- Sanjay Suman, specialist registrar in medicine for the elderly
Medicine for the elderly is the largest general medical subspecialty in the United Kingdom. As Sanjay Suman explains, it deals with a wide range of clinical, preventive, remedial, and social aspects of illness in older people
Currently, 930 consultants and 466 specialist registrars are working in medicine for the elderly (MFE) in the United Kingdom. There has been a recent drive to improve standards of care, rooting out ageism from the NHS following the publication of the national service framework for the elderly in 2001. The healthcare needs of the elderly are being taken more seriously and greater resources are available to provide both community and hospital based services.
What does working in geriatric medicine entail?
A large part of the daily work of MFE doctors is general medicine. Elderly patients present with a variety of respiratory, cardiac, neurological, and malignant diseases. The clinical presentation is often atypical, requiring a high index of suspicion on the part of clinicians. MFE doctors develop a broad range of clinical decision making skills to deal with a diverse range of problems.
Box 1: Subspecialty interests within MFE
Old age psychiatry
Movement disorders (Parkinson's disease)
MFE doctors work with other professionals such as physiotherapists, occupational therapists, speech and language therapists, dieticians, social workers, and nurses.⇓
Close liaison with primary care colleagues
In order to deliver a seamless health service for the elderly, a close relationship between community and hospital based specialists is vital. MFE consultants are sometimes required to assess patients in their homes. Good communication with primary care doctors ensures effective management of chronic diseases in the elderly.
Box 2: Pros and cons of working in MFE
Job satisfaction (making a difference by improving a patient's quality of life)
Strong general medical component
Holistic medicine (not always protocol bound)
Opportunity to develop subspecialty interest
Easier to get on a training programme
Major expansion in consultant numbers in future
Increasing public awareness and political will to improve services
You are always younger than your patient
Greater inpatient workload
High burden of chronic diseases
Traditionally not seen as a glamorous branch of medicine
Slower pace in general (may be seen as an advantage)
MFE consultants are increasingly expected to provide a specialist service in any one of their chosen subspecialties (box 1). Specialist registrars are encouraged to develop a subspecialty interest early on in their training programme.
Many MFE consultants have an interest in teaching, research, or management. They may also be members of important committees such as the ethics and drugs and therapeutics committees.
Desired qualities for practising MFE
Good clinical skills A thorough grounding in clinical medicine is a prerequisite. Atypical presentations of everyday illnesses are common in old age and the clinician has to be alert to this.
Team leadership MFE doctors often lead by formulating treatment plans, monitoring progress, and setting a patient's discharge dates.
Communication skills Excellent communication skills are needed to work closely with other professionals. Moreover, MFE doctors need to interact with patients' families, often breaking bad news.
Holistic approach A balanced and realistic approach is adopted in deciding how far to investigate and how active the treatment plan should be. Small cumulative functional gains may translate into a better quality of life for elderly patients.
Specialist registrar training
Training in MFE is mostly offered alongside general medicine (dual accreditation) for a total of five years (four years for MFE alone). Selection for training numbers takes place through structured interviews conducted by a panel. Prerequisites for short listing include general professional training in medicine at senior house officer level for two years; experience in MFE is highly desirable but not essential.
It is essential to have membership of the Royal College of Physicians. Experience in a locum registrar job (locum appointment for training) after gaining membership considerably increases the chances of obtaining a training number. Experience of research and audit and having work published are advantages.
Flexible training programmes are available. Training opportunities have been greatly enhanced by a recent expansion in training numbers. A similar drive to expand the number of consultants in MFE means getting a job after successful completion of training should be relatively straightforward.
Box 3: Typical week for specialist registrar in MFE
Monday Morning outpatient clinic: assess two new and six follow-up patients. A fit 79 year old patient has presented with angina and dizzy spells. Auscultation reveals an ejection systolic murmur. Echocardiogram confirms a tight aortic stenosis. Patient is referred for assessment for aortic valve replacement. In the afternoon I review some new patients admitted over the weekend.
Tuesday Attend a consultant ward round in the morning and dictate discharge and clinic letters in the afternoon.
Wednesday Attend a community hospital with my supervising consultant. A stroke patient we transferred from our unit is now able to mobilise with a frame and is due to be discharged later in the day with a care package. In the afternoon I work on my audit project: management of acute coronary syndrome in the elderly.
Thursday Attend a specialist falls clinic in the morning. (I am developing a special interest in falls management.) A patient has experienced recent unsteadiness and falls; appreciable postural hypotension is detected and I decide to stop the culprit drug (doxazosin). In the afternoon I teach a group of undergraduate medical students for an hour and later review some patients on my firm.
Friday Formal ward round with my junior colleagues. Supervise a knee joint aspiration and rigid sigmoidoscopy carried out by my senior house officer. Urate crystals are reported in the synovial fluid aspirate; colchicine treatment brings prompt relief to the patient.
Trainee specialist registrars gain experience in inpatient and outpatient management. On-call duties entail supervising an integrated take (looking after patients of all age groups) and an opportunity to practise specialist skills such as inserting a temporary pacemaker and central line insertion.
Modular training and specialist attachments
During the training period trainees are required to gain specialist experience in various subspecialties of medicine for the elderly. This is achieved by fixed commitment for one or two sessions a week in a designated subspecialty (module). A particular module may be followed for six months or longer, depending on the training requirement and trainee's interest. A posting to a specialist firm allows skill development by working alongside consultants with specialist interests. In addition, trainees can gain exposure to psychiatry in old age and palliative care medicine by arranging a session each week.⇓
The expanding horizon
Increasingly, good quality clinical trials are recruiting elderly patients, thereby expanding the evidence base for managing clinical conditions such as heart failure, coronary artery disease, and stroke
The programme of national service frameworks is part of the government's agenda to improve standards and reduce unacceptable variations in health and social services. It focuses on
Rooting out age discrimination
Providing person centered care
Promoting older people's health and independence
Fitting services around people's needs
Enhanced service models
Intermediate care services: aimed at bridging the gap between primary and secondary care. Such services may prevent unnecessary admissions and facilitate early hospital discharges
Stroke unit: acute stroke care is provided in a designated area (similar to a coronary care unit) by specially trained staff
Transient ischaemic attack (TIA) clinic: enables rapid risk assessment and fast track carotid doppler study
Falls and syncope clinic: comprehensive evaluation of fallers who may need specialist investigations such as a tilt table test
Orthogeriatric unit: medical care of patients with bone fractures (usually fractured neck of femur) is optimised MFE physicians
Research can be undertaken at any stage of specialist registrar training; one year may count towards completion of training. Research opportunities include stroke medicine (thrombolysis for acute stroke is of major research interest), falls, osteoporosis, and dementia.
Most specialist registrars are encouraged to do audit projects and poster presentations at national forums and to publish findings and case reports.
In the United Kingdom individuals aged 75 years or over are the fastest growing section of the population. Medicine for the elderly will need to expand to keep pace. The development of new types of treatment and the growing evidence base for treatment of diseases common in old age will enable better standards of care. Expansion of a structured training programme should equip future MFE consultants with the professional and personal attributes needed to provide excellent services for our elderly population.