Should physicians be routinely involved in the care of elderly surgical patients? No
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1072 (Published 04 March 2011) Cite this as: BMJ 2011;342:d1072
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Editor
Dr Herd should be congratulated for a succinct and erudite article.
As higher trainees in surgery, we regularly run a surgical firm at ground
level and of course in our elective and emergency practice come across
many elderly patients.
Physicians with an interest in the care of the elderly patient have
defined competencies and areas of clinical interest and we believe the
call for one size fits all cover of elderly surgical patients demeans the
specialist role of these highly trained individuals.
The NCEPOD report highlights deficiencies in the assessment of vital
signs, recognition and management of nutritional deficit, fluid management
and assessment of pain. In the modern era, this is unacceptable and should
be addressed urgently but we suggest that this can be managed by educated
and motivated surgeons. It is interesting to note that in the 2010 JCST
Syllabus for General Surgery there is no specific mention of competency in
the management of the elderly surgical patient. Is this something that the
surgical community needs to address?
Our plea is that whilst we are capable of performing operations, we
have received general clinical training as undergraduates and
postgraduates arming us with skills to deal with the elderly population.
We are able to take a history, perform an examination and formulate a
diagnosis and management plan. Relegating us to technicians without the
responsibility to ensure the patients recover will ironically diminish the
holistic nature of surgical practice.
There are occasions where there is diagnostic or management
uncertainty as in all areas of medicine and this is very much where the
multi-disciplinary team shines as experienced primarily from our
perspective in cancer and vascular surgery. It would be wonderful to have
the option to seek specialist advice from an elderly care physician in the
'A-level' cases and perhaps we may have a role to play in the multi-
disciplinary teams of elderly care wards?
Yours sincerely
Mr Rahul Velineni MBBS BSc MRCSEd
Mr Jaspal S Phull MbChB MRCS
Mr Vivek Gupta MbChB FRCS(Gen)
Competing interests: RV and VG are Specialist Registrars in General Surgery in a South Wales DGH and JP is a Specialist Registar in Urology at the same institution.
Promote excellence not indifference
Wilkinson & Wilson and Herd make opposing arguments for and
against the involvement of geriatricians in the care of elderly surgical
patients[1]. Anecdotes of elderly relatives who have been operated upon
and daily experience working in hospitals corroborate the NCEPOD finding
of serious shortcomings in the care of some elderly surgical patients [2].
The video Orthopedics versus Anaesthesia showcases an orthopaedic
surgeon insisting that he must fix a fracture despite the protest of the
anaesthetist that the patient is asystolic and has failed cardiac
resuscitation [3]. Whilst this may be a cliche, many medical registrars do
perceive an indifference of some surgeons to medical comorbities. This is
attested to by the surfeit of 'refer to medics' or suchlike in surgical
ward round notes and stories of referrals being made for which a junior
medical student could have appropriately diagnosed that condition, for
example performing urinalysis and prescribing antibiotics in a patient
with pyrexia.
If surgical training bodies sincerely wish to improve outcomes in
elderly surgical patients, in the face of limited number of geriatricians,
surgical trainees should be mandated to demonstrate excellence in the
management of medical conditions, perhaps by completion of MRCP, as a pre-
requisite to progression to higher training. Whilst some surgical trainees
might not be able to demonstrate this level of achievement, those with
interest in medical care and ability to perform this care would be able
to.
Such a benchmark would provide society with a generation of surgeons
better engaged with the clinical demands of our ever-ageing population.
References
[1] Wilkinson K, Wilson H, Herd B. Should physicians be routinely
involved in the care of elderly surgical patients? BMJ 2011;342:d1072
[2] National Confidential Enquiry into Perioperative Deaths. An age
old problem--a review of the care received by elderly patients undergoing
surgery. NCEPOD, 2010.
[3] http://www.youtube.com/watch?v=q0S5EN7-RtI [accessed on 13 March
2011]
Competing interests: No competing interests