We’re all geriatricians now
As Geriatric Medicine grows in size and influence as part of the NHS response to the increased prevalence of physical frailty, Adam Gordon, writing for Old Age Psychiatrist asks what does this mean for the specialty’s relationship with Old Age Psychiatry?
“You know, we’re all geriatricians now.”
They are words to make one’s heart sink if, in fact, one is not a fully trained geriatrician.
These words are almost never uttered by a fully trained geriatrician. This is probably because we recognise the collective failings of our health and social care system when it comes to meeting the care needs of older people with frailty. If, indeed, we’re all geriatricians now, then the lived experience of a significant proportion of patients is a sad indictment of the state of geriatric medicine.
The thing is, of course, we’re not “all geriatricians now”. The assertion that frequently attending to older patients with frailty is synonymous with having developed adequate competencies in management of multi-morbidity, polypharmacy, care across the interface, multidisciplinary working and the full array of conditions common in later life, is akin to asserting that “we’re all cardiologists now”, simply because we all happen to care for patients with hearts.
There are, amongst the medical profession, those who would seek to espouse a model of care driven by ever increasing sub-specialisation. They would assert the best way to care for older people with multiple problems is to have one –ologist per problem and then a GP to hold it all together. This is to fly in the face of the evidence that demonstrates for inpatients and, increasingly, for those at home, that the needs of older patients are best met by models of care which are multi-domain, multidisciplinary, iterative and case managed. We call this Comprehensive Geriatric Assessment (CGA) – not because we like the words but because it’s what it has grown to be called in the research literature over the last thirty years or so.
Perhaps because it is so inextricably linked with such a robustly evidence-based model of care, geriatric medicine is not under threat of extinction. The emerging consensus that physical frailty is both measurable and a legitimate focus of medical attention has provided further justification for, if anything, an expansion in geriatrician numbers. The Equality Act hasn’t influenced this narrative because the need for geriatricianly input is driven more by the presence of physical frailty than chronological age. Geriatric medicine last year attracted more applicants for Higher Specialty Training than any other physicanly specialty and yet, despite this, we recognise that the specialty will never expand in sufficient numbers to provide care for all older patients with frailty.
“A bit more geriatrician”
The solution, according to the BGS, is that some colleagues from outside our specialty could do with being “a bit more geriatrician”. There is now pretty unanimous agreement across the European Union about what medical undergraduates ought to be taught about ageing and geriatric medicine and pretty conclusive evidence that inadequate time is spent teaching it in UK medical schools. The BGS is working with the Medical Schools Council to address their question bank for medical finals, to ensure that core topics are covered within it. We’ve managed to gain recognition of the importance of training in geriatric medicine from both the Foundation Programme and Core Medical Training.
Where does old age psychiatry fit into this? The answer is, probably, all over the place. Of the five domains of CGA – Medical, Functional, Social, Environmental and Psychological – it is the last domain, focusing on mental health, where geriatricians often feel most exposed. Physical assessment is the natural jurisdiction of the physician, whilst the multidisciplinary team – usually comprising a nurse, occupational therapist and physiotherapist – makes up for our blind spots in the other domains. If the objective of our health service is to ensure uninterrupted, iterative, multidisciplinary, case managed care – to ensure that all older people who need CGA can have it – then Old Age Psychiatrists need to work in every arena where geriatricians work and seek to work. If this is not possible, then all other doctors will have to become “a bit more old age psychiatrist.”
Geriatricians could inevitably do this. So could most other doctors – if only to brush up on recognition and management of delirium and recognition of depression and dementia.
The best way of achieving these assorted goals would be if Old Age Psychiatrists and Geriatricians could find ways to work more closely together around strategic goals. Those two areas I’ve described so far are good initial foci:
- building a common agenda around where new service models ought to go and the relative contribution of old age psychiatrists and geriatricians as part of the integrated care agenda.
- working to promulgate a curriculum in ageing and frailty in which all doctors should be expected to establish competencies.
The BGS and Old Age Faculty of the RCPsych have already started shared work in each of these areas. But there’s such obvious overlap between our specialties that there ought to be more common agendas that we’re seeking to address. Ever closer union might not be fashionable in political circles right now but it has a lot to recommend it in terms of our respective specialties and meeting the commonly recognised needs of older people with frailty.
Re-published with the kind permission of Old Age Psychiatrist (Issue 63 2015)