs.uk/pages/news/article?227E16A3-42B1-4FCB-BF6B-CEF787F9743C)

5. British Geriatrics Society Reading List
http://www.bgs.org.uk/Publications/Publication%20Downloads/Compend_5-3%20Reading%20List.doc

Review date: July 2010 Author : Chris Turnbull for BGS Education & Training Committee