Medical Specialties - Geriatric Medicine (4 Dec 2024)

SPEAKER_00 0:00

On Friday the 24th of January, we'll hold our Medical Trainees Conference at the College in Edinburgh. You can also join online. Organised by the RCPE Trainees and Members Committee, the conference is free for RCPE collegiate, associate and student and foundation members. We'll cover managing medical emergencies, think about cases that have changed our practice, move on to navigating complexity and ambulatory care, and finish with clinical lessons. We'd love to see you there. Book now on the RCPE website.

SPEAKER_02 0:47

My name is Dr. Marilena Giannudi, and today I'm delighted to be joined by another, hopefully to you very familiar name, Dr. Kat Ralstone, who is also on the Trainee and Members Committee. And we will be talking about geriatric medicine, as some of you may have heard of it. Others may hear of it as Medicine of the Elderly, and others as care of the elderly. And we'll just be using those three interchangeable terms. Dr. Kat Ralstone is a medicine of the elderly trainee based in South East Scotland. So hello Kat and welcome. Hi, I'm Rilina. Thanks so much for inviting me. As you probably know, we're just going to talk a little bit about your specialty. So I guess the best place to start would be why did you go into Medicine of the Elderly?

SPEAKER_00 1:31

I always knew I wanted to do medicine, but I wasn't sure what. And I certainly wasn't a person that was in medical school and knew exactly what they wanted to do. I probably came to it quite late, so I think FY3 year was when I properly decided on Medicine of the Elderly. I always liked Clarking in the people who were more complicated and interesting, generally that was the older adult. And I liked a sense of sort of that looking at the whole patient and having conversations around sort of realistic medicine and uncertainty. And that maybe started off my journey. And I also liked variety. So I liked acute medicine, I liked palliative care, I liked neurology, and that was part of making it difficult to have a decision on what I wanted to do because I liked everything. The other thing that I had some good advice from a consultant on looking at who's in your specialty and thinking about whether they're your pack or your tribe. So I'm not saying that you need to absolutely fit in, and it's really good if there's variety in a specialty, but it can be useful to think about do you share the same values as those people? Do you fit with the vibe that they have? And I think in medicine of the elderly, you have people who are generally reflective, who like to think, but also who like to have a conversation, love chatting. And they're also very generally practical and realistic. And I think that kind of fitted in with what I was interested in and what I thought about myself. And I think there's also a lot of variety to be had in medicine of the elderly, like I've mentioned. So I was initially interested in urology, actually, and then I thought, well, I can sub-specialise in stroke and movement disorder. You know, there's lots you can do in medicine of the elderly that you maybe can't do if you're in a especially that deals with one system. For all those reasons, that's why I ended up going into Medicine of the Elderly.

SPEAKER_02 3:16

My next question describe a typical day is almost impossible given the variety that you can have. So maybe if we talk about a typical week and what that may look like.

SPEAKER_00 3:27

I'm a registrar in medicine of the elderly, so I'm ST6 at the minute. And it's pretty variable. So Medic of the Elderly registrars or trainees train dual train. So we'll also do general medicine as well, as I'm sure everyone knows listening to the podcast. So if I'm doing medicine of the elderly, which I'm doing right now, the typical day is generally nine to five. At the minute, I decide my week based on what I need to get out of my curriculum and what I'm interested in. I might be doing a ward round on an acute frailty ward, so assessing people who've presented with a big variety of medical problems. I might also do a day at hospital at home, so our service as a hospital at home team, which is really excellent, which aims to provide comprehensive geriatric assessment at home and prevent sort of admissions that might not be needed. So I'll be out driving in my car doing visits to people in the house, which I really love. Sometimes I also run an acute frailty clinic every couple of weeks, which is rapid access for GPs or other servers in the hospital to admit into. And I see people with falls, syncope, dizziness, weight loss, heart failure, lots of different things, often multiple things at once. And I have a lot of time, which is nice in a clinic to do a proper assessment and plan with a patient who comes to that service. So it's pretty variable, but generally would involve some ward rounds on acute wards, maybe some community practice in hospital at home or a community hospital, and also some outpatient clinics which can include acute filty or movement disorder or stroke. So quite a big variety at the minute.

SPEAKER_02 5:05

What are your on calls like then, Kat? Do you just do kind of care of the elderly on calls or do you do acute medicine on calls as well?

SPEAKER_00 5:13

So I think this will vary where you work. Most of the time my on calls are for general medicine. So I'm the Med Redge on call. And obviously that's usually quite busy. In a way, it's quite nice because there's always a lot of representation for my specialty interests. So there's lots of older adults on the acute take and on the wards. And I think that feels perhaps more comfortable as an MOE trainee than maybe if you're sort of late on in your specialty year and are sort of very embroiled in your specialty. I think that people always get worried about being the med reg. And I would say that just as an aside, it's completely doable. Do not be put off your specialty that you're interested in by the fear of being the medical reg, because when you get to that point, you will absolutely be able to do it and it'll be totally fine. And there's always someone you can ask for help. You're not alone in that. On calls generally at the minute in medicine of the elderly and my specialty block in Southeast Scotland has a slightly different way of doing it. So we do blocks of GIM and blocks of medicine of the elderly, whereas I think in other places you'll do medicine of the elderly and do on calls for GIM and it's all interspersed. But you would generally do nights and weekends. The weekends can be days or nights, and generally they're 12, 12 and a half hour shifts. When I'm doing GIM, I'll do evenings or on-take days as well. So they're generally busy, but it's very doable and it's just part of the job. When you're a consultant, you'll be, it depends on where you're working in MOE. So if you work in a tertiary centre that has a big MOE footprint, you might just do medicine of the elderly on calls. Otherwise, in a district general, you'll generally be on call for general medicine. So do a day on take and on call from home overnight. On calls generally are busy when you're on call, but roaster is not too bad generally, and perfectly doable if it's the career that you're interested in, otherwise.

SPEAKER_02 6:56

I know that you mentioned finding your pack and that you're interested in lots of different areas of medicine, which is why medicine of the elderly seemed to fit for you. But do you think there's a specific skill set that one needs to have or one needs to kind of work on in order to be a good physician within this specialty?

SPEAKER_00 7:16

Yeah, absolutely. And I don't think it's something that you are born with. I think it's something that everyone can grow and develop. I think first of all, you need to be interested in looking at the whole person. So interested in looking at all the complexity that comes with multimorbidity that's often interacting and sometimes directly opposing each other in terms of the management, be interested in thinking about what matters to that person, not just looking at the physical, but looking at the social and psychological as well. So I think that's really important. And with that comes excellent communication skills. So you need to be very comfortable in communicating uncertainty, talking about subjects that some people might find challenging, like death and dying, and also communication within the multidisciplinary team because you're often collaborating with other specialties and with other services as well. So that's really important. And I think the other thing is that it's important that I guess you like a challenge or you like complexity. So having a bit of a detective mindset is really important when you're looking after people, older adults with frailty, because people present atypically. It's not always a UTI. In fact, there's mostly not a UTI when someone presents with delirium. So thinking about well, what's actually going on with that person and what can we do to help reverse or improve aspects of their condition that we've identified, liking that complexity and being a bit of a detective, I think is an important mindset to have as well.

SPEAKER_02 8:40

So, what advice would you give to trainees listening to the podcast and thinking, I really want to do it, but I don't know where to start?

SPEAKER_00 8:48

Yeah, great question. I think, first of all, if you're convinced that this is what you want to do, great. Please join us. We always need more geriatricians out there. And the first thing I would say is have a look at the application criteria, work out what you might need in terms of thinking about gaining points or gaining things to talk about in your interview and kind of work backwards from there. So do that as early as you can, just because stuff that you do in FY or in IMT are going to really count when you get to that application stage. If you're not 100% sure, then I would talk to consultants and registrars in your area in the field and just get a feel for is this something that you might be interested in? If you can do a taster week, do one just to get a feel for what the specialty looks like. The most important thing is to speak to the consultants because this is going to be the majority of your working career. So you're only going to be a registrar for four, what, four years now? And people get really worried about that med-red year, but actually that's such a small part of your career. So look at the consultants. What does their job look like? What does their on-calls look like? Are they happy? And I think that was a good tip I got in terms of what kind of specialty are you interested in. The other thing I would say is look at what's out there in terms of what to join. So societies like the British Geriatric Society, and you can join as a member. It's pretty cheap if you're not a trainee. Even as a trainee, it's reasonably cheap. They have lots of local and national conferences. And if you submit abstracts, you can present posters or oral presentations, and that also would look really good on your CV, as well as getting interested in the specialty and getting all the educational CPD from that. I'd advocate that for sure. And if you're also not sure, don't feel like you need to rush into things post-FY2. There's loads of time to consider what you want to do. Think about a clinical fellow year, but be selective. So look at what they can offer you and what they've got going on. So do they have a hospital at home team? Do they have community? Do they have acute frailty inreach into other services or a surgical, you know, orthogiatrics team? So think about what experience you could get and also what they can offer you in terms of supporting quality improvement work, teaching, research, just to think about showing your interest in specialty and things to talk about in interviews as well.

SPEAKER_02 11:01

Thank you, Kat. I just want to reiterate what you've already said to anyone listening, which is don't be scared of being a medridge. Because I think everyone is so terrified of that, and they start saying, I can't possibly do ex specialty or y specialty because I can't be a medreg. And I guess what I want to reiterate is that you have all the knowledge, you've passed paces, you can't be a medridge without it. So ultimately the difference between being a medical SHO and being a medridge is that you're now the one making decisions. But actually your knowledge isn't that different one from the other. And for me personally, I think actually being a medical SHO, I know it's an old term that we shouldn't really be using, but being one of the doctors before speciality training, whether that's uh you know, Foundation Year 2 or internal medical training, uh that is a much harder job than being the Medridge. The other thing that I want to ask you if you don't mind, you've mentioned all these exciting parts and the different parts that when you're on the wards, you may not necessarily see hospital at home and acute frailty. So stroke medicine, when you go into that from geriatrics as opposed to from neurology, how does that work its way into your training exactly?

SPEAKER_00 12:10

Yeah, good question. So your training has to include all these elements as part of a training for medicine of the elderly. So all medicine of the elderly consultants will have done some time in stroke movement disorder community. That's part of the training pathway. You also sub-specialise, and that's quite new in the last couple of years. So you choose a subspecialty that you're interested in, which include movement disorder, continents, community, which is the one I've chosen, and there's about five of them. So therefore, within your chosen subspecialty, you get more time in training to come out with a subspecialty, basically. If you want to do stroke, you also do an extra year purely in stroke medicine that you applied for. So you did an additional year of training in stroke medicine. And I think overall, don't quote me on this, but you need two years in stroke. The one is your extra year, and one is the other times in training that you get in stroke to then qualify as a stroke consultant as well as elderly consultant. The other specialties you don't need to do an extra year. If you think about when you're going to be a consultant, if you're interested in, say, Parkinson's or movement disorder, you want to have done enough training in that time to be able to then be a consultant running a clinic in movement disorder. So you will probably choose that as your sub-specialty and you will actively look out for opportunity to do that within your training. And you choose what you need to get out of your training. So you need to be quite proactive in that and look at your curriculum, look at what you've done so far, and think, well, I want to go to this hospital, do this clinic, this rotation in hospital at home to get my competencies in. There's quite a lot of variety in what you can do, and you're kind of an ownership over your own training.

SPEAKER_02 13:42

When do you need to make that choice, Kat? And I'll make sure that it's all referenced in our footnotes for anyone listening as well, all the details of this.

SPEAKER_00 13:49

Yeah, so I think your subspecialty you will make at that choice, I imagine, when you go into ST4. Our curriculum changed halfway through my training, so I went back after a year of programme and had to then choose a subspecialty halfway through, which is less ideal. But I imagine for those coming in new in ST4, you will choose that subspecialty then. And in terms of the stroke, specialty year, you don't need to choose that straight away. You can't choose it like in ST7 though. So I think there's probably a cutoff in terms of when you can choose it. But I know people who've gone in between ST5 and ST6, and that's that's been fine. So I think as you're as long as you're not doing it in your last year of training, I think that's okay. So you don't need to choose straight away.

SPEAKER_02 14:26

The only thing that we haven't quite covered, which I like to talk about on this podcast, is describing an interesting case. And I know I'm putting you on the spot, but before you said not all deliriums are UTIs, and actually nearly none of them are urinary-attract infections. So I'm not saying you have to bring a delirium case to us, but do you maybe have another one that kind of stood out that you've recently been involved in?

SPEAKER_00 14:49

I've got one that I've talked about before about hospital at home that I might talk about. I once had a case of delirium UTI given trimethoprin the other day that actually ended up having massive homnerembolis as the reason for their delirium. That's just to say that people present with frailty syndrome. So they present atypically with problems that can be due to lots of different things, and you need to think about what else it could be. So people present with reduced mobility or delirium, and that's why that detective mindset is really important. So think about what else that could be. And there's a really good podcast I did with Claire Bostock in clinical conversations as well, if you're interested. Okay, so I'm going to talk about a chat who I saw in hospital at home. Now, hospital at home is a service where we aim to provide hospital-level care in people's home environments. It's better for patients generally and reduce risk of delirium of hospital-acquired infections. Generally, older adults with frailty will want to remain at home as well and have treatment at home if they can. And we have a service that allows us to be able to go out daily. We can provide IV antibiotics, oxygen, sometimes fluids, and do comprehensive geriatric assessment in people's homes. So that's hospital at home. I was referred to a guy who had severe CBD. He was in his 80s and he'd been referred with breathlessness. When I got there, so you carry your bag, your ECG machine, everything with you into the house. And I love hospital at home because you get a really good idea of what people's home environment looks like. Are they taking their medication? You get such a better picture than if it's in a clinic room. When I got there, he looked pretty breathless, took his pulse, and he was in AF, which was new with fast ventricular response. I did his ECG, Marilena, and it was like rate to 190. I can see your face going, oh he was hypoxic. So I think at that point you could have very easily gone, let's just bring him into hospital. 999 ambulance. And I actually I had a wee chap. He'd been in and out of hospital lots recently. He'd had a terrible time, didn't want to go back to hospital. I could see that he had increasing frailty. He was needing an increased support in terms of carers, his mobility was declining. He now had a hospital bed in his living room. And actually, you know, he was just thinking, is this the right thing for me? So we decided together that he didn't want to be readmitted to hospital, but he did want treatment at home. He had pretty good social support, he was safe on his feet with a Zimmerframe, he had his hospital bed, like I mentioned, his daughter was staying with him. And really, when I spoke to him about what matters to him, he wanted to be at home with his daughter, he wanted to be able to have a dram, so a whiskey in the evening. And if that meant he died, then that meant he died. He'd had a good life, that was what mattered to him. So thinking about what's potentially reversible here, well, we could rate control him. His blood pressure is a bit low, so I ended up giving him digoxin to help with his rate, gave him some oxygen via nasal prongs at hospital at home and a nebulizer machine. I looked at his medication and he was on lots of medications and he was sick of taking them that probably weren't actually doing him much good. This chap's probably in his last year or two of life if he survives this illness. So thinking about what's important to him, we stopped his statin together, we stopped his antihypertensive medication that was making him dizzy when he stood up, and we also looked at medications for breathlessness, so and trying a little bit of more oromorph, so liquid morphine and lorazipam to see if that helped with his breathlessness as well as some diuretics because he looked a bit overloaded. And actually, he had a really good result. So I saw him again over the next couple of days. He'd reverted to cyanus, which was great. He felt much improved from his symptoms, he was enjoying not having to take so many tablets. And we had an opportunity to have a wider discussion around what mattered to him and what he'd want in the future. And he wanted to stay at home, he wanted a focus on reversing reversible things, but also on symptom control and a very clear plan communicated to his GP that's all written down so that if he was unable to make decisions, that would all be clear in black and white. And his daughter was part of that conversation too. And I just think that the ambulance had been called out at three in the morning, he would have just been whipped into hospital, or we could have just whipped him into hospital. Then he might have got hospitalized acquired pneumonia, died in hospital on his own. And you just think actually being able to do a comprehensive assessment, work out what's reversible and treat that importantly, so make him feel better while doing what mattered to him is so rewarding in a way that you just don't get quite a lot of the time. And I think being able to provide that service is really, really important. So I would just really advocate hospital at home as being a great thing, first of all. And also I think when you have the time to do a good assessment on someone and have all these conversations and do what feels like the right thing, it's just a really rewarding part of medicine that can be rare when you're busy on calls.

SPEAKER_02 19:36

That's a wonderful example of what you can offer. That communication element is so easily lost in hospital, even however much we try to kind of keep it there. I kind of don't want to end past this because that was such a nice way to end. But there's just one thing that I keep hearing a lot about, and that's how judicians approach the end-of-life decisions and the discussion around advanced care planning. And you know, I've been in a situation where I've been like, well, why has this GP not discussed this with you? But I think it's all our responsibility to do that when we do see a patient that we think we should be having these discussions with. But a lot of us almost shy away from that and think, well, let's get over this initial episode and then we can kind of discuss that. But there is never an ideal time. And just listening uh to that story there, I got the impression that you didn't make all those decisions straight away. Yeah. You kind of made some decisions and then you came back to them when you went to reassess the patient after. And I just wanted to ask how did you go about making these decisions and having these discussions with patients? Because I think uh that that's what's really scary as we get more senior and we end up having uh taking more of the responsibility of having these discussions and the decisions that are made from them. So could you maybe give us some advice as to how you approach this?

SPEAKER_00 21:00

Yeah, that's a really good question. And I think your point that this is everyone's business is very true. And that's the case for just medicine of the elderly completely, because we've got an aging population with increasing frailty, and you know, it's everyone's job to be looking after these patients and doing so in a way that encompasses what matters to them. The timing is interesting, and you find that if it's an acute situation, sometimes you're just pushed into having this decision because that person might deteriorate very quickly. And I think that's okay to do it at that time if you need to. And like I say, you might have perhaps a shorter conversation that's just looking around things like escalation and resuscitation because that's an urgent thing that needs to happen if the person's really unwell. I wouldn't say that that's the right time to have the conversation most of the time. Most of the time, a period of stability is the right time to have conversations about future care planning. And like you say, in this case, we had an immediate conversation about do you want to go to hospital? Is that the right thing? And then could follow that up as he got better with wider conversations about what mattered to him. Whenever I'm Thinking about this, I guess the first thing to say is it's a collaborative approach. So we have a good understanding of what treatments or what my options might be reasonable and might help, or what might not help in that situation. And we can't be offering things that we don't think are an option. So I think that's one thing to say. But what the patient feels and what matters to them is equally as important. So it needs to be a collaborative conversation with the patient. So the timing, as I've said, I think is in a period of stability. So once someone's over their acute illness, when they're waiting for that package of care or whatever in hospital, often then we're not doing very much. And actually that can be a nice opportunity to have that conversation. Thinking about down the line, if they become a well-in the community again and in clinic, like in a fragile clinic, that's a perfect time to have it. So think about what opportunities we have. And then in terms of guiding the decision making, I've mentioned a little bit about if it's an acute setting, a lot of it's about reversibility. If someone has come in with an overdose, you know, of their beta blocker or something and they're bradycardia for that, there's good reversibility there. Whereas someone's coming with an aspiration pneumonia on the back of lots of aspiration pneumonia, the reversibility is less. So thinking about it in that context as well as what else is going on with them. A good framework that I've used before and that I think is useful is something called Red Mat, which we can link to in the show notes. And that's sort of an acronym that just helps you set out having those conversations and is about how you approach the conversation. It's got good conversational prompts as to how you approach if someone is sort of fairly fit, but you want to just talk about the future a bit all the way to when someone you think is actively dying and kind of has a little bit of expectation setting at the start, as well as importantly talking about what you know about their health and then asking what they know about their health and then coming up with a plan together, including what matters to them. So I think that's quite a useful framework that I've definitely recommended in the past. I think by Cassie, it's just about the more you do a bit, the less scary it seems. And people want to talk about it. I think you'd be surprised actually by the amount of time if you actually open up a conversation, people won't volunteer this. And older adults particularly might have a paternalistic view where they're waiting for the doctor to tell them what to do and actually wouldn't volunteer that. But if you actually start talking about it, people generally want people to know what their wishes are. As long as you're doing it in an empathetic way that involves what matters to that person and thinks about what might be helpful and what might not be helpful, then you can't go too far wrong.

SPEAKER_02 24:22

Thank you so much for that. I think that's the end of my questions, Kat. Any final comments for you for our listeners about how amazing geriatrics is?

SPEAKER_00 24:31

I think it's a really interesting specialty. Obviously, I'm completely biased, but I think there's a massive variety in what you can do. My favorite bit is the communication and the complexity and being able to make a difference in situations where other people might not see opportunity, but I do. I think that's really important. And I think it's just to say, even if you don't go into geriatric medicine, it will be your business because, like I said, we have an aging population and every specialty has older adults in it who are frail. And it's important that we have enough time to do a good job with these people and to be able to give them our time and make time to work out what's important to them. And also make sure that our attitudes towards older adults are not buying into a biased, well, we don't do anything for that person because they're 98. You know, there's always something that we can do, whether that's reversing reversible things that are wrong with them or whether that's enabling a good death. And I think that that's just really important. So even if you're not interested in gyro medicine, you're still listening to the podcast. I think it's important to know about it in any specialty. Thank you so much, Kat.

SPEAKER_02 25:31

Thank you for your words of Budstone. And thank you to all of you for listening to us today. As always, you can listen to the rest of our career series on career conversations, and we've got lots of clinical episodes on clinical conversations. Kat's already mentioned one to do with geriatrics, and there is also another one with Dr. Sean Nynan that you can find on clinical conversations as well. Please feel free to have a look at our podcast streams for more episodes. Thank you for listening.

SPEAKER_01 26:11

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