Core Medical Training

Transcription

Training opportunities for junior doctors in South Glasgow Medicine for the Elderly Service
Caroline Whitton, Lara Mitchell, Tricia Moylan,
Training opportunities for junior
doctors in South Glasgow Medicine for
the Elderly Service
Caroline Whitton, Lara Mitchell, Tricia Moylan
30/10/14
1
Contents
Introduction ................................................................................................................... 3
Basis of proposal ........................................................................................................ 5
Background .................................................................................................................... 6
Patient numbers and Level of Acuity ......................................................................... 6
Acuity 1 Acute Admissions Unit – 1st 24 hours .......................................................... 7
Acuity 2 Acute Assessment – includes delirium/dementia ....................................... 7
Acuity 3 Complex Care and Rehabilitation including GORU ...................................... 9
Acuity 4 Interim Care ............................................................................................... 10
Acuity 5 NHS Continuing Care .................................................................................. 10
Liaison ...................................................................................................................... 11
Outpatient and Day Hospital ................................................................................... 11
Current Provision of junior staff .............................................................................. 12
Foundation Training ..................................................................................................... 14
Foundation Year 1 .................................................................................................... 15
Foundation year 2 .................................................................................................... 17
GPST ............................................................................................................................. 21
Core Medical Training .................................................................................................. 25
Specialty training (ST 3+).............................................................................................. 30
Undergraduate Medical Students ................................................................................ 34
Teaching and training opportunities............................................................................ 35
Specialty teaching and training ................................................................................ 35
Unit teaching programme ........................................................................................ 35
Aspirations for service and training developments ..................................................... 38
Conclusion .................................................................................................................... 40
Acronyms ..................................................................................................................... 44
References ................................................................................................................... 46
2
Introduction
The purpose of this paper is to present the training opportunities for junior doctors
within the South Glasgow Medicine for the Elderly Service. This encompasses the
new South Glasgow Hospital (nSGH) and outlying units following amalgamation of
Southern General Hospital (SGH), Victoria Infirmary (VI) and Gartnaval General
Hospital (GGH).
The recently published ‘Shape of Training’
(1)
makes clear recommendations about
UK Postgraduate medical training which include adapting to an increasing ageing
demographic and being responsive to patients needs. In addition it advises placing
trainees in teams, instituting apprenticeship-style training and co-locating trainees
with Supervisors.
Recently South Glasgow trainees have reported dissatisfaction with Geriatric
Medicine placements – based mainly on workload issues, concerns around acute
medical receiving and ability to engage with learning opportunities. GMC trainee
surveys, Deanery visits and local feedback highlight these issues. Some of this has
been resolved by increasing the amount of support staff. Additionally increasing the
availability of senior cover into acute medical receiving and Hospital at Night (HAN)
has helped although this has lead to dissatisfaction at more senior levels. To date,
Geriatric Medicine trainees have combined with medical trainees to populate acute
medical rotas. This has worked in some ways by improving continuity of care on
wards and accommodating exposure of more trainees to training in Geriatric
Medicine. However it has resulted in trainees becoming less team based with the risk
that they feel anonymous. By the allocation of trainees purely to Geriatric Medicine,
we can improve the team ethos and determine the training environment in which
they work.
This proposal is based on ensuring two crucial tenets:
● A high quality training environment
3
● That curricula requirements are met
Quality of Training Environment
The quality of a training environment is determined by factors such as:
● Robust patient safety mechanisms:
o Effective handover
o Adequate induction
o Appropriate workload
o Ensuring that trainees are not working beyond their competence
o Support for routine tasks
o Clinical Supervision
● Adequacy of learning experience :
o exposure to varying aspects of the clinical specialty including outpatient work
o local teaching
o ability of trainees to attend regional teaching through study leave
o
access to educational resource
● Educational support:
o Educational Supervision
o Feedback
This is generic to all levels of trainees. The paper will describe several means by
which these factors can be achieved. These include team based working, extended
attachment to individual units, appropriate skill mix in each area (an appropriate
range of training seniority), accessibility to trainees of out-patient clinics and subspecialty encounters. For the latter two trainees must be specifically timetabled to
attend in order to gain experience.
4
Training and curricula requirements
This paper will review the curricula requirements for trainees through all seniority
levels from FY 1, through FY 2, GPST, CMT and Specialty trainees. In the following
chapters, the available training experience within the South Glasgow Medicine for
the Elderly Service will be mapped against training curricula at each level.
Basis of proposal
A proposal is put forward founded on the following factors:

A team based ethos with opportunities for apprenticeship learning

Rotas will be educationally sound – this includes accommodating posttake ward rounds and removal of late/back shifts

Ward cover will include a combination of FY 1, FY 2 – GP ST and CMT
trainees to enable a constant range of seniority and support more junior
grades.

ST 3+ specialty trainees will be attached to Consultant to allow them to
take advantage of all training opportunities and to progressively achieve
independence and autonomy

Junior trainees will be ward based and rotation through wards will be
kept to a minimum so that trainees are able to create and maintain
professional relationships

A balance will be struck between this and experiencing different areas of
elderly care

There will be adequate staffing of all wards

Trainees will be given the opportunity and encouraged to attend outpatient clinic and Day Hospital activities for their educational value

All trainees will have high quality education, training and supervision
5
Background
Patient numbers and Level of Acuity
The South Glasgow Medicine for the Elderly Service will provide care for about 570
in-patients of which around 400 occupy acute and rehabilitation beds and 170 reside
in NHS Continuing Care units. In order to inform the following proposal the table
below indicates anticipated patient requirements. Wards are designated by level of
acuity as shown, with descriptors, in the table below:
Level
Descriptor
Proposed
Number of Total
location
beds
of wards
18
1
Stack 28
1
Acuity 1
AAU
nSGH Stack
Acuity 2
Acute assessment
nSGH
Acute assessment
Langlands
120
4
Delirium/dementia
Langlands
30
1
Acuity 3
Complex
Care
and New
Rehabilitation
Victoria 48, 56
4
Hospital (NVH),
Drumchapel
Hospital (DCH)
Geriatric Orthopaedic GGH
Rehabilitation
86
3
Unit
(GORU)
Acuity 4
Interim care
Anticipated not 0
0
to be required
Acuity 5
NHS Continuing Care
Mearnskirk,
64, 24, 60, 6
Rogerpark, DCH,
26
St
Margaret’s
Hospice
Each of these levels will be described in more detail.
6
no.
Acuity 1 Acute Admissions Unit – 1st 24 hours
This is the acute receiving unit for all new admissions. The projected average length
of patient stay is less than 24 hours and there are 18 beds within this ward. Senior
support will comprise two post-take ward rounds each day with senior presence over
the whole day. This is in line with recent recommendations for a Consultant presence
12 hours per day and 7 days per week (2). There will be a senior specialty trainee (ST
3+) attached to the unit, working with the Consultant of the day and as part of the
HAN team. There will also be support from the Elderly Care Assessment Nurse
(ECAN).
A model is suggested for junior doctor input that is equitable with the other medical
acute receiving areas. For each 24 hour period there should be:
1 FY 1
1 FY 2- GPST
1 CMT
This provides 24 hour cover for ward rounds and admitting of patients, along with
management of patients in the ward area (review, ordering investigations and
chasing results, ordering of discharge medications). Trainees will work two shifts:
10:00 hours – 22:30 hours or 22:00 hours – 10:30 hours. This enables time within the
shift to be involved in the two post-take ward rounds which are occurring each day
to improve the educational value of the role. We intend to dispense with ‘late shifts’
within this area as they are educationally unsound.
Acuity 2 Acute Assessment – includes delirium/dementia
The nSGH Stack and Langlands wards will be utilised for acute elderly patients. This
includes one ward specified for delirium/dementia care which will have regular input
from psychiatry. We are currently working on proposals for the Consultant
Psychiatrists to educationally supervise trainees within this block in order to enhance
psychiatry training.
7
Patients will be transferred from the acute admissions unit. The average length of
patient stay is projected to be 15 days although may be shorter.
Our current input of junior staff into equivalent wards across VI, SGH and GGH is
woefully inadequate and this is an area we hope to address with this proposal.
Currently in some areas we have a situation where one junior member of staff
provides cover for two 30-bedded wards. Not only is this inadequate in terms of
provision of safe levels of care, it is also educationally extremely poor not least
because trainees are not able to accompany Consultant ward rounds (which are
likely to occur concurrently on different wards). Additionally trainees have very little
opportunity to be exposed to the wide range of Geriatric Medical service provision
such as out-patient and Day Hospital work.
We propose a model which provides equity with the nSGH Stack medical wards on
the basis that patients in Geriatric Medicine within nSGH Stack and Langlands wards
are equally as sick. We recommend the following junior staffing levels per each of 6
wards:
Trainee
09:00-17:00
17:00-21:30
21:30-09:30
FY 1
1
1 per 6 wards
HAN
FY 2- GP ST
1
1 per 6 wards
HAN
CMT
1
1 per 6 wards
HAN
The late shift cover will be provided by one member of the team at each seniority
level as part of a long day. Overnight cover will be provided by the HAN team.
We are keen to involve FY 1 trainees within these wards, both to give them
experience in Geriatric Medicine and also to provide equity of medical provision with
8
other acute medical patients. This will mean that more senior trainees are able to
provide input appropriate to their own level of training.
Consultant input will be through twice weekly formal ward rounds and MDT.
However it will be spread such that there will be a daily Consultant presence
(including weekends) in order to provide review of new and sick patients. The senior
rota is being designed with internal cross cover so that there will never be a patient
without access to a Consultant and regular Consultant review.
Geriatric specialty trainees (ST 3+) will be attached to Consultants. Rotations will be
designed to ensure that there is nominally one Specialty trainee per acute ward.
Acuity 3 Complex Care and Rehabilitation including GORU
This is a group of frail patients who require regular comprehensive geriatric
assessment. Consultant input is planned through twice weekly formal ward rounds
and MDT. Two Consultants will input into each ward on different days so that there
will be a Consultant presence 4 week days out of 5 to facilitate review of new and ill
patients. Weekend cover is provided at junior level but with a named Consultant
available to visit or give telephone advice.
Our current trainee input into rehabilitation wards is low. There is often the situation
that one junior covers 2 wards (i.e. total 60 patients). This neither provides safe
levels of care nor a supportive educational environment. Trainees are not always
able to accompany Consultants on ward rounds and have very little opportunity to
be exposed to the wide range of Geriatric Medical service provision such as outpatient and Day Hospital work. This situation must change and the proposal hopes to
rectify this.
The proposed model of care places two trainees on each ward of 30 patients. This is
one less trainee than on the acute wards although we anticipate that acuity 3
9
patients are still likely to be ill and frail. Turnover is expected to be high, particularly
in the Geriatric Orthopaedic Rehabilitation Unit (GORU) as this will serve the GGC
trauma centres in both nSGH and GRI.
The proposed model (below) places two trainees on each ward. Evening cover is
provided through ‘long days’ with one trainee covering the NVH and DCH and
another covering GGH. Overnight cover is provided by HAN. It is anticipated that one
trainee will be based in GGH as part of the HAN team and another based in nSGH as
part of the HAN team.
Trainee
09:00-
17:00-21:30
17:00
FY 2- GP ST
1
1
per
21:30 – 09:30
21:30-09:30
GGH
NVH and DGH
NVH
HAN
and DCH
CMT
1
based
at
nSGH
1 per GGH
HAN based at
GGH
Acuity 4 Interim Care
It is assumed that this will no longer be required.
Acuity 5 NHS Continuing Care
This is a very frail group of patients deemed too unwell to be cared for in Care
Homes and requiring complex and frequent medical and nursing interventions.
Currently junior trainee input into NHS Continuing Care is mainly at weekends and
out of hours although junior trainees provide cover for all NHS Continuing Care
patients in St Margaret’s Hospice and some cover in Drumchapel Hospital currently.
In Mearnskirk and Roger Park daytime care provision is by Specialty Doctors and GP
10
Clinical Assistants. Night time cover is provided by GPs (through GEMS). We are
exploring alternative ways of providing out of hours and weekend cover by GPs.
Additionally we are currently undertaking a review of junior trainee input into St
Margaret’s Hospice and Drumchapel Hospital.
Our specialty trainees do have involvement as this is an important area of the
Geriatric Medical service. This would continue through attachment to specific
Consultants. In terms of exposure to managing long term conditions and advanced
care planning, these wards provide ideal training areas. Whereas the aim is to have
no service requirement for junior trainees, we would encourage them to accompany
Consultants for their own education.
Liaison
We anticipate that junior trainees will not be involved in liaison but that trainees at
ST 3+ levels may be.
Outpatient and Day Hospital
We currently run general and subspecialty Consultant-led clinics every day.
Number per week
Out Patient Clinic
General
6
Movement
5
Disorders
Falls
5.5
Syncope
1.5
TOTAL
18.0
Day Hospital
11.5
11
Our clinics and Day Hospital sessions provide an ideal opportunity for interface with
community work, management of chronic disease and assessment of frailty. For
Foundation trainees and GPSTs in particular (who may become General
Practitioners), they represent an opportunity to understand the multi-disciplinary
secondary care support that is available to primary care for complex, frail patients.
We would like to see involvement of junior and senior trainees in all out-patient and
Day Hospital sessions and are able to facilitate this with the proposed number of
trainees. We recognise this as very important for education and envisage that this is
undertaken as part of training rather than to support service. Additionally outpatient and Day Hospital sessions provide an ideal opportunity for trainees to
undertake supervised learning events.
Current Provision of junior staff
Our current provision of junior staff to Geriatric Medicine across all sites is:
Hospital
FY 1
FY 2
GP ST
CMT
VI
3
3
5 (plus 1 for 1
ST 3+
3
stroke)
SGH
1
2
2
2
4
GGH
0
4
2 (plus one 3
2
for stroke)
Total
4
9
9
6
9
● Currently GGH has 2 extra FY 2s. One of these is in an academic programme.
The other has a predominantly community focus. Therefore they have limited
service commitment. GGH also has 2 ST 3 posts, one of which is vacant and
the other for four months.
12
● VI has three FY 1 trainees rotating through delirium/dementia and Geriatric
medicine (included within the above figures). This is part of a recent initiative
to increase Foundation posts. There is also one ST 3 post not included in the
above numbers as it is attached to Medicine.
● The two extra ‘stroke’ posts at GGH and VI are nominally GPST for the
purposes of this calculation, but could be FY 2 or CMT. They cover stroke
rehabilitation wards and are involved with acute medical receiving.
● There is a further trainee at SGH who covers stroke and neurology, not
counted within these figures and who does not take part in acute medical
receiving
In the following pages we will elaborate on the training opportunities for each
seniority level and demonstrate the way in which they map to the relevant training
curricula.
13
Foundation Training
The purpose of Foundation training is broadly two-fold (3):
∙
Patient safety
∙
Personal development
It provides generic training to act as a link between medical school and future
training. It aims to:
∙
Build on undergraduate education
∙
Nurture safe & effective practitioners
∙
Provide generic training
∙
Develop interpersonal skills in a multidisciplinary setting
∙
Provide an opportunity to develop leadership, team working and supervisory
skills
∙
Give workplace experience to inform career choice
The foundation curriculum is comprised of:
∙
Professionalism
∙
Good clinical care
∙
Recognition and management of the acutely ill patient
∙
Resuscitation
∙
Discharge and planning for chronic disease management
∙
Relationship with patients and communication skills
∙
Patient safety
∙
Infection control
∙
Nutritional care
14
∙
Health promotion, patient education and public health
∙
Ethical and legal issues
∙
Maintaining good medical practice
∙
Teaching and training
∙
Working with colleagues
The Geriatric Medicine department, through comprehensive geriatric assessment of
frail elderly patients with multiple co-morbidities covers practically all areas of the
curriculum. Particular areas of quality of experience pertain to management of
chronic diseases, discharge planning, communication skills, ethical and legal issues
and working with colleagues. Thus attachment to Geriatric Medical wards will
provide Foundation trainees with a rich educational experience in a highly supported
environment. Our Consultant trainers have many years of experience providing
Educational and Clinical supervision. Additionally the non-medical members of the
clinical team (nursing staff, allied health professionals) are enthusiastic about
engaging with training through being part of the Placement Supervision Group.
Foundation Year 1
Specific outcomes for FY1 include:
'Foundation year 1 (F1) enables medical graduates to begin to take supervised
responsibility for patient care and consolidate the skills that they have learnt
at medical school. Satisfactory completion of F1 allows the relevant university
(or their designated representative in a postgraduate deanery or foundation
school) to recommend to the GMC that the foundation doctor is granted full
registration.'
(3)
Through education and clinical teaching and training the senior team will facilitate
each FY 1 trainee to build on their undergraduate training and provide generic
training thus nurturing safe and effective practitioners. Each FY 1 trainee will be
15
attached to an acute ward with a nominated Clinical Supervisor and Educational
Supervisor. Additionally each FY 1 will form part of a medical team (encompassing
themselves, FY 2 or GP ST, CMT and ST 3+) and in addition a larger team of health
care professionals (nursing staff, physiotherapist, occupational therapist, Speech and
language therapists). This will give manifold opportunities to develop interpersonal,
team working and leadership skills.
An example FY 1 rota could look something like this:
Wk
1
Mon
A: POD
10:00 22:30
2
Zero Hours
3
Zero Hours
4
5
6
7
8
9
10
11
12
Stnd Day
09:00 17:00
B: POD Night
22:00 10:30
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
Leave
Tue
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Wed
A: POD
10:00 22:30
Zero Hours
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
Leave
Leave
Zero Hours
Thu
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Fri
A: POD
10:00 22:30
Sun
A: POD
10:00 22:30
B: POD Night
22:00 10:30
B: POD Night
22:00 10:30
C: Long Day
09:00 21:30
C: Long Day
09:00 21:30
Zero Hours
Zero Hours
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
Leave
Leave
Zero Hours
Sat
A: POD
10:00 22:30
In order to involve FY 1 trainees in covering each of the 6 acute wards, provide
annual leave and exposure to acute receiving; roughly 12 FY 1 trainees will be
required. In this rota weeks one through three are attached to the acute receiving
unit, then the remaining 9 cover the wards with allowance for holidays. As there are
6 wards this would be designed in blocks of 6 weeks with a float week to cover zero
days.
16
It would be preferable to have the FY 1 trainees attached solely to Geriatric medicine
within a block so that they would feel part of the Geriatric team. This facilitates
induction and the provision of Educational and Clinical Supervision and training.
There is inherent handover time built into the receiving weeks (through the timing of
shifts and Consultant ward rounds). FY 1 trainees will be encouraged, during this
time, to take an active part in clerking in and managing acute admissions. For the
acute wards morning handover would be built into the daytime shift between 09:00
and 09:30 (HAN team finish) utilising an appropriate tool such as SBAR. Evening
handover would occur between 16:30 and 17:00 again utilising an appropriate tool.
Foundation year 2
Specific outcomes for FY 2 include:
'Foundation year 2 (F2) doctors remain under clinical supervision (as do all
doctors in training) but take on increasing responsibility for patient care. In
particular they begin to make management decisions as part of their progress
towards independent practice. F2 doctors further develop their core generic
skills and contribute more to the education and training of the wider
healthcare workforce e.g. nurses, medical students and less experienced
doctors. At the end of F2 they will have begun to demonstrate clinical
effectiveness, leadership and decision-making responsibilities that are
essential for hospital and general practice specialty training. Satisfactory
completion of F2 will lead to the award of a Foundation Achievement of
Competence Document (FACD) which indicates that the foundation doctor is
ready to enter a core, specialty or general practice training programme.'
(3)
The purpose of Foundation Year 2 is to build on the first year of training with
particular focus on training in the assessment and management of the acutely ill
17
patient. Training encompasses the generic professional skills applicable to all areas of
medicine - team work, time management, communication and IT skills.
Working within the South Geriatric Medicine department provides trainees with
many opportunities to achieve these goals. Frail elderly patient, often with multiple
co-morbidities, are cared for across the full range of illness acuity from initial
emergency admission, through management in acute Geriatric Medical wards,
comprehensive geriatric assessment and rehabilitation, then discharge planning. In
addition training gives exposure to several specific sub specialty areas such as falls,
post-fracture and bone health, movement disorders, delirium and dementia.
A rotation for FY 2 trainees could look like this:
Wk
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Mon
A: POD
10:00 22:30
Zero Hours
Zero Hours
Stnd Day
09:00 17:00
B: POD Night
22:00 10:30
Leave
Leave
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Zero Hours
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
17
Zero Hours
18
D: Night
21:00 09:30
Tue
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Zero Hours
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Wed
A: POD
10:00 22:30
Zero Hours
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Thu
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Zero Hours
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
18
Fri
A: POD
10:00 22:30
Sat
A: POD
10:00 22:30
Sun
A: POD
10:00 22:30
B: POD Night
22:00 10:30
B: POD Night
22:00 10:30
C: Long Day
09:00 21:30
C: Long Day
09:00 21:30
D: Night
21:00 09:30
D: Night
21:00 09:30
Zero Hours
Zero Hours
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Stnd Day
09:00 17:00
Zero Hours
Each trainee rotates through acute medical receiving in weeks 1-5. They are then
attached to one of the elderly care wards for the remaining weeks until they do a
week of nights at week 18. This allows a block of receiving followed by an extended
attachment to a team, providing apprenticeship training and continuity. This is
beneficial to patient, trainee and team.
Within the receiving block, shift times have been set up to ensure that trainees gain
maximum educational value. It is anticipated that FY 2 trainees will be based on the
acute receiving ward, will take an active role in admitting and managing acute
patients and will then be able to attend morning and evening post-receiving ward
rounds. On the main geriatric wards specific handover time has been built in
between 09:00 and 09:30 then 16:30 and 17:00. Late shift hand over will be to the
HAN team who will also attend morning handover. The exact mechanism of
Consultant Supervision of handover is a work in progress but will be factored into
Consultant job plans.
The proposal deliberately groups FY 2 trainees with GPST trainees at this stage. This
is in order to build in a separate parallel rota for CMT trainees who are likely to have
more experience. Depending on the numbers and specific grades of trainees that are
allocated to the unit, it would be possible to alter these ratios. The current
suggestion is that there should always be two trainees who are more senior than FY
1 on each of the Geriatric Medical wards. One should be either FY 2 or GP ST; the
other should be a Core medical trainee (CMT). This brings inherent senior support to
each ward, ensuring that trainees are not acting beyond their capabilities. In addition
it allows trainees to attend clinics and Day Hospitals on a regular basis (all grades)
without compromising care on the wards. Furthermore it enables trainees to be
released for education and training without overloading with cross cover those that
remain.
A goal for Foundation training is to increase exposure to community care (1), (4)
19
Through specific liaison with community teams and Day Hospital, trainees can gain
experience in aspects of community care. For Foundation posts being designated as
'community' posts, the Consultant Geriatrician acting as Educational Supervisor
would have a specific interest in Community Geriatrics and would include the FY2
trainee in aspects of the role pertaining to that. Alternatively all FY 2 trainees could
be given some exposure to aspects of community work.
A further goal for Foundation training is to increase exposure to psychiatry training.
The nSGH will have a specific delirium/dementia ward (30 patients) within the
Langlands building. This has regular input from the Psychiatry team who provide a
joint weekly MDT and ward round with the Geriatric Medical team. We have
approached the Consultant Psychiatrists who provide this service and they are keen
to support education and training of our trainees within their specialty. Thus we
offer Geriatric Medical posts which are specifically tailored to elderly care psychiatry,
based within the delirium/dementia unit. Educational supervision of these posts will
be provided by the Consultant Psychiatrists.
20
GPST
Within GPST the training curriculum
(5),
an attachment to an elderly care unit is
viewed as important as:
• The United Kingdom has an increasingly ageing population
• The care of older people will make up a higher proportion of workload as a
general practitioner (GP)
• Co-morbidity, difficulties in communicating, the problems of poly-pharmacy
and the need for additional support for the increasingly dependent patients
in general practice are important issues in the care of older people
• The epidemiology of problems presenting in primary care is different in
older people. Many cancers are more prevalent in the elderly population and
may be of insidious onset
• General practitioners working together with other members of the primary
healthcare team have an important role to play in the delivery of
improvements in the care of older people
Review of expected GP competencies suggests several areas in which attachments to
departments of Geriatric Medicine can be of great value.
The following table shows the major areas of the GP curriculum and the
competences required by the MRCGP exam. A third column determines whether
specific training could be garnered from an attachment to Geriatric Medicine.
21
GP Curriculum
MRCGP Competence
Covered in Geriatric medicine
attachment
Primary care management Clinical management
Yes
Working with colleagues and Yes
in teams
Primary care administration No
and IM&T
Person-centred care
Communication
and Yes
consulting skills
Specific
problem-solving Data gathering interpretation Yes
skills
Making a diagnosis/making Yes
decisions
Comprehensive approach
Managing
medical Yes
complexity
Community orientation
To some degree
Holistic approach
Practising holistically
Yes
Contextual features
To some degree
Attitudinal features
Maintaining
an
ethical Yes
approach to practice
Fitness to practice
Scientific features
Maintaining
Yes
performance, Yes
learning & teaching
22
Geriatric Medicine offers, par excellence, training in managing medical complexity,
practising holistically and working within teams. An ethical approach to practice is
particularly emphasised through our interaction with patients who lack capacity. Our
ethos is safeguarding human rights and empowering patients as the central decision
makers in their own care. Clearly those close to our patients are extremely important
and through communication and consultation we strive to embrace their opinions
and include them in the care planning process.
The opening of the nSGH offers an exciting opportunity for us to review the way in
which our GP trainees integrate with our service. It allows us to optimise that both
for patient care and for education and training. We propose training rotations such
that GP trainees are based on a particular ward for 10 weeks to provide for
continuity of care and training, team working and apprenticeship style training.
There will be 5 week blocks on the acute admissions unit within this. We suggest two
trainees per ward, one at GPST or FY 2 level and the other at CMT level in order to
provide a spread of interest, expertise and seniority. In recognition of the fact that
some GPST trainees have the same experience as CMT trainees, this can be flexibly
arranged depending on both particular trainee confidence and competence and also
on the final mix of trainees allocated to the unit. GPST trainees share a rota with FY 2
trainees (shown below). This involves rotating through a block of acute receiving
followed by a longer attachment to a single ward area. During a six month block,
GPST trainees will rotate between two base units, one encompassing acute geriatric
care and the other slower stream complex care and rehabilitation, based in general
rehabilitation wards or GORU. Trainees will be specifically attached to particular
outpatient clinics and Day Hospital sessions in order to broaden the Educational
experience.
23
Wk
1
Mon
A: POD
10:00 22:30
2
Zero Hours
3
Zero Hours
4
5
6
7
8
9
10
11
12
13
14
15
16
Stnd Day
09:00 17:00
B: POD Night
22:00 10:30
Leave
Leave
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Zero Hours
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
17
Zero Hours
18
D: Night
21:00 09:30
Tue
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Zero Hours
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Wed
A: POD
10:00 22:30
Zero Hours
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Thu
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Zero Hours
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Fri
A: POD
10:00 22:30
Sat
A: POD
10:00 22:30
Sun
A: POD
10:00 22:30
B: POD Night
22:00 10:30
B: POD Night
22:00 10:30
C: Long Day
09:00 21:30
C: Long Day
09:00 21:30
D: Night
21:00 09:30
D: Night
21:00 09:30
Zero Hours
Zero Hours
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Stnd Day
09:00 17:00
Zero Hours
Each trainee will have a nominated Educational and Clinical Supervisor within our
system. Additionally there would be designated senior specialty trainees to provide
support to each clinical area.
24
Core Medical Training
Specific recommendations from the JRCPTB for Core Medical Training (6) include:

Trainee lead learning utilising the eportfolio as the scaffold

Competency based learning utilising a large curriculum

Continuation of good medical practice building on Foundation training

High quality supervision of training from Consultants in clearly defined
designated roles.
Mapping the CMT curriculum
(7)
against potential experience to be gained from an
elderly care placement demonstrates a high level of coverage of the curriculum.
Certain areas are particularly usefully covered within Geriatric Medicine. These
include common competencies such as:

Team working and patient safety

Managing long term conditions and promoting patient self-care

Relationships with patients and communication within a consultation

Breaking bad news

Communication with colleagues and cooperation

Principles of medical ethics and confidentiality

Valid consent

Legal framework for practice
They also embrace symptom based competencies in particular:

Cardio-respiratory arrest

Shocked patient

Unconscious patient

All 22 ‘top presentations’

The ‘other important presentations’.
Geriatric medicine is highlighted as one of the System Specific Competencies.
Trainees themselves indicate that they would value placement within Geriatric
Medicine
(8).
They recognise the increasing Elderly population, the need to manage
25
frail patients with complex multiple co-morbidities within hospital settings and the
advantages to quality of care to be gained through the involvement of the multidisciplinary team.
The importance of Leadership within medical training is well recognised (9, 10). This is
central to the provision of high quality, safe, compassionate care. It involves skills
such as management of teams, negotiation, critical evaluation of services and
assuring quality as well as being able stand as an advocate for individual patients and
to have the vision to evolve care provision. This is crucial particularly to avoid system
failings such as those highlighted by the Francis report
(11).
Trainees desire training
within these areas but also envisage them as being inculcated from apprenticeship
learning (8).
Through a team based approach to the delivery of health care, with CMT trainees
attached for sustained periods to each team, we would hope to provide this
experiential learning. The Geriatric Medical team based at the nSGH is comprised of
enthusiastic trainers, delivering patient-centric and compassionate, empowering
care. Our aim will be for each CMT trainee to work with a particular team for a large
part of each attachment, with blocks of exposure to the acute take. Clinics will be
done with the defined Consultant team who will also provide care within the inpatient setting. Thus trainers will take advantage of the ability to capitalize on
learning through their position as role models, demonstrating good geriatric care
through their Leadership of teams and empowerment of and communication with
patients
A recent survey commissioned by the JRCPTB of all Core Medical Trainees in 2013 (12)
has highlighted several concerns with CMT. These include the following:

Service demands have impacted significantly negatively on training
opportunities such that trainees are unable to access out-patient and
teaching sessions

Trainees spend a huge amount of time doing menial tasks
26

Clinical and Educational Supervision are variable with a particular deficit of
Consultant feedback

CMT trainees do not feel prepared to be medical registrars and indeed core
medical training has put them off acute medical specialties.
As a response to this the JRCPTB is in the process of developing quality criteria for
CMT posts to improve the educational experience and thus enhance quality of care
and patient safety (currently in draft form, obtained directly from the JRCPTB). These
include suggestions which are particularly pertinent to the current proposal:

A placement in Geriatric Medicine (minimum of four months) in each
programme.

Minimum of 16 months in placements contributing to the acute medical take
with on-call days and nights in an acute placement concentrated in blocks to
facilitate continuity of care between acute admissions area and specialty
wards

Shift patterns to be structured to ensure trainee attendance at relevant posttake ward rounds and handovers.

Minimum of 40 outpatient clinics over 2 year programme.

Cover arrangements to facilitate attendance at outpatient clinics and other
learning events, e.g. PACES training, as protected learning time.
Elsewhere within the Scottish Deanery this has been addressed. In both South East
Scotland and East of Scotland, all CMT trainees have placements in Geriatric
Medicine
(13).
In SES all CMT trainees have one four month attachment to Geriatric
Medicine. In EOS all CMT trainees have a six month attachment to Geriatric Medicine
in year 2.
This proposal suggests that each of the Geriatric Medical wards (30 beds) is staffed
by CMT trainees and an FY 2 or a GPST. Additionally there should be an FY 1 trainee
in the acute ward areas. This staffing level facilitates trainees in being able to
regularly attend educationally rich opportunities such as out-patient clinics, Day
27
Hospital sessions and training sessions. Furthermore it makes it possible for training
to include specific attachments with other members of the team. This might include
accompanying AHPs on home visits, spending time with the Elderly Care Assessment
Nurses and tissue viability team. By this means we would hope to augment the
experience of training.
While it is our aspiration to bolster the numbers of staff providing support for more
menial tasks (to include phlebotomists, nurse practitioners, cardiac physiologists) the
presence of several layers of seniority of medical staff means that remaining jobs can
be allocated appropriately and shared.
In terms of providing Clinical support and supervision, there will be significant
Specialty trainee and Consultant support to all areas. In addition to assuring safe
delivery of care, this enables junior trainees to work more closely with seniors,
through an apprentice-based structure enhancing feedback and supervised learning
events.
28
Specifically a CMT rota may look like this:
Wk
1
Mon
A: POD
10:00 22:30
2
Zero Hours
3
Zero Hours
4
5
6
7
8
9
10
11
12
13
14
15
16
Stnd Day
09:00 17:00
B: POD Night
22:00 10:30
Leave
Leave
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Zero Hours
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
17
Zero Hours
18
D: Night
21:00 09:30
Tue
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Zero Hours
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Wed
A: POD
10:00 22:30
Zero Hours
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Thu
Zero Hours
A: POD
10:00 22:30
B: POD Night
22:00 10:30
Zero Hours
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Fri
A: POD
10:00 22:30
Sat
A: POD
10:00 22:30
Sun
A: POD
10:00 22:30
B: POD Night
22:00 10:30
B: POD Night
22:00 10:30
C: Long Day
09:00 21:30
C: Long Day
09:00 21:30
D: Night
21:00 09:30
D: Night
21:00 09:30
Zero Hours
Zero Hours
B: POD Night
22:00 10:30
Stnd Day
09:00 17:00
Leave
Leave
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
C: Long Day
09:00 21:30
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
Stnd Day
09:00 17:00
D: Night
21:00 09:30
Stnd Day
09:00 17:00
Zero Hours
Ideally CMT trainees would form a separate tier within a medical rota. This rota is
identical to that provided for FY 2 and GPST. It is envisaged that the three groups of
trainees will populate two such rotas, resulting in the described seniority mix at all
times. The exact staffing of the two rotas will be dependent on the final mix and
numbers of trainees allocated to the nSGH and South Glasgow Geriatric Medicine
service.
All CMT trainees will have a named Educational and Clinical Supervisor.
29
Specialty training (ST 3+)
The JRCPTB Geriatric Medicine Curriculum 2010 (amendments 2013) defines
geriatric medicine in terms of ‘specialist medical care of the frail older person and
promotion of better health in old age’
(14).
This covers all aspects of in-patient care
from the acute medical receiving unit, though the acute, rehabilitation and
continuing care wards and encompassing all non-Geriatric specialist areas such as
HDU, CCU, acute stroke, medicine, surgery etc. Additionally it includes consideration
of out-patient care provision within the hospital setting (Day hospitals, clinics) and
also care at home and within care homes.
Principle learning objectives include:

Ability to perform comprehensive geriatric assessment – including mood,
cognition, nutrition, gait and fitness for surgery

Diagnosis and management of both acute illness and chronic disease

Provision of rehabilitation

Assessment of the need for care placements and transfer of care to those or
to the community

The ability to apply Geriatric skills in a community setting

Assessment and management of the Geriatric ‘Giants’ of Falls, delirium,
incontinence and reduced mobility

Develop
competence
in
specialty
areas
such
as
Palliative
Care,
Orthogeriatrics, Psychiatry of Old Age, Specialist Stroke Care, Syncope and
Movement Disorders.

To develop an understanding and competence in research methodology,
preferably through involvement with research
This is underpinned by core learning objectives which include:

Basic science and biology of ageing

Pathology, presentation and management of Geriatric Giants
30

Presentation, underpinning pathology, management and prevention of the
many clinical problems that can occur in older age, with an understanding of
multiple pathology and clinical complexity. This includes conditions seen
more commonly in the elderly population such as pressure sores and ulcers.

A thorough understanding of drug therapies, and the impact of age, comorbidities and polypharmacy

Development of expertise in Comprehensive Geriatric Assessment and
rehabilitation in the older patient, then what is required to transfer of care
out with hospital

Legal concerns including competency and the Law; Ethical issues including
consent, resuscitation and the use of life-prolonging treatment; empowering
the patient through these decisions.

An understanding of NHS structure and management
Also included are those ‘higher level’ competencies which include:

Falls and syncope

Orthogeriatrics and bone health

Continence

Dementia and pyschogeriatric services

Intermediate care and community care
From the point of view of training an ideal unit is one in which trainees can gain
experience and proficiency in all or most of these competencies during their
attachment. The unit must provide an optimal learning environment to facilitate
trainee development. Trainees should have positive roles models that are
enthusiastic about training and passionate about their own specialty. In addition,
trainees should be encouraged to develop Leadership skills and enhance their own
teaching and training abilities.
We believe that the new South Glasgow Geriatric Medical Service will be able to
provide all of this. In the current guise, based within GGH, SGH and VI, we provide in31
patient and out-patient care across all levels of acuteness and clinical presentations.
Within our group of 25 Geriatric and Stroke Consultants we can provide particular
training in syncope, falls, movement disorders, orthogeriatric and stroke medicine.
We have strong links with many other specialties including Palliative Care, Old Age
Psychiatry, Orthopaedics and bone health, tissue viability and Urogynaecology. We
have well forged routes for trainees to gain specialist experience in these areas.
Often this involves four week placements (Psychogeriatric Medicine and Palliative
Care), weekly clinic attendances (specialist Endocrine mineral metabolism clinics,
attachment to the tissue viability team and incontinence clinics hosted by
Urogynaecology). These will continue as we transfer to the new site. There are
strong links with the acute medical teams such that trainees are regularly attached
to the medical specialty wards, ITU and CCU for placements. These too will continue,
as will regular liaison with surgical wards.
A number of our Consultants have specific allocated sessional time to provide a
Community service. This includes Day Hospital provision, including telephone advice
for GPs and rapid access assessment for admission avoidance, liaison with social
services, liaison with community teams and involvement in evolving Intermediate
care services. Trainees will be able to rotate attachments to Consultants to gain this
experience.
Through the continued development of our delirium/dementia service and the direct
input of the psychiatry team into that, we can provide specialist training in this area.
Furthermore we have recently completed a successful business case for the
development of Elderly Care Orthopaedic Nurses (ECON) and additional Consultant
sessions to enhance orthopaedic liaison which enhances our Orthogeriatric service.
This will provide further training opportunities. In the nSGH we aim to provide a
liaison service to all other specialties and trainees can be involved in the
development and delivery of this.
Within the new service Specialty trainees will be Consultant based for periods of 6
months. This enables an apprenticeship team-based approach to training offering
32
many opportunities for feedback and undertaking of assessments. Our ST 3+ trainees
will be supernumerary in some of their roles to enable them to take advantage of
the many educational opportunities on offer and also to gradually gain
independence working alongside Consultant colleagues on a one to one basis. They
will take part in a senior on-call rota with ST 3+ medical trainees providing support to
more junior trainees. Rotas have been developed so that all trainees undertaking
acute receiving duties can take part in post-take ward rounds to enable appropriate
feedback and facilitate undertaking of assessments such as ACAT.
A potential rota involving 9 Specialty trainees could look like this:
Wk
1
2
3
4
5
6
7
8
9
Mon
Tue
Wed
Thu
Fri
Sat
Sun
B: Receiving Night B: Receiving Night B: Receiving Night B: Receiving Night
Zero Hours
22:30 10:00
22:30 10:00
22:30 10:00
22:30 10:00
A: Receiving Day
Stnd Day
A: Receiving Day
Stnd Day
A: Receiving Day A: Receiving Day A: Receiving Day
10:00 22:30
09:00 17:00
10:00 22:30
09:00 17:00
10:00 22:30
10:00 22:30
10:00 22:30
A: Receiving Day
Stnd Day
A: Receiving Day
Stnd Day
Zero Hours
10:00 22:30
09:00 17:00
10:00 22:30
09:00 17:00
Stnd Day
Stnd Day
Stnd Day
Stnd Day
B: Receiving Night B: Receiving Night B: Receiving Night
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
22:30 10:00
22:30 10:00
22:30 10:00
Stnd Day
Stnd Day
Stnd Day
Stnd Day
Zero Hours
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
Stnd Day
Stnd Day
Stnd Day
Stnd Day
Stnd Day
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
Stnd Day
Stnd Day
Stnd Day
Stnd Day
Stnd Day
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
Stnd Day
Stnd Day
Stnd Day
Stnd Day
Stnd Day
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
Stnd Day
Stnd Day
Stnd Day
Stnd Day
Stnd Day
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
09:00 17:00
Night time shifts will be done as part of a HAN team providing support to acute
receiving and more junior members of the team. Such a rota allows more than 66%
of time based with a single Consultant. Less than 33% of time involves the acute take
and this will be specific to Geriatric medicine.
All ST 3+ trainees will have a named Educational and Clinical Supervisor.
33
Undergraduate Medical Students
The 2012 Glasgow medical school undergraduate curriculum is divided into 4 phases.
Phases 1 and 2 are predominantly science based. Phase 4 is Clinical and phase 3
provides the link between the two. Phase 4 runs from the middle of year 3 until the
middle of year 5, before final examinations. Students rotate through a series of
clinical units gaining experience in generic skills such as history taking and clinical
examination along with common medical and surgical presentations. In the early
years students are introduced to topics such as ethics, professional standards and
communication skills. These are then built upon in the clinical setting throughout the
course. Currently the Geriatric Medicine department does not have much
involvement in undergraduate training. Visits are hosted for year 1 undergraduates
and some Consultants contribute to CBL teaching. We have hosted medical students
who are undertaking summer electives in the Department of Geriatric Medicine. We
offer a range of student selected components and when there are taken up they are
positively reviewed. A recently attached student undertook a project based on a
patient’s ‘life story’ in which he examined her experience of a health care episode.
Through this he gained significant insight into the impact of hospital admission in an
elderly lady. By means of his presentation the whole team were reminded of the
importance of empathy and compassion.
We feel that our department offers many areas that would enhance undergraduate
training. We can deliver experience and training in ethical and legal issues par
excellence. An enormous variety of clinical presentations can be seen, introducing
undergraduate students to medical complexity and multiple system involvement.
Students can gain an idea of communicating in more challenging circumstances such
as with those patients with confusion, sensory impairment and dysphasia. Within a
large department there are multiple opportunities for students to develop generic
skills and to experience many different aspects of Geriatric Medical care. We would
therefore welcome closer links with the undergraduate medical school and the
opportunity to introduce undergraduate students to our specialty.
34
Teaching and training opportunities
In order to provide a rounded training experience, it is important that educational
opportunities are provided and embraced. The quality of the training environment is
necessarily crucial to this.
Specialty teaching and training
Through the staffing of the unit as described, there will be many opportunities for
informal teaching during the delivery of patient care. Moreover staffing levels will
facilitate trainees being able to attend all levels of specialist teaching from hospital –
based FY 1 teaching, through Consortium level FY 2 teaching, GPST and regional CMT
and Specialty trainee teaching programmes.
Unit teaching programme
Additionally the unit will run its own core teaching which will be focussed on topics
pertinent to Geriatric care. This is likely to be run concurrently across two sites –
nSGH campus and GGH, in order to facilitate attendance by all medical staff.
Previously joint multidisciplinary Clinical Governance meetings have been run
between SGH and VI – this will be explored for the whole unit – perhaps one
afternoon per month. Additionally we recognise the importance of regular Morbidity
and Mortality meetings. There will be a mix of senior Consultant presentations,
trainee presentations (at all levels) and outside speakers in order to facilitate an
interesting programme.
35
Current teaching programmes are included below as potential examples.
SGH F2/GPST/CMT TUTORIALS
August – December 2014
Week beginning
Speaker
Topic
18th Aug
DME ST
Polypharmacy
25th Aug
DME Consultant
1st Sept
DME Consultant
Comprehensive
Geriatric Assessment
Anaemia in the Elderly
8th Sept
DME Consultant
AWI/Guardianship
15th Sept
DME Consultant
Stroke
22nd Sept
DME Consultant
Syncope
29th Sept
Bank
Holiday
6th Oct
DME Consultant
Neuroradiology
13th Oct
DME Consultant
20th Oct
DME Consultant
How to avoid clinical
incidents
Incontinence in Elderly
27th Oct
DME Consultant
Falls/Bone health
3rd Nov
DME Consultant
Parkinson’s Disease
10th Nov
DME Consultant
Delirium
17th Nov
DME Consultant
NOACs
GGH:
Tuesday lunchtime:

Presentations by junior staff e.g. interesting cases, audit

Morbidity and mortality meetings

External speakers e.g. psychiatry, cardiology

Presentations by Consultants and senior trainees on specialist topics, updates
on recent CPD meetings.
36
VI Medicine for the Elderly Educational Meetings
Friday 1pm
Date
08/08/14
15/08/14
SHO tutorial
CME meeting
No meeting
Stroke Update
Consultant
22/08/14
29/08/14
Quality Improvement Project: Improving
recognition of low mood & depression in
elderly inpatients
ST 4
Falls & Bone Health
Consultant
05/09/14
12/09/14
Morbidity & Mortality meeting
ST 7
Syncope
Consultant
19/09/14
26/09/14
02/10/14
10/10/14
17/10/14
24/10/14
Sponsored Meeting:BMS
Apixaban/NOAC
External speaker/Consultant
AWI
Consultant
SSC student presentation
Teaching and medical education
Consultant
No meeting
Dizziness
Consultant
31/10/14
7/11/14
14/11/14
21/11/14
28/11/14
05/12/14
Significant Clinical Incidents Review
Junior trainee
Heart Failure in the Elderly
Consultant
FY2 Audit presentations
Continence
ST 7
FY2 Audit presentations
Delirium
ST 6
12/12/14
Morbidity & Mortality meeting
Consultant and trainees
19/12/14
Christmas Quiz
26/12/14
Public Holiday
37
Aspirations for service and training developments
It is our aim to develop several areas of our service and therefore training. These
include:

A comprehensive surgical liaison service
(15, 16)
– this will involve provision of
input into surgical wards. We envisage several approaches to this
1. Pre-operative assessment of patients to give optimal medical
preparation for surgery
2. Peri-operative medical input and early rehabilitation
3. Post-operative longer term rehabilitation and placement of frail
elderly patients
4. Shared Clinical Governance, audit and research
5. Joint education and training
The Geriatric Medical team can not currently offer such structured, regular
input but are very keen, through service development and liaison with
surgical colleagues, to see it happen.

Outreach of Geriatric Medical services to the front door of the hospital
through embedding comprehensive geriatric assessment into the Emergency
Department with the aim of avoiding admission and readmission to hospital.
(17).

An enhanced Community Geriatric Medical service. This could include:
1. Contributing in a regular and structured way to patient care in Care
Homes and to evolving Intermediate care services.
2. Development of Hospital at home services (18)
3. Closer liaison with GP colleagues – involving joint management of
patients, outreach into the community, education

Strengthen the research base in clinical Geriatric medicine and in medical
education. Examples of research questions might include:
o What is the influence of the Hidden Curriculum on Professionalism in
Geriatric Medicine trainees?
38
o What are the styles of Leadership that Geriatric Medicine trainees
observe in Consultants and how do they perceive the impact of these?
o Can the techniques of regular patient review at multi-disciplinary
team meetings be utilised to enhance reflective abilities?
o How can a Personal Development Plan be used to enhance reflective
learning and is this variable across different grades?

Offer placements to non-Geriatric Medical specialty trainees looking to gain
experience in Geriatric Medicine (e.g. medical, surgical, orthopaedic and
emergency medicine trainees).
Some of these aspirations require development through resource and planning. They
would enhance the service the team are able to provide and also represent excellent
opportunities for training – both in the leadership required to develop services and
through service provision.
39
Conclusion
We are a team of Consultant Geriatricians who are passionate about education and
training, believing this to be the key to nurturing of our medical workforce and
providing safe and effective health care. In addition we are a group of Consultants
who are ardent about our specialty, dedicated to delivering high quality patient
centric care. Trainers play a vital part in providing an effective learning environment
(19).
We believe that these two facets of enthusiasm for training and fervour for our
chosen speciality can combine to create an ideal learning environment – both for
specialty trainees already committed to a career in Geriatric Medicine and to
students and junior trainees developing generic clinical skills.

Through our specialist tool of Comprehensive Geriatric Assessment we
provide truly holistic care for our frail patients with multiple co-morbidities,
long-term conditions and complex psychosocial backgrounds. We are faced
daily with moral and ethical dilemmas and engage trainees in examination of
these.

Through our rehabilitation process of constant reassessment of actual versus
anticipated patient progress we embed techniques of reflection which are
crucial for good clinical care. (20, 21, 22)

Through our team based structures and high levels of Consultant
engagement with patients, we can provide the regular contact and feedback
that trainees desire, delivering apprenticeship based training to all levels.

Through our high profile on the Geriatric Medical wards, the members of the
Consultant team are in a position to act as positive role models, able to
demonstrate the importance of empowerment of our frail patients.

Through regular structured teaching we will promote continued learning and
education for all grades.

Through our multi-disciplinary approach we encourage team working and
leadership development.
40

Through interface with almost every other medical specialty we can impact
on elderly care out with our own setting. In addition we work closely with
GPs and community teams.
The following table recaps the number and grades of trainees required for each level
of acuity. ST 3+ trainees are excluded from these calculations as they will be based
with individual Consultants.
41
Acuity Level
Descriptor
Location
No. of beds
No. of wards
Trainees per ward
FY 1
FY 2-GPST
Total trainees
CMT
FY 1
FY 2- GPST CMT
1
AAU
Stack
18
1
Full shift rota
2
Acute
Stack
28
1
1
1
1
1
1
1
Assessment
Langlands
150
5
1
1
1
5
5
5
GORU
GGH
86
3
1
1
3
3
Complex Care
NVH
48
2
1
1
1
1
DCH
56
2
1
1
1
1
3
Full shift rota
Baseline ward cover
6
11
11
AAU rota
4
4
4
Nights/Leave
2
3
3
TOTAL
12
18
18
42
Utilising the numbers of trainees described above the following table demonstrates
the shortfall of trainees required to fulfil this proposal:
Hospital
FY 1
FY 2
GP ST
CMT
ST 3+
VI
3
3
6
1
3
SGH
1
2
2
2
4
GGH
0
4
3
3
2
Total
4
9
11
6
9
Required
nSGH
12
9
9
18
9
Shortfall
nSGH
8
0
0
12
0
Current
The clear deficit is within FY 1 and CMT training. Historically trainees within these
groups have not been significantly exposed to training in Geriatric Medicine but we
feel, for the manifold reasons explored above, that it is time for this to change.
The opening of the nSGH with the development of the new South Glasgow Geriatric
Service provides an exciting opportunity to review the way we educate trainees in
geriatric medicine. It presents us with the chance to consolidate our current positive
approaches and further develop these. The trainees numbers proposed enable
delivery of Geriatric training across the whole breadth of seniority of training from
Foundation Year 1 to Senior Specialty Trainees with aspirations to engage further
with undergraduate training and other specialties.
43
Acronyms
nSGH
New South Glasgow Hospital
SGH
Southern General Hospital
VI
Victoria Infirmary
GGH
Gartnaval General Hospital
GMC
General Medical Council
HAN
Hospital at night
FY1, F1
Foundation Year 1
FY2, F2
Foundation Year 2
GPST
GP Specialty Trainee
CMT
Core Medical Trainee
ST
Specialty Trainee
AAU
Acute Admissions Unit
NVH
New Victoria Hospital
DCH
Drumchapel Hospital
ECAN
Elderly Care Assessment Nurse
MDT
Multi Disciplinary Team
GORU
Geriatric Orthopaedic Rehabilitation Unit
GRI
Glasgow Royal infirmary
GGC
Greater Glasgow and Clyde (Health Board)
44
DH
Day Hospital
GEMS
Glasgow Emergency Medical Service
SBAR
SES
Situation Background Assessment
Recommendation
Foundation Achievement of Competency
Document
Member of the Royal college of General
Practitioners
Joint Royal College of Physicians Training
Board
South East Scotland
EOS
East Of Scotland
HDU
High Dependency Unit
CCU
Coronary Care Unit
ITU
Intensive Therapy Unit
ECON
Elderly Care Orthopaedic Nurse
ACAT
Acute Care Assessment Tool
DME
Department of Medicine for the Elderly
NOAC
New Oral Anticoagulant
CBL
Case Based Learning
CPD
Continued Professional Development
AWI
Adults with Incapacity
FACD
MRCGP
JRCPTB
45
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47

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