Getting out of our box – subspecialty training in Community Geriatrics

13 December 2013

Jenny Thain is a Specialty Trainee and Wei Mei Chua is a recently appointed consultant in Geriatric Medicine.  Jenny is based in Nottingham and Wei in Derby, UK.  Both took part in a newly designed Specialty Training Rotation in Geriatric Medicine at Nottingham University Hospitals in 2012-2013. Here they share their experienceshutterstock_99252104 In August 2012 we were privileged to take up the first dedicated specialty training post in Community Geriatrics in the UK. We were, at that time, two less-than-full-time trainees in the East Midlands region, and both of us were in the latter stages of our training. Over the years we had participated in the odd community session, such as domiciliary visits and community hospital ward rounds. But it was only when we took up this post – which lasted a year - that we discovered the extensive nature of the sub-specialty and what it had to offer. We now have a much better understanding of what Community Geriatrics entails. We have been able to take part in, and lead, residential intermediate care MDT meetings and community hospital weekly ward rounds. We attended supervised domiciliary visits and, once we were comfortable working independently outside of the hospital, we began to conduct these independently. We also performed transfer of care assessments for patients moving to intermediate care and long-term social care placement in a care home. By doing so, we learned a lot more about how these facilities really work and the strengths and limitations of the care available. There were opportunities to accompany an assortment of community-based practitioners including the heart failure and Parkinson’s disease nurse specialists, community matrons, falls team and end-of-life care team. This enhanced our knowledge of community medicine and its surrounding infrastructure – in short we now know what these people do, rather than assuming we know what they do from having spoken to them over the phone a few times. The post gave us a greater appreciation of the many clinical and logistical difficulties that are faced in the community. As hospital-based physicians we have the advantage of accessing investigations easily and rapidly. In the community one has to rely more on clinical judgement to manage a patient appropriately, in order to avoid hospital admission.  When you’re sitting a patient’s front room, a chest x-ray is no longer an straightforward investigation – it means a trip to hospital for a patient who may be physically dependent, cognitively impaired, or both – and therefore requires careful consideration. The importance of good communication has always been emphasised throughout our training. Hospital discharge summaries in particular are a useful source of information for the receiving primary care physician, most notably the importance of documentation of comprehensive geriatric assessment (CGA). However, by seeing these communications from “the other end” we found we were able to better understand the shortcomings in hospital communications. During the post we used this growing knowledge to help lead projects to improve transfer of care documents.. Management responsibilities were actively encouraged throughout the post. We were able to take part in commissioning meetings and act, alongside our consultants, as expert advisers to local strategic planning and innovation groups involved in the commissioning of services to the community. As with any new idea, there were challenges.  One difficulty was achieving the right balance between hospital- and community-based medicine.  The proposed timetable was roughly 50 percent hospital and 50 percent community.  By nature, community geriatrics has to be flexible to be responsive to needs.  We initially found that, due to our flexible timetable coupled with hospital staff shortages, a much larger proportion of our time was spent on the acute ward.  Learning to manage this was, however, an important part of the skillset, since our consultant colleagues face similar challenges in their daily work. We now feel better equipped for careers in Community Geriatrics.  Indeed, Wei has gone on to do a post in the community, where she has found the skills developed during this post invaluable.  But we also think that this post has made us better hospital doctors.  By being confronted about what tests are “really essential”, we’ve become more careful in how we investigate patients in hospital.  By considering hospital as part of continuum of care, starting and finishing the community, we’re now better able to work with colleagues “on the outside” to deliver patient-centred management plans. So we’d encourage all trainees in the UK, where possible, to get out of their box and get into the community.  Whatever aspect of geriatric medicine they want to pursue in a future career, they’ll be better off for the experience. A copy of the curriculum for the 1 year rotation in Community Geriatrics at Nottingham University Hospitals is available from Dr Adam Gordon, Consultant and Hon Assoc Professor in Medicine of Older People – contact him by email: adam [dot] gordon [at] nottingham [dot] ac [dot] uk

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