What do geriatricians actually do?

It’s a question that I’ve come to think about again as use and abuse of the Clinical Frailty Score proliferates, but now in the context of a pandemic, where there are concerns about the availability of critical care beds, and a need for rationing but an admirable desire not to be ageist.It’s a question that I’ve heard colleagues locally and nationally answer, with varying degrees of confidence and detail.

So, what do you actually do? Aren’t all your patients just dying? What do geriatricians do that other doctors don’t do? Here are questions that get asked to geriatricians, and that we sometimes answer variably with words and phrases like “holistic care,” “whole person,” “general medicine,” and “kindness.”

So, why should someone be admitted under the care of a geriatrician, on a geriatric ward if they are say, 85 years old with a pneumonia? What benefit would they gain compared to being admitted to a geriatric medicine ward then say a respiratory or a general medicine ward?

Well, it depends. Most doctors are pretty good at managing most cases of pneumonia. If on day 3, your patient is not requiring oxygen, fluids or intravenous antibiotics, and is eating and drinking and walking around it is pretty easy to let them go home with some advice.If your patient is not walking around, and needs help washing and dressing, then it depends – on what they are normally like. Actually, for patients who are severely frail and dependent, say normally immobile and living in a nursing home then from a purely discharge point of view, getting a patient home might be quite easy – although there are other benefits from comprehensive geriatric assessment…

For patients who normally live at home, independent, or with varying degrees of frailty then their newfound dependence can cause frustration for some doctors.“Medically fit!”“Needs PT/OT.”“Why are they still here?”So, is there any benefit of a geriatric MDT looking after such patients? What does “The Evidence” show? Well, a Cochrane review of 13,766 patients across 29 trials from 9 countries showed that older people who are admitted to hospital and get access to comprehensive geriatric assessment are more likely to be alive in their own homes at one year. In fact, the number needed to treat is 33

Surely by now we should be at a point where not providing this evidence based treatment makes you an outlier? There’s a couple of barriers here though. First of all, not all geriatricians are completely convinced by what we do.  “It’s just common sense, isn’t it.” And even when we are proud of what we do, which is a lot, sometimes we find it hard to articulate.

So what is “comprehensive geriatric assessment.”Well, it’s led by someone with specialist expertise in looking after older people, usually, but not exclusively a geriatrician. It is multidisciplinary with expert input from therapists and nurses, who want to look after frail older people, and who know how to assess them, how to talk to them and how to provide rehabilitation. It is usually provided in a specialist geriatric ward but also makes use of home based and intermediate care services when this is more appropriate. It is tailored to the individual. Knowing what a patient is normally like, knowing how severe this illness is, knowing how to treat this illness in its broadest sense (see below) and knowing what goals are meaningful and realistic for patient and carer, are key.

It is structured and often covers the following areas:·         

  • Active problem list·         
  • Consideration of co-morbidities – how they might interact with acute problems, and how they might impact on each other·         
  • Cognition assessment – looking for and treating delirium, and identifying memory problems·        
  • Mood assessment·         
  • Falls assessment – knowing that a multicomponent treatment plan can reduce risk of further falls·         
  • Nutrition assessment·         
  • Medication assessment with particular attention to the problems of polypharmacy and use of the geriatrician’s scalpel – deprescribing·         
  • Assessment of bladder and bowel function, knowing that constipation, urinary retention and incontinence can be managed and that failure to manage them hinders rehabilitation·         
  • Assessment of function including not only whether someone is dependent or independent in a binary way, but enough detail at least to assess someone’s [tinyurl.com/CFSRockwood]clinical frailty score. A change in function is important to note here, and is at the heart of acute geriatric medicine·         
  • A social assessment including formal and informal support services·         Occupation, hobbies and interesting facts·         
  • An environmental assessment·         
  • Goals and wishes for the future·         
  • Ceilings of care and advance care planning.

These issues are often grouped into fewer, broader domains – physical/medical, mental, social, environmental and functional assessments but you can see how it can be hard to articulate exactly what comprehensive geriatric assessment is. This problem is further compounded by the ability of many organisations to “tick the boxes” of comprehensive geriatric assessment without necessarily managing the problems identified.

This really is quite difficult to describe, but let me try. A 90 year old lady is admitted to a general ward with a fall. A thorough history is taken but difficult to elicit due to “confusion.” Examination and bloods seem unremarkable. An ECG and troponin appear to have shown evidence of a myocardial infarction so triple antithrombotic therapy is started. A urine dipstick is pleasingly positive for everything and the urine, does indeed smell.  Antibiotics are duly administered. The pharmacist reviews several medications, but the ward team ask “GP to review.” Various care plans are filled out and a plan for “PT/OT” is made. Someone, somewhere suggests a rehab bed, or maybe 24 hour care. Both sound good because with this person’s confusion, there is no way that they could possibly manage at home.All boxes have been ticked but no meaningful plan has been formed. Frustration is everywhere. 

In an alternative universe the person is seen by a specialist geriatric team who look through the emergency medicine department notes and decipher that the patient appeared to walk into the emergency department with no apparent complaint. She had an ambulance call out the day before with “confusion” but no cause could be found.  Whilst in the department, she complained of central chest pain, and indeed had ECG and biomarker changes of a myocardial infarction. 

A collateral history is obtained. She used to ramble with her father and remains an avid walker, well known to people in her neighbourhood. Despite significant memory problems, there is no history of getting lost. She has lived in this area for some time, and indeed found her way to the hospital safely. This is at odds with her apparent “wandering” in hospital which seems to be risky until we realise her need to roam, that can be alleviated by a member of staff escorting her to the hospital shop for a newspaper.

She has carers twice a day who help her with personal cares, meals and medications. Her daughter helps with shopping and cooking and cleaning. She remains physically active despite her “end of the bed” frailty and indeed was found chopping wood in the garden with an axe just a couple of weeks ago, something she has always done. 

When we assess her bleeding risk, using the CRUSADE score, we judge her at high risk of bleeding, and she prefers to be on fewer medications. Although she had dual antiplatelets for a week, we switch to monotherapy on discharge. Her blood pressure is very low and falls further on standing so we stop antihypertensives and amitryptilline, which no-one can remember the indication for. After discussion with her and her daughter, we decide that the benefits of a statin would be limited. 

The physiotherapist has also spoken to the daughter and takes a careful history of cognitive decline for the past year, in keeping with possible dementia where family have provided increasing support, first for finances, and then with meals and shopping. Carers started 6 months ago. She likes walking, as we already noted, but also the music of David Bowie, which is odd because she used to hate Bowie when her teenage daughter was a fan, but now livens up when she hears his music on the ward. 

The example above is based upon a couple of real cases I have seen in the last year, and I hope illustrate what we do on geriatric wards. We are inquisitive. We are thorough. We are specialists in frailty and its related syndromes. We de-prescribe, not with abandon, but with careful gleeful consideration. We work with an MDT where we all gather and share information and modify each others plans. We consider the impacts of co-morbidities. We understand the value of methodical assessment of bladder and bowel function, of delirium and falls assessments, and of mood. We consider patients preferences and values, and we lap up their stories to enrich our understanding.

Her preferences are to be at home, and the family note that although she has memory problems, they are not particularly worse in hospital and she has a strong support network of family and friends. The occupational therapist identifies the need for rails to be fitted to the stairs and the front entrance. Although she can walk unsteadily holding onto someone else, she is currently not able to manage the stairs on her own so she is discharged home with the help of the intermediate care team who will move her bed downstairs and provide therapy at home to practice the stairs. She will be followed up in the memory clinic.

We have soft hearts, hard heads and thick skin. We try and stop people dying when this what they want. We restore function when this is possible. We don’t write people off, but we don’t press on at the end of an illness trajectory. We recognise when treatment isn’t working or isn’t in keeping with someone’s values and preferences. We look after frail older people. We do this because we value older people and want to work with them. We like working with uncertainty and competing demands. We like working in teams and allow space for others to contribute, even though we usually lead. We like not just knowing that treatment needs to be different for frail older people, but how this is different, because we have specialist knowledge, expertise and experience.

If Comprehensive Geriatric Assessment was a drug, we would give it everyone. But there are no drug reps here, only specialists in geriatrics.

We need to do what drug companies do: Educate. Lobby. Publicise. Persuade. Preach.

It’s not easy to explain, but explain we must. You can’t bottle this. This is geriatric medicine, and this is what we do.

How to take a history of memory problems

A good collateral history of cognitive decline is a crucial part of assessing cognition and you may even be able to make a diagnosis with this information. Here’s what to cover…

Remember to think about previous level of executive function so ask about occupation and educational attainment. Remember also that some people may never have paid the bills, or done the grocery shop so a change in function is important.

What is the duration of memory problems. How has it progressed? Gradually/suddenly/fluctuating

Any difficulty remembering appointments, family occasions?

Any difficulty writing cheques, paying bills, balancing the chequebook?

Any difficulty planning and buying items for a weekly shop?

Any difficulty taking medications according to instructions?

Could they plan a simple journey to a new or unfamiliar location? Do they get lost while walking or driving in familiar places?

Any difficulty recognising family members? Friends? Neighbours?

Any difficulties in speech/language? Repetitive questions? Forgetting words? Jumbling speech?

Have they become more socially withdrawn? How is their mood?

Could they manage to cook a meal? Any accidents in the kitchen?

Any other safety issues at home?

Any safety issues driving?

What ADLs can they no longer perform as a result of cognitive decline?

Alternatively, questionnaires such as the functional activities questionnaire or IQCODE may be printed out and given to patients and caregivers.

How to take a Collateral History

Many of you may have been tasked with the request to “take a collateral.” What does this mean? The heart of acute geriatrics is about gaps in function, and sometimes the patient isn’t able to tell us so we need to find out from somewhere else.

What is your patient like normally? How are they now? And what are the reasons for this?

You’ll get some tips for bridging gaps in my guides to assessing delirium and falls. But here’s some tips for taking a collateral history….

Firstly, always take a collateral history. It’s deeply distressing to see that a patient has been in hospital for hours, maybe days, with pages and pages of writing and yet it’s impossible to see anywhere what the patient is normally like, or what has happened. A clerking that says “Confused ?more than normal” isn’t good enough!

So pick up the phone and contact a relative/friend/neighbour/caregiver. If they are from a care home you could do this any time of day or night.

Rant over. Here’s what to cover…

 

When were they last well? Most acute illnesses are days to a few weeks. If you are struggling to get an answer, try asking what the patient was like two weeks ago

When they are well…

How do they walk? Aids? How far? Can they manage stairs?

Do they leave the house? When did they last leave the house?

Can they wash and dress themselves? Can they toilet themselves? Are they continent?

Cook? Clean? Shop? Manage the bills? If someone used to be able to cook a meal and plan the weekly shop and manage their finances but no longer can, this is a clue to worsening cognition and further questions need to be asked.

Where do they live? (House/bungalow/flat/care home) Steps into property or in property?

Who do they live with?

Any formal carers?

Any informal support – family/friends/neighbours?

Occupation? Previous and current hobbies? Nice to build up a picture of the person and a good way to chat and build rapport on ward rounds

Any family concerns – better to address these early on than everyone being upset on the planned day of discharge

Power of Attorney – for health? Finances?

Taking a clear collateral history is one of the most valuable things you can do in geriatric medicine. When I’m dealing with a patient recovering from pneumonia who needs two staff to transfer out of bed, it matters a lot whether this is normal for the patient or whether they normally walk independently.

Bridging this gap involves treating acute medical issues, addressing polypharmacy, ensuring patients aren’t constipated or in retention, treating pain, addressing mood and cognition, providing rehabilitation and addressing their environment – a little more than “MFFD, PT/OT” – and what we call comprehensive geriatric assessment.  

We cover a lot of the how to do this in my 21 tips

Don’t treat junior doctors the way you wished you had been treated

 

My first consultant was a charming white haired Irish man who was one of those doctors that seemed to make patients better with his very presence. When people talk of a “good bedside manner” I think he was the kind of doctor they refer to. He was not shy in praising us, his junior doctors, usually in front of the patients. I was also terrified of him, and in retrospect he had a profound influence on my style as a doctor, although it has been difficult for me to match his charm and Irish accent (sadly, I used to have one, but try being the only Asian kid in a school in Aberdeen who said “tirty tree and a turd.”)

 

Over the years, magpie-like, I have observed the best and worst of consultants, registrars and other junior doctors, and borrowed the behaviours of those I liked, whilst trying to avoid the attributes of those I didn’t. The clinical lead of cardiology, who seemed to be able to chat with patients genially, in the most efficient of ward rounds, whilst helping me with the occasional discharge letters, so that I could “get on with something more important.” The medical registrar, with a black sense of humour, who seemed to know everything, and introduced me to uptodate.com. The professor who was courteous and comprehensive in his approach, yet enlivened by the “fascinating breadth of geriatric medicine” even in the months before his retirement.  In addition, there have been numerous geriatric medicine consultants who have been role models, both in their diligence with their patients and their support of my career – one consultant from my previous hospital tracked me down via switchboard of my current one on a Friday evening so that he could give me last minute feedback for my CMT application, whilst another seemed more upset than me when it looked like I wouldn’t get my first choice rotation for my geriatric registrar post.

 

Despite the blank spaces in my eportfolio, I have reflected on my experiences and spent much of my time supervising junior doctors attempting to live by the motto “treat others as you would want to be treated.” I considered how other people had got the best out of me, and, in turn, how I might the best out of others.

 

So, on my ward rounds, I teach – a lot. I chat to my juniors, and try and find out what type of people they are. I think it is important that we know each others’ names (although I’m bad with remembering them, and recently introduced my FY1 to a patient as “Fattoush” – a Lebanese salad), a little about who we are as people, and find some time to have inane chat.

 

On night shifts, I bring lots of chocolates and sweets to the first shift, suggest that others do so for the rest of the shifts, and that we try to spend at least 15 minutes getting together where a “no-work chat” is strictly enforced – the temptation to moan about tedious events is too great. I usually find that people may be reserved on the first night shift, but by the last shift are happily swapping stories and snacks. This means that work is just a touch more enjoyable, that tedium or stress can be lubricated with banter (sorry –it’s an awful word, but you know what I mean), that people are comfortable asking for help yet are more likely to help each other out. Without quite considering the reasons why, I believed, and still do, that “social capital” is important at work.

 

Like that first consultant, I try and praise people where possible in public, and rebuke them in private. Being embarrassed on ward rounds by some consultants I encountered has stuck with me quite deeply. Perhaps I am overly sensitive but it’s hard to forget these occasions and I would have much preferred to be taken aside for the required feedback – which I would welcome – I want to know how to improve.

 

As well as teaching, giving feedback and trying to find some fun in work, I also think it’s important to stretch people. When I quiz my FY1 on their views on escalation of treatment or when a patient can go home, they may tell me “that’s not my decision to make.” I ask them to imagine that it is before talking through the rationale for these types of decisions. I used to give people homework (!) consisting usually of important journal articles that covered topics encountered at work. I think it’s very important for people to push themselves, to move outside their comfort zone.

 

I reconsidered some of these approaches a couple of years ago when I succeeded in making three junior doctors cry in quick succession. On one occasion, I had a particularly busy night shift and the daytime FY1 had made it much busier. I was searching for “bed 6’ with an AKI when they had moved bed, I reviewed a patient who was septic and had no cannula let alone antibiotics prescribed, and encountered several other minor omissions throughout the night. By morning I had calmed down, but took the FY1 aside to give what I thought was some measured feedback on how she could improve. She was very apologetic, genuinely so. The registrar had been off the admissions ward all day and the SHO was struggling with the volume of admissions, leaving her unable to ask for help on her very first shift on call in medicine. I could see that this was a thoughtful and conscientious doctor, who hadn’t had much support the previous day, and ended our conversation by telling her not to worry, but to reflect and improve in the future because this level of performance wasn’t acceptable.

 

Pleased with myself for not jumping to conclusions and not completely losing my temper, I went to get my coat from the doctors’ office where I found her sitting sat the table, inconsolable. Things had gone even worse than she had feared. She had been expecting her first on call shift to be tough but to be left alone like that had been her worst nightmare, and here I was, confirming all her fears about her substandard level of ability.

 

She soon proved herself to be a caring and highly competent doctor, but reflecting on this event with one of my friends later, it was pointed out how intimidating a usually friendly senior registrar giving you fiercely negative feedback could be. I had been on the receiving end of this kind of feedback, and worse, in the past. Didn’t people just need to toughen up a bit?

 

It’s taken me a long time to figure out, and it seems so obvious when you type it out, but what I have come to conclude is that people are different. And this means that treating everyone how I would want to be treated is only the right approach for some people, those people broadly similar to myself, who are probably a minority of the people I meet. Whilst personality typing like Myers-Briggs is rightly criticised for its lack of validity (amongst other things), where considering personality type might be useful is to introduce the concept that people prefer to work in different ways, prefer to receive information in different ways, prefer to receive feedback in different ways and have different motivations.

 

 

A simpler model to apply in everyday work and life is the social styles model. In healthcare, with our rapidly fluctuating teams it is hard to take the time to assess how best to get the best out of different individuals, but at least having an appreciation of this is important.

 

So some people may prefer working alone, may not like being grilled, may not want me to be their friend, may not want to go for a drink after work, may rather eat lunch alone, may find moaning about work very therapeutic, may get embarrassed if praised in public and may be very sensitive to critical feedback, even given privately – in short may have preferences exactly the opposite of mine.

 

The answer is clear – take some time to assess the situations and treat people how they would want to be treated, not how you would want to be treated, in order to get the best out of them. If I was to give that FY1 I mentioned earlier some feedback today, I would have asked her how she found the on call shift, realised she was trying to do a good job, sympathised with how difficult these situations can be, given her some tips on what she could do better, and avoided criticising her at all. She was already criticising herself.

We’re just begging you not to make it any worse

In the last year, two junior doctor friends of mine, who I had rather hoped might join me in geriatric medicine quit their jobs.

Dramatically. Handed their notice in and everything. I had worked with both of them before and know them to be bright and hard working and caring.

So why have they quit? Is it really the case that we are just spoilt public sector workers who don’t realise we have it so good and just need to wake up to life in the real world? Why have 4 in 10 of doctors who have completed foundation training decided not to go on to train as a GP or specialist? Why, when you sit in a hospital canteen, does it seem like no-one really wants to be here anymore? Why would half of doctors recommend an alternative career? 

Remarkably, those stories reflect the state of play before the government went after our contract with such vengeance that we aren’t even asking for them to make our lives better. We’re just begging you not to make it any worse.

Most people who know me outside of work will know that I don’t like to complain about it (too much, although the rota…). My parents, who were junior doctors in the 80s and 90s, worked harder. My wife who is a lawyer, works harder.

But I haven’t got my head in the clouds. Hospitals can be challenging places to work – tougher and more emotionally draining, I’d argue, than even a very high pressured law firm, with rotas and systems that sometimes appear designed to squeeze us dry of joy and energy. I’ve got a few thoughts on how we might address some of these issues but that’s for another day because there is an elephant in the room – the junior doctors contract dispute.

An incredible 98% of doctors voted in favour of a strike. Why then, are all the geeks from school, the straight A students who did Duke of Edinburgh’s Award, the goody two shoes, so riled up?

Hospitals have become increasingly difficult places to work. Even in the short time I’ve been a doctor, the volume of work, the complexity of work, and the increase in the demands the organisation puts on us has gone up massively. Where once I might write a quick note for a stable patient on a ward round, now I am meant to check their MRSA status, review their VTE proforma, check their oxygen prescription, review their cannula site, consider the need for catheterisation, consider their falls risk, fill out their dementia CQUIN, ensure the discharge summary is typed up laboriously in advance, consider their “fit to lodge” status, estimate their date of discharge…These are all things we should be doing but demands have increased while resources and systems haven’t kept up. By the time the COPD bundle, the pneumonia bundle, the AKI CQUIN and the sepsis CQUIN hit us we’ll barely be able to spend any time with the patient for the paperwork and tickboxes. There are many other issues, some of which are touched on here, and others here, which I’ll return to in another blog.

Not everyone would have been happy, but there might have been a case for reforming the contract to best reward those that do work of the greatest intensity, at the most unsociable of times i.e. evenings, nights and weekends. NHS Employers claim that a “fairer system that rewards those who work the most unsocial hours is needed” but the pay offer is one of increased pay for work done Monday to Friday 9-5, and reduced pay particularly for Saturday working. So, perversely, those rare junior doctors who don’t do out of hours work would be the ones who get a pay-rise, while most of us who work weekends, would lose out. And a lot of people will lose out – that’s why the government have had to offer us “pay protection” that means pay would be protected from these changes for three years, whilst the most junior doctors and future generations would then receive a paycut that affects them for the entirety of their “junior doctor” career (9 years and counting, after the six years of medical school, for me).

For some reason we also seem to be blamed for patients dying at the weekend. This has come about after several pieces of research suggesting higher mortality for patients admitted on a weekend. It’s hard to know what to make of the data, where the problem lies and how to fix it, and whether it is worth the cost. I suspect there is a “night effect” and a “winter effect” too. If this was the case should we cut doctors pay for nights in December then? I’m willing to acknowledge there looks like there is a problem, and to talk about how we might fix it, including at what cost, and to discuss to what extent weekday services may be affected. And I’m not alone. Our own royal colleges have produced a report on the issues and several trusts have already implemented seven day working, at extra cost.

What I’m not convinced about is that this problem can be fixed, or should be fixed by going after junior doctors. There is probably a bigger problem with senior cover than junior cover in hospitals on a weekend. And there are further problems with nursing staffing levels, access to diagnostics and community services. For most of my nine years as a doctor I have worked about one weekend a month. How many weekends should I work? 1 in 3? 1 in 2? I worked a 3 in 5 rota for 8 months and the effect on my social life was crippling. I might be dedicated to my job, but I would also like to see my wife, my family, my friends and even indulge in the odd non-medical activity, which would no doubt be heresy to the Daily Mail, or Katie Razzall who seems to be very  concerned about the amount of free time we have.

More than one weekend a month (on top of the on call days, and nights, not to mention the exams, and audits, and papers that we also have to squeeze into our spare time) is not reasonable to me, and I have some concern over hospitals trying to create horrible rotas in the name of “efficiency” without considering the detrimental effects such rotas can have on teamwork and patient safety.

So, I’m angry. I’m angry that Jeremy Hunt has come after us at a time when morale was already low. I’m angry that I’m having to defend myself against mistruths that have been spread in the press. I’m angry that I’m having to convince my friends and colleagues that being a doctor is actually worth it, when I should be able to inspire them for the remarkable possibilities that the profession offers us. I’m angry that Jeremy Hunt seems to think that doctors and their contracts are causing patients harm at weekends, when we were already addressing the issue.

I’m angry that its come to this.

 

Twenty (One) Tips for junior doctors working with older people

  1. Be good to older people. Many of your patients will be frail and vulnerable. Much of society may view them as a burden. You should not. These are mothers, fathers, husbands and wives. They have been
    on this planet two or three times as long as you have and many of them will have rich tales to tell. It is your job to look after them as well as you can, with empathy and kindness.
  2. Be part of the team. Physiotherapists, occupational therapists, other allied health professionals and experienced nurses will know things that you don’t know – both day to day information, and nuggets of clinical wisdom. Introduce yourself to them, ask about progress, and feed back relevant information. You are now working in a multidisciplinary team.
  3. Older people are really complicated. Acute coronary syndrome (to give just one example) will rarely be treated in a standardised fashion on an elderly ward. Some patients may be suitable for all the drugs on an ‘ACS protocol’. Others may not be suitable for more than one (or even none). Far more will be in between. Look at what your seniors are doing, and ask them why. Remember there is very little black and white in geriatric medicine and different doctors may do different things. Think about their reasoning and decide what kind of doctor you will be. The AGS guidelines on multimorbidity provide a great insight into the reasoning of a thoughtful and knowledgable geriatrician
  4. Because they are complicated, it may be helpful to write summary lists of problems (active, and inactive). It is also useful to consider nutrition, mobility, continence, and mood – document these periodically so that you record the progress of the patient in the notes. If you do this, you are well on your way to performing a comprehensive geriatric assessment! https://www.bgs.org.uk/resources/2-cga-in-primary-care-settings-the-elements-of-the-cga-process
  5. Review the medications – polypharmacy and adverse side effects are common in the elderly. And what benefit is there really for drugs like statins for frail older people in their last few years of life? This document from NHS Scotland is very helpful. https://www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf
  6. Take time to talk to relatives. In fact, offer to do so. Even if it’s just a quick “Hello, my name is…( http://drkategranger.wordpress.com/2013/09/04/hellomynameis/) I’ve been looking after your mum/dad/grandparent.” You could quickly summarise their progress (with the patients consent). You can also use it as an opportunity for some collateral history. I appreciate that you are very busy and can’t have in depth conversations with all relatives. But imagine you are a relative of a patient, with little idea of what is going on. You can provide much reassurance. And unless you need to spend a long time speaking to relatives, I think it’s perfectly acceptable to convey what you need to and say “Sorry, but I must get on..” It’s important that you show a willingness to engage with relatives. You will soon find that many relatives are grateful, and you find your job more rewarding.
  7. Speaking of collateral history – always get one! If you are ever clerking an elderly patient with cognitive impairment who cannot provide a full history, pick up the telephone and speak to a relative/care home worker/ neighbour. If a patient arrives on your ward and no-one has taken a collateral history, please do so.
  8. If the relatives are unable to visit the ward, or only able to visit when you’re not there e.g. weekends or evenings, then (with the patient’s consent), give them a telephone call and offer to inform them of progress. Otherwise families may feel as if they are in the dark, or that nothing is happening.
  9. Understand what frailty means. http://www.clinmed.rcpjournal.org/content/11/1/72.full. In particular, the understanding that relatively minor stressors can result in significant decline in overall health is important to the assessment of the frail older patient.
  10. Be excellent at diagnosing and managing delirium. https://www.bgs.org.uk/resources/14-cga-in-primary-care-settings-patients-presenting-with-confusion-and-deliriumTreat infection (if it’s there), but don’t just treat infection. Reorientation and early mobilisation are important. Carefully review the medications. Treat pain, dehydration and electrolyte abnormalities. Look for constipation (which is often present) and urinary retention, but use urinary catheters for as short a time as possible. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842841/table/t2-1820465/
  11. Pain can easily go unrecognised among older people. Is your patient agitated and distressed? Consider prescribing analgesia. Co-prescribe laxatives with opioid analgesia.
  12. Monitor the patients bowels. Constipation can contribute to delirium, poor appetite, immobility and urinary retention.
  13. Monitor the patient’s bladder. Consider the possibility of urinary retention (another cause for agitation and distress) and learn how to use your ward bladder scanner.
  14. Don’t perform urine dipsticks for older people. https://www.sign.ac.uk/assets/sign88_algorithm_older.pdf. The positive predictive value is so disappointing that you might as well toss a coin. Asymptomatic bacteriuria is common in older people. Give antibiotics for UTI if patients have acute urinary symptoms, or have bacteriuria and evidence of systemic inflammation (fever/raised inflammatory markers) without another more likely source of infection.
  15. UTI is commonly overdiagnosed in older people, partly because of excess weight given to features such as the character of urine and urine dipstick results. Remember the smell doesn’t tell! Don’t assume a UTI every time your patient becomes unwell but instead, perform a thorough clinical evaluation. We wrote this article on how to diagnose urinary tract infection in older people http://www.bmj.com/content/349/bmj.g4070.
  16. Be excellent at managing falls. https://www.bgs.org.uk/resources/12-cga-in-primary-care-settings-patients-at-risk-of-falls-and-fractures. A ‘mechanical fall’ is a rare event. Most elderly people admitted to hospital will have acute illness and/or recurrent falls that may be multifactorial in nature. Often I find junior doctors will talk about patients with “mechanical” falls being admitted for “social” reasons and in their next sentence mention the pneumonia, acute kidney injury or urinary retention. Make the link – if a patient has recently started falling more frequently or “gone off legs” there will be a reason! Treat acute illness e.g. infection, constipation, renal failure, but don’t give antibiotics if there is no evidence of infection (that seems like an obvious statement, but often people reflexly reach towards trimethoprim!). Remember to also do a thorough review to identify risk factors for falls, and treat appropriately. The falls may be ‘multifactorial ‘– but what are the factors? And how will you address them?
  17. When you are doing tasks at the bedside e.g. venepuncture, cannulation, take the opportunity to find out a little bit more about your patients. Ask them where they live, what their hobbies are, how long the have been married for etc. You will have a much richer picture of your patient as a person, and most of your patients will appreciate you for talking to them.
  18. If your patient is hard of hearing, get their hearing aids, refer them for hearing aids or use an electronic amplifier. Some wards have one, but if they don’t you can buy one as an app for your smartphone which you can then connect to headphones.
  19. You will often get asked: “Do they have capacity?” Capacity is decision and time specific. A patient may have capacity to choose what they want for lunch but not to consent for endoscopy. Read https://www.bgs.org.uk/resources/15-cga-in-primary-care-settings-mental-capacity-issues for more details of capacity assessment.
  20. If a patient “sounds chesty” frequently and has recurrent pneumonia, consider the possibility of recurrent aspiration. A SALT review and modified diet may reduce their risk of further aspiration.
  21. Never diagnose a patient as “acopic.” Patients who are labelled with this offensive term usually have several co-morbidities, often have evidence of an acute illness, and always deserve a thorough assessment. http://www.ncbi.nlm.nih.gov/pubmed/24098878

Start With Why

Welcome to the elderly medicine ward. My name is Dr Sean Ninan.

I hope you enjoy your time on the ward. You will certainly learn lots. By the end of your time here you will see patients with classic geriatric syndromes, sepsis, malignancy, acute kidney injury, neurological disorders and much more. We will teach you to become very good at assessing patients with delirium, falls, blackouts, immobility, parkinson’s disease, dementia as well as general medicine topics like sepsis, acute kidney injury and acute coronary syndromes. You will learn what frailty really means and what it means to perform a comprehensive geriatric assessment. I expect you to learn about these topics because you will be looking after patients with these problems, but wherever possible, we will try to tailor learning to your chosen career, whether that is general medicine or general practice. If you are going to be a surgeon, paediatrician or something else, then bear with us! It is still important that you learn about geriatric medicine in order to provide a good quality of service, and hopefully you will still enjoy it, and take some of what you have learned into your future career. I also hope that we can convince some of you along the way to join us in geriatric medicine in the future.

I am a geriatrician because I love general medicine and I care for older people. I believe that older people get a raw deal in many parts of the health service and sometimes get suboptimal care if looked after by people who aren’t trained to deal with their complex needs. Older people include some of the most vulnerable members of society. It is important, that we as health professionals stand up for them and care for them. You may see a frail, older person in a hospital nightgown. Take a step back and try to remember that these people are parents, grandparents, husband, wives, brothers and sisters, that many of them have lived rich lives and that they deserve our care and respect, that they are our future selves. When you do your ward rounds, when you take blood or insert cannulas, take the opportunity to talk to them about their lives, their hobbies, their previous jobs, their families. Many of them will enjoy talking to you and you will get a fuller picture of the person behind their illness.

I care about excellence. I believe in delivering high quality care because patients deserve it and because I like to do things properly. If you are casual, or take shortcuts, we won’t get on, so please don’t. It reflects on me and the rest of the team. If you do your best, and learn about some of the things that I have just mentioned, you will enjoy your job more and feel proud of your work. I will be proud of you, as will the rest of the team.

I know that being a junior doctor is hard. I know that at times it can feel thankless. But it can be very rewarding, and on this ward we recognise those who go the extra mile. On the other hand, if you are struggling with anything at work, or if you observe things at work that concern you, then come and see me. I want to know.

Good luck! I hope you enjoy your time here.”

This is (an abbreviated) version of the introductory talk that I intend to give each set of junior doctors that rotate to my firm when I (hopefully) make it as a consultant. Obviously, some of it will include “housekeeping” and “ground rules” but a large part of it is about motivating junior doctors to work well in the team.

I was watching a TED talk by Simon Sinek who was delivering the key messages of his book “Start with Why: How Great Leaders Inspire Action.” (www.ted.com/…/simon_sinek_how_great_leaders_inspire_action.html). He explains why he think some people have become great individual leaders, or leading companies, while others have been left behind. They start with why – their cause, their belief. It struck me. He gives examples of people, and companies, who were perfectly competent, as good if not better than their contemporaries, who didn’t succeed because they didn’t inspire belief. He contrasts the fortunes of Tivo, who built an excellent personal video recorder that hasn’t been very successful versus Apple, whose products we lap up and queue for, even when they enter a new market where there are many established competitors. The reason, he says, is that Apple start with why. Their modus operandi is to challenge the status quo and to innovate. The way they challenge the status quo is by making beautifully designed products that are user friendly. Their products happen to be excellent as a result of the why and the how.

In healthcare, you will see organisations outline their visions, missions and goals. These are usually packed full of buzzwords and clichés. They rarely, really, articulate why. On the ground level it is even less common. I have certainly worked in excellent teams, where you can see that people are striving to provide high quality healthcare. Often people lead by example. Often they will tell you “how we do do things round here” with reference to their guidelines and pathways and protocols (all good things, in my opinion, used sensibly). But you rarely hear people say why.

Perhaps, we could argue that individuals who have chosen to be doctors, nurses and other health professionals should be internally motivated. They should be doing the job because they care. And we should. But healthcare organisations are busy places where it is not uncommon for people to fatigue in their motivation or, sadly as we saw in Mid Staffordshire, their compassion.

That is why, if I become a consultant, every time I have a new team, I will start with why.

Everything else comes from there.

Help The Aged

I can see it everywhere.

In the TCI list for AAU – “acopia.”

In the nurse’s voice “Can you give her some lorazepam please?”

In the SHO’s tone “Another one admitted with falls. Nothing wrong with them.”

In the referral letter – “This lady has no (insert your own specialty here) -ological issues. Please could you take over her care”

Some healthcare workers do not enjoy dealing with older people. Part of me can understand why. It’s hard. Frail elderly patients place a lot of demands on staff. They need help washing and dressing. They need feeding. They need taking to the toilet. They call out. They call out again. About the same thing you just reassured them about. And they don’t tell you what’s wrong with them. They come in “off legs” or confused, the same presentation hiding a multitude of diagnoses – from constipation to cord compression.

But looking after frail, older patients should be, as Francis put it, the “core business” of hospitals and their staff. Whilst I understand that it can be hard to care for such patients, what I don’t understand is the lack of empathy many people have for older people. Empathy is the foundation of compassion, a prerequisite for caring for others.

It is distinct from sympathy where you may feel sorry for someone else. It is the ability to put yourself in someone else’s situation, in their shoes. I think many people struggle with it, and surprisingly, I think, some doctors struggle with it. Why is this patient overweight? Why won’t they stop smoking? Why won’t they stop drinking? Why do I have to clerk the frail old patient who can’t tell me what’s wrong with me?

Imagine the scenario of a frail, dependent patient being treated for a pneumonia. She is sick and her chances of mortality is high. You are treating her with oxygen, intravenous antibiotics and intravenous fluids. She isn’t getting better so you speak to the family to update them. You explain that you are worried that the patient may not get better and may even die.

The family are shocked by what you have said and distraught.

“But what do they expect?” says your junior doctor, “She’s 85!”

She is 85. She is also a mother, a grandmother, a wife, a sister, a treasured friend, a favourite neighbour. She met her husband as a teenager. They have barely spent a day apart since their marriage. She spent 9 months carrying her daughter and 18 years raising her. She was there on her daughters wedding day, at the birth of her grandchildren, at both their weddings.

Two generations have sat on her knee. Two generations have been taught how to read and write, how to cook, how to care for others. Two generations have laughed with her. And now their grief makes us uncomfortable.

We struggle when we see frail, older people in hospital, their current predicament so far removed from that of a junior doctor or nurse in their 20s or 30s. But many of us will have had experience of caring for older relatives. Hopefully, most of us will grow old. How is it possible to not feel empathy for people who are like us, like our relatives?

It is the most short sighted example of a lack of empathy. Rohinton Mistry, in “Family Matters,” one of his several excellent books, tells the story of a family struggling to come to terms with the impact of suddenly having to care for an elderly relative.

“What folly made young people, even those in middle age, think they were immortal? How much better, their lives, if they could remember the end. Carrying your death with you every day would make it hard to waste time on unkindness and anger and bitterness, on anything petty. That was the secret: remembering your dying time, in order to keep the stupid and the ugly out of your living time.”

The next time you see an elderly patient, remember that one day it might be your relative, or even you, in that situation.

As Jarvis Cocker once said, “Help the aged. One day you’ll be older too.”