International medical trainee in elderly care medicine - a personal experience
Adeniji Leye describes his experience of the NHS as an international student on the Royal College of Physicians (London) training programme.
The international medical training initiative is a programme of the Royal College of Physicians (London in my case) in collaboration with other postgraduate medical colleges around the world. It seeks to develop skills and competencies in middle-level specialist trainees, which would be transferable to participating countries at the end of the training period while also offering a good exposure to the workings of the National Health Service in the United Kingdom.
Having the opportunity to work in a geriatric unit within the UK offers good exposure to the model of elderly care being practised here. In Nigeria, where I come from, and in much of Africa, the qualitative experience of elderly care is based on a communal model whereby every member of the family is involved in caring for the elderly and old age is venerated. This appeared to work pretty well until a few decades ago when the realities of urbanisation and travel reduced the effectiveness of this practice, as young people left the homestead and their elders were left to fend for themselves. So, as in many other industrialised countries, elderly care is a growing problem. There are no geriatricians and no specialised post graduate training for elderly care medicine in Nigeria - this despite the fact that about 5 per cent of the current population in Nigeria (which stands at about 170 million) is aged 60 years and above (so around 8.5 million people).
Doing the rounds
Coming from a background in Neurology, there is significant overlap between neurology and geriatrics and this was something I was keen to explore while taking up the MTI fellowship.
I started with a six week induction programme. This was designed by my educational and clinical supervisors with the aim of getting acquainted with the workings of the hospital and to rehearse for the roles I shall be undertaking. During this period I spent time in the cardiac, chest, radiology and stroke wards as well as the elderly care wards and the emergency unit. I was present at ward rounds and clinic sessions run by these specialties and also attended the medical ambulatory care unit and the elderly care assessment unit. In addition, I attended falls and TIA clinics. I observed and participated in the initial assessment of emergencies/triage, acute stroke assessment, thrombolysis, endoscopic sessions as well as thoracoscopy. I spent time in the Movement disorders clinic and had the opportunity to observe the inter-individual heterogeneity of Parkinson disease presentation and the differences in the response to treatment. I did some time with the on-call medical team. I was also able to attend regional seminars organised by the British Geriatrics Society and interact with trainees as well as practising geriatricians.
I found intriguing, the complex social and psychological problems of older people. In general they were less direct in articulating their problems and often cognitive impairments make them unaware of these deficits. I noticed that treatment aims were realistically modest and I was also able to appreciate the continuum of care available to older people from hospital to care settings such as nursing homes, and assisted living. One immediately discerns the outlines of a logistic ultra structure supporting such a model (institutional linkages, communications and a carefully supervised regulatory framework) congruent with the social and ethical context of the community in which it is situated. In contemplating, the mass of resources and personnel to keep this model going, one begins to realise that elderly care is not cheap.
While a single-pathology approach worked well in other medical specialties, I found this not to be the case in elderly care. Often, itemising the problems of the patient one by one and solving them or attempting to solve them usually proves mutually rewarding for patient and doctor alike. I have also been able to appreciate the unique insights that an interdisciplinary approach can contribute to the management of older people with multiple co-morbidities with diverse inputs from every sector of care. There is a strong emphasis on palliation and end of life issues with advance considerations of the wishes of the patient documented and discussed well with the family. I found the do not resuscitate (DNAR’s) documentation process very revealing coming from a background where, discussing in advance about a patient’s death, may not be culturally appropriate and usually elicits a range of dramatic emotions from denial to anger. Also, I found the trainees friendlier, less competitive and patient.
Working within the NHS has meant working within a well organised environment with emphasis on adherence to best evidence and protocols. This can appear a bit overwhelming at times due to the range of protocols and pro-formas on almost every aspect of patient care. However, these are quite helpful in challenging situations and are a good way to refresh one’s knowledge. Also, trainees are allowed to try things out for themselves in a learning environment which I find pretty much experiential rather than didactic.
Benefits and recommendations
Practising within a UK hospital for a young doctor coming from overseas can at first be a daunting task. There is a sense in which the doctor struggles to cope with a completely different way of practising medicine. Fortunately for most, this phase is short. What I found most helpful in adjusting were the initial induction programme I had, the opportunity to ‘work backwards’ with the foundation doctors and junior trainees (some of whom, I found out, during our coffee time discussions, also struggled to cope initially) and the excellent mentoring I enjoyed from my supervisors during this period. It also helped that I met a few Nigerian doctors and nurses already within the system who helped me settle in.
An appreciation of the problems of ageing both in health and in disease states will add an edge to the quality of care I can provide to many of our underserved seniors back home. I now apply many of the principles learned during my rotations to clinical problem solving on my own. I would recommend that this program be extended to trainees from those areas of Africa where geriatric needs, are as yet unmet both to increase physician awareness about geriatric issues and to promote the visibility of the specialty on the continent.