Training requirements for higher specialist trainees in geriatric medicine in orthogeriatrics and bone health
This page clarifies the training standards for higher specialist trainees in geriatric medicine in orthogeriatrics in the context of the new training curriculum and syllabus.
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 and Bone health by completing the optional higher level training.
Core curriculum competencies
- Acute presentation and care, including Initial emergency department care and pathways
- Surgical and anaesthetic issues including optimal timing of surgery and management of perioperative issue such as fasting, medicines management and analgesia.
- Hip fracture: common types and their management including operative and non-operative.
- Understanding of postoperative care, common problems and complications.
- Different models of orthogeriatric care including role of intermediate care and community services in rehabilitation and in prevention.
- Causes and management of falls as per other curriculum competences.
- Causes and management of osteoporosis and role of fracture liaison services.
- Awareness of relevant National Publications and Guidelines including NICE and SIGN guidance, BOA and AAGBI.
- Understanding of National Audit Programmes National Hip Fracture Database/Falls and Fragility Fracture Audit Programme (England, Wales and Northern Ireland), Scottish Hip Fracture Audit ( Scotland)
- Diagnostic skills to include assessment of comorbidities and any acute/subacute illness.
- Able to do a comprehensive medication review and have specific knowledge regarding
- interventions for analgesia, bowel care, anticoagulants, blood products and osteoporosis treatment.
- Nutritional assessment using recognised score and appropriate interventions.
- Assessment of frailty using a recognised score .
- Communication, team and leadership skills.
- Proactive Discharge Planning and planning transfers of care for Advance care Planning and Palliative Care.
- 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 and recognise that the expected outcome may change and requires regular review.
- An approach to the management of elderly people with fracture that seeks to maximize early recovery/independence.
- Enabling patient involvement and choice.
- Close collaboration with theatre team, orthopaedic surgeons, anaesthetists and other professionals to optimisation for early surgery.
- Effective engagement with and education of non-specialist teams caring for when fragility fracture patients who are not on orthopaedic wards.
- Work with team, across whole pathway from admission to discharge to meet Quality Standards and best care.
- Close collaboration with the MDT to effect discharge.
Specific learning methods: Core curriculum competencies
- Pre-operatively-compassionately explanation to patients and families of the risk and benefits of surgery, potential outcomes and where appropriate initiating advanced care planning conversations
- Post-operatively explaining (using information gained from collaboration with the MDT) the anticipated trajectory for the patient
Optional higher level curriculum competencies in orthogeriatrics and bone health
- Detailed in depth knowledge of the effects and risks of injury, surgery and anaesthesia on older people.
- Knowledge of common fracture types, their management and prognosis.
- Knowledge of common injury patterns in older people and how to assess and initially manage them in general wards / non-specialist areas, liaising with or referring to specialist services including MTC as appropriate:
- Knowledge of peri-operative complications both generic (e.g. wound infection, delirium, AKI, pain) and specific (e.g. increased blood loss with Subtrochanteric fractures, DHS cut out , avascular necrosis).
- Knowledge of possible post-operative trajectories and outcomes.
- Awareness of the factors that may impact rehabilitation e.g. fear of falling, continence, pain, fatigue, fixation failure etc.
- Knowledge of appropriate assessment tools to inform clinical management decisions.
- Ability to understand and evaluate different models of delivering orthogeriatric services ideally with exposure to different models of service during training.
- Have a detailed knowledge of National Hip Fracture Audit Programmes (NHFD/Falls and Fragility Fracture Audit Programme (England ,Wales and Northern Ireland), Scottish Hip Fracture Audit (Scotland) and understand how they have influenced different models of orthogeriatric care.
- Have knowledge of relevant national guidelines e.g. BOA, AAGBI and understand the evidence base used to inform them.
- Be aware of and keep up to date on relevant evidence reviews that inform practice e.g. Cochrane reviews and relevant NICE Guidance e.g on TLOC, falls, Hip fracture, Technical guidance on treatment for osteoporosis.
- Be aware of and able to contribute to local policies for this group of patients.
Causes and management of falls - as per Falls curriculum competence
- Be able to do a falls assessment as required by Best Practice Tariff for Hip Fracture.
- Be aware of multiple risk factors for falls and how to modulate them.
- Able to recognise when falls are ‘unexplained’ and possibly syncopal including orthostatic hypotension, Vasovagal syndrome VS, Carotid Sinus hypersensitivity.
- Be able to interpret ECGs and appropriately refer on for further testing e.g. tilt / cardiac - ILR
- Falls programmes and the evidence base for their effectiveness.
Bone health and osteoporosis
- Knowledge of the causes of osteoporosis and appropriate strategies for the prevention and treatment of osteoporosis.
- Drug and non-drug treatments for osteoporosis.
- 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).
- Other relevant metabolic bone disorders (osteomalacia, Paget’s disease, etc.).
- Understanding of medical and surgical management of common metabolic bone diseases eg. osteomalacia, Paget’s disease & primary hyperparathyroidism.
- Awareness and recognition of atypical bisphosphonate related fractures.
- Awareness of Pathological fractures (non-fragility).
- Public health and ‘whole life’ strategies for bone health.
- To be familiar with local fragility fracture data and be able to describe how this influences the way in which orthogeriatric care is delivered locally.
- To be able to work with and influence other specialities and professions caring for this group of patients.
- Able to critically appraise and benchmark current service against national standards/data e.g. NHFD and identify areas for improvement to use QI methodology to monitor and continuously improve it.
- Clinical assessment of patients with fragility fractures including understanding risks of complications.
- Discharge planning.
- Assess patients for and medically optimise for surgery.
- Leadership and membership of a multidisciplinary team.
- Ability to assess falls risk and institute fall prevention measures including referral to appropriate services where appropriate e.g. exercise classes, tilt testing.
- Health promotion.
- Compassionately explains to patients and families the impact of recommended interventions for, and possible outcomes of fragility fractures.
- Uses advanced communication skills to understand what matters to the patient and use this information to guide care.
- Advocates for early operation and discuss risks / benefits of delay in a collaborative manner with anaesthetist and surgeons.
- Recognises limitations of own knowledge and engages with other specialities for advice regarding complex cases e.g. cardiology, haematology
- Visible inclusive leadership style working in a collaborative interdisciplinary and multi-agency manner.
Specific Learning Methods – higher level curriculum competencies
- Experience - at least 6 months fulltime equivalent (although not necessarily consecutively) of working in a variety of orthogeriatric settings including preoperative assessment and management, acute postoperative care, post-surgical rehabilitation and discharge planning.
- 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 more specialist service to patients with fragility fractures and falls -related injuries that occur on general wards or present to district general hospitals.
- Exposure to/experience in a Major Trauma Centre Unit is desirable (e.g. in a taster or brief secondment) but not mandatory to achieve the requirements.
- For Higher Level Competence a minimum of 12 osteoporosis sessions is required (includes clinics and also other sessions such as time with fracture liaison service). This may include osteoporosis sessions which are also counted towards the core competence. Trainees should also be encouraged to attend clinics in other relevant specialties, such as rheumatology.
- Evidence in portfolio of contribution to Audit of care against national standards/guidelines/protocols .
- It is expected that in addition to the formal teaching for the core curriculum trainees completing the higher level competencies will have attended more advanced or specialised teaching e.g. conferences such as POPS, Age Anaesthesia, specialist session at BGS national meeting.
- It is also expected that they will have taken and evidenced in their portfolio the opportunity to provide teaching and support to junior doctors and other professions in aspects of orthogeriatric care.