“Modernising Medical Careers” to “Shape of Training”—how soon we forgetBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2865 (Published 30 April 2014) Cite this as: BMJ 2014;348:g2865
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We welcome the reminder from Drs Fuller and Simpson about lessons learned from Modernising Medical Careers as the profession reconsiders the structure of postgraduate training through the Shape of Training review. The issues raised in their article are important and reflect shared concerns raised in the recent joint statement by the UK Royal Colleges of Physicians about Shape of Training1. Their uncertainty about the role of credentialing and how it will impact upon the content of core and higher medical training is shared by most, if not all, medical specialist societies. They are correct to state that there is some uncertainty about how the need for medical generalism can be reconciled against an ever-expanding body of subspecialty expertise across all branches of medicine. There are, however, some parts of their letter that we believe lack an evidence-base.
The population presenting to services across the NHS is increasingly frail, affected by multiple comorbidities, polypharmacy, an increasing prevalence of cognitive impairment and physical dependency. The model of care proposed by Drs Fuller and Simpson to care for this cohort – recourse to multiple medical specialism - is not evidence-based. One of the examples that they use to underline their argument, the Cochrane Review of Stroke Unit Care2, is an exemplar of quite the opposite. The studies included in this review described a model of care that used multi-professional assessment, across multiple domains, to establish management plans that were iterated forward against clearly stated goals. The Stroke Unit trialists were conducting Comprehensive Geriatric Assessment. Comprehensive Geriatric Assessment has also been considered as part of a separate Cochrane Review considering generic older populations with frailty and has been shown to have an impact equivalent to, if not surpassing, that of Stroke Unit care3. For almost all the studies included in these analyses the control arm was "usual medical care", exactly the model of multiple medical specialism that Drs Fuller and Simpson advocate in their letter.
The dichotomy here, though, is a false one. Patients, regardless of age, who present with a clearly-defined single-organ pathology need a single-organ specialist with adequate expertise to manage their condition. Patients with advanced frailty need specialists in Comprehensive Geriatric Assessment who can draw upon the rapidly expanding evidence-base in the care of older people to ensure they get the best, most clinically effective care. The role that geriatricians have to play in caring for this latter group is well recognised by doctors in training, with more applicants to geriatric medicine than any other physicianly specialty for the 2014 higher medical training intake. That leaves us with the bulk of patients who present to acute medical, or surgical, or other hospital admission units. Some of these will have frailty, some of them will have single organ pathologies, many will have both. The challenge going forward is to produce a cadre of doctors - from consultant down - as competent in the initial management of frailty-related aspects of care, as they are the organ-specific ones. The latter have historically been well taught to under- and post-graduates. The former continue to be under-recognised in UK medical curricula at all levels4.
The Shape of Training review gives us the opportunity to ensure that our future medical workforce is fit for purpose. Single-organ specialists should not feel threatened by the need to come to terms with frailty and comorbidity. An NHS which is fit for purpose will need expertise in both.
2. Stroke Unit Trialists’ Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013;9: CD000197.
3.Ellis G, Whitehead Martin A, O’Neill D, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst. Rev. 2011. CD006211.
4. Gordon AL, Blundell A, Dhesi JK, et al. UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine. Age Ageing 2014. 43(2): 293-297
Competing interests: No competing interests