Clarification of training requirements for higher specialist trainees in Geriatric Medicine in Orthogeriatrics
Based on the specialty training curriculum for geriatric medicine August 2010 (amendments 2016).
It is important to distinguish the basic training requirements for all higher specialist trainees in geriatric medicine who need to be able to assess and manage older patients presenting with the common geriatric problems from the smaller number of trainees seeking to demonstrate additional competencies in orthogeriatrics by completing the optional higher level training.
- Surgical and anaesthetic issues and understanding of postoperative care and complications (including pain control and tissue viability)
- Different models of orthogeriatric care including role of intermediate care
- Causes and management of falls
- Causes and management of osteoporosis and role of fracture liaison services
- Relevant National Publications and Guidelines including NICE and the Blue Book
- Understanding of National Audits and the Hip Fracture Database
- Diagnostic skills
- Drug and non drug interventions
- Team and leadership skills
- Planning transfers of care
- Nutritional assessment and intervention
- An approach to the management of elderly people with fracture that seeks to maximize function
- Close collaboration with orthopaedic surgeons, anaesthetists and other professionals to ensure best care
Specific learning methods
- Work in orthopaedic wards where hip fractures admitted for operation, orthogeriatric wards, rehabilitation facilities.
- Discussions with anaesthetists, orthopaedic surgeons, other medical specialities eg cardiology, nurses, physiotherapists, occupational therapists, social workers, fracture liaison nurse, falls co-ordinator.
- Attend osteoporosis clinics and falls clinics
Specific learning methods – Core curriculum competencies
- To gain experience in this topic trainees should be placed in units designated either as Trauma Units (TU) or Major Trauma Centres (MTC). A minimum attachment of 12 weeks over the five year training programme is recommended. Trainees should see a minimum of 30 patients, at least 10 that they have reviewed on their own initially and then reviewed later with an orthogeriatrician.
- Trainees should spend time on orthopaedic wards where hip fractures are admitted for operation, orthogeriatric wards, and rehabilitation facilities. Reference should made to other areas of the curriculum such as falls, delirium, continence, tissue viability and palliative/end of life care which are relevant to this group of patients.
- Trainees should gain experience of discussions with anaesthetists and surgeons on medical optimisation before surgery. It is expected that a trainee would attend at least one hip fracture operation to observe the whole theatre process from induction of anaesthesia to recovery.
- Liaison with MDTs on trauma wards and selection of patients for rehab beds is expected. In an orthogeriatric attachment trainees should see the full range of outcomes of hip fracture surgery. The trainee should be able to assess which patients are likely to make a good recovery and return home, those who have ongoing rehabilitation needs and those who have a high likelihood of dying while in hospital. Trainees are expected to gain experience in the management of a wide range of post operative complications, such as pneumonia, acute kidney injury and thromboembolism. Learning will also take place by using audit data such as the National Hip Fracture Database, and undertaking morbidity & mortality reviews.
- Trainees should undertake falls and bone health assessments acutely, but also attend relevant clinics. A minimum of 6 falls and/or bone health clinics should be attended.
- It is expected that trainees will also be exposed to formal teaching sessions during their five year training programme (local, regional and national training and CPD meetings).
- Educational supervisors must be able to assess a trainees competence in these areas using a combination of direct observation and supervised learning events (e.g. CbD, mini-CEX, ACAT and MSF) in order to complete curriculum sign off. This should be continued over the five year programme
- Optional higher level curriculum competencies in Orthogeriatrics and Bone Health. (section 47)
- To have advanced knowledge and skills in order to assess and manage older patients presenting with fracture, particularly hip fracture, from presentation to discharge.
- To have advanced knowledge and skills to assess and manage fracture risk.
- Causes and management of falls and osteoporosis
- Effects and risks of injury, surgery and anaesthesia on older people
- Effects and risks of surgery and anaesthesia on older people
- Knowledge of appropriate assessment technologies to inform clinical management decisions, eg on rehabilitation, use of intermediate care, discharge planning and prognosis
- Different models of orthogeriatric care and of evidence base of evaluations
- Drug and non-drug treatments for osteoporosis
- Other relevant metabolic bone disorders (osteomalacia, Paget’s disease, etc.)
- Knowledge of the causes of osteoporosis and appropriate strategies for the prevention and treatment of osteoporosis, including the evidence base for pharmacological and non-pharmacological treatments.
- Understanding of medical and surgical management of common metabolic bone diseases eg. osteomalacia, Paget’s disease & primary hyperparathyroidism.
- Clinical assessment of fracture patients including understanding risks of complications
- Leadership skills in interdisciplinary and multi-agency working
- Discharge planning
- Assess patients for fitness for surgery
- The appropriate use and interpretation of bone densitometry and the WHO FRAX tool
- Ability to manage osteoporosis in special groups (eg men, younger adults, steroid-treated, Down syndrome)
- Ability to assess falls risk and institute fall prevention measures including referral to appropriate services where appropriate eg. exercise classes, tilt testing
- Ability to critically appraise an orthogeriatric service in order to assess whether it is evidence based and follows national guidelines eg “Blue Book”
- Leadership of a multidisciplinary team
- Health promotion
Patient-empathetic view of compromises which may occur between patient’s safety and improved mobility
Specific Learning Methods
- Experience of working in a variety of orthogeriatric settings including preoperative assessment and management, acute postoperative care, post-surgical rehabilitation and discharge planning. At least 6 months fulltime equivalent (although not necessarily consecutively)
- Keeping up to date with evidence base for interventions and national/international guidelines.
- Attending national / international conferences or study courses on post-hip fracture care, osteoporosis and metabolic bone diseases and falls.
- Attending osteoporosis clinics (at least 15)
Specific Learning Methods – higher level curriculum competencies
The curriculum requires experience of working in a variety of orthogeriatric settings including preoperative assessment and management, acute postoperative care, post-surgical rehabilitation and discharge planning for at least 6 months fulltime equivalent (although not necessarily consecutively). This should include both Trauma Units and Major Trauma Centres, and cover a range of trauma in older people. A minimum of 15 osteoporosis clinics is required, and trainees should also be encouraged to attend clinics in other relevant specialties, such as rheumatology, and to gain experience of a fracture liaison service.
Assessment standards will be set higher than those expected for core curriculum orthogeriatrics grids commensurate with the knowledge, skills and behaviours required to provide a specialist service.