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Training in old age psychiatry for geriatrics STRs - How are we doing?

The British Geriatrics Society’s Education and Training Committee (ETC) conducted a web-based survey on training in Old Age Psychiatry (OAP) among geriatric Specialty Registrars (STRs). The survey addressed two broad groups: the current STRs and the Training Programme Directors (TPDs) in geriatric medicine across all the deaneries in the UK.

Of the 107 responses from the STRs, the majority were from West of Scotland (15%), West Midlands (13%), London (12%), Yorkshire and Humber (8%), and East Midlands (7%) and remaining regions submitted 5 or fewer responses each. The responding STRs were most commonly between years 3 and 7 of training; 24% were in the 6th, 19% in the 5th, 19% in the 7th and 16% in the 3rd year of training. 

 

At the time of the survey, 56% of all responding STRs had no attachment in OAP, due chiefly to the unavailability of training opportunities and to the lack of time as a result of workload and / or rota pressure. Although the majority of these STRs intended to have the training in the future, a considerable number (15%) were uncertain if this would be possible. When asked about the organisation of such training, the majority of the trainees foresaw that they would organise it themselves, 11% did not know who would organise it, and only 4% felt it would be organised by the deanery.

Among the STRs who have already had their OAP training, the majority organised it themselves. Only one STR had training organised by the deanery. The training arrangement varied from being formal full time (39.6%) to informal sessional (33.9%), formal sessional (18.9%), and ‘ad hoc’ (7.6%). Trainees listed a wide range of opportunities for the OAP experiences that were available, including the opportunity to attend the Day Hospitals, memory clinic, general psychiatry wards and clinics, psychiatry MDT meetings, various community and care homes settings, CPN appointments and joining the liaison psychiatrists. The duration of attachments was highly variable. 

Of 107 STRs, 41 (38%) stated that there was no recognised cross-speciality training between geriatrics and OAP, but examples of joint educational opportunities between geriatrics and OAP from 9 (8%) respondents included: Joint Annual Meetings, an interface geriatric fellowship post, the placements, the joint educational events at RCPSG, once a year joint BGS/RCPsych half-day meeting, a week of dedicated OAP training, an annual half-day meeting, and evening lectures a few times per year with external speakers (largely related to dementia). 

Examples of good practice witnessed by geriatric STRs during the OAP attachments included attendance at MDTs, memory clinics, long appointments, experiencing patient-centred approach, working with CPNs and witnessing good leadership. Few examples of poor practice observed by some STRs included working with “CPNs with lower skills”, long length of stay, long waiting lists, and no access to MDT/OPD.

Topic During attachment Outside attachment
Delirium 19 48
Depression 30 37
Dementia 37 34
Anxiety 24 25
Paranoid states 24 14
Drugs 30 30
Medico-legal issues 20 40
Mental capacity assessment 21 46
Organisational aspects of old age psychiatry 25 17

 

The most common free text comments from STRs on the areas that require improvement included: 

  • integration of geriatric and OAP training 
  • longer time for the attachments
  • standardised and more structured training
  • formal links to the curriculum
  • need for more joint working system during training between geriatrics and OAP.

Summary of findings from the survey of TPDs:

Of the 27 TPDs in the UK, 14 responded (51.8%).  According to these respondents, all of their training programmes (100%) offered OAP training to geriatric STRs. Most (64.7%) of the training arrangements were described as informal (29.4%) or ad hoc via individual STRs (35.3%). 35.3% of the TPD respondents indicated the availability of formal OAP training arrangements – either sessional or on a full-time basis. 

According to the TPDs, a wide range of opportunities for OAP experience were available to the STRs, the commonest being memory clinics (100% respondents) followed by psychiatry ward-based experience (93.3%), attendance at psychiatry MDT meetings and assessment of patients at community and care homes (86.7%), attendance at psychiatry outpatients (73.3%) and CPN visits (53.3%).  The average duration of an old age psychiatry attachment for a typical STR was highly variable, ranging from 2 sessions per year to 4 weeks of full-time attachment.

Most respondents (81.3%) indicated that formal attachments of psychiatry trainees to obtain experience in geriatric medicine were not routinely undertaken in their training programmes. 

Free text comments from TPDs on the areas that require improvement included: the requirement for more integration between geriatric and OAP training, clear and defined routes to access training opportunities, and the need for a mandatory fixed period of OAP training before signing off a trainee’s competency in that domain. 

Conclusion

The two surveys throw an interesting light on the state of OAP training for geriatrics STRs both from the trainee’s and the trainer’s perspectives.

At the point of the STR survey, 56% had not had any training in OAP as a result of various factors including lack of opportunities and time due to workload, though the majority were planning to undertake this training in future. On the question of who should organise this training, STRs’ responses varied considerably, though 27% felt that it was their own responsibility.  A majority of STRs who have already had training in OAP organised it themselves.

While the training programmes offer psychogeriatric experience through wide-ranging opportunities, it emerged that trainees get more teaching on psychiatry-related topics outside the OAP attachment than within it. The duration of OAP attachment was also highly variable. 

The TPD survey indicated that most psychogeriatric training arrangements from the TPDs’ perspectives occurred on an informal and ad hoc basis, with variable duration of attachment or experience. Most of the training programmes offer OAP experience through wide-ranging opportunities, notably memory clinics, psychiatry ward rounds and MDT meetings, community-based assessments and psychiatry outpatients. There is a widespread acknowledgement among STRs and TPDs on the need for more integration between geriatrics and OAP training, as well as for more structured OAP training as such, the improvement of the formal links to the curriculum and for clarification of the recommended OAP training duration. 

Indrajit Chatterjee
Consultant geriatrician at the Glan Clwyd Hospital, Rhyl
and Sanja Thompson
Consultant geriatrician
Oxford University Hospitals, Oxford
on behalf of the BGS Education and Training Committee

 

Tags: psychiatry, education, training

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