Training tomorrow’s doctors is a challenge for the consultants of today, with competing demands of service delivery, access targets, research priorities, clinical governance - not to mention their own continuing professional development.

All consultants teach in their own specialty, and in addition may have a role in basic medical training and in higher specialist training in General (Internal) Medicine (G(I)M). However, whereas most organ-based specialities have a Specialty Question Group in the MRCP(UK) diploma examination, geriatric medicine does not. Although the Colleges have answered criticisms about the under-representation of geriatric medicine in this examination by ensuring that there is a geriatrician sitting on each of the organ-based Specialty Question Groups, this is insufficient and does not do justice to our specialty. This may also send a message to junior doctors that geriatric medicine is relatively unimportant.

This issue has been around for many years, but is brought into focus by the latest Federation of Royal Colleges Census (2002) which identified a total of 1037 consultants in geriatric medicine, compared to 737 in cardiology, 693 in diabetes and endocrinology, 626 in haematology and 619 in respiratory medicine. Many Specialty Question Groups in the MRCP(UK) examination cater for specialties with fewer consultants than these. Furthermore, geriatric medicine is at the forefront of the numbers of additional consultants needed to satisfy the European Working Time Directive and the projected numbers that will retire aged 60 over the next ten years.

In addition, there is still concern that SpRs in G(I)M, either alone or in combination with a specialism other than geriatric medicine, do not receive adequate training in managing acute ill health in older people. Whereas many, but not all, medical SHOs undertake a short period working in a Department of Geriatric Medicine prior to MRCP(UK), there is no requirement for SpRs in G(I)M to have structured training in geriatric medicine to the same extent as they do for Coronary Care and ITU experience. This is at a time when the number of emergency admissions of older people is increasing year-on-year as a consequence of changing demography.

Recently the Specialist Training Authority has approved a new subspecialty qualification in Acute Medicine for General (Internal) Medicine NTN holders. This is aimed at a consultant who will play a lead role in the delivery of acute medicine at the “front door” and could have a managerial role in a Medical Assessment or Medical Admissions Unit. The sub-specialty curriculum is designed to complement the existing G(I)M curriculum and concentrates upon practical skills related to insertion of central venous lines, protecting the airway, ventilation, management of patients at risk of cardiac arrest, use of advanced methods of monitoring vital signs, the management of patient distress, the compassionate handling of patient demise, and the management of alcohol/drug intoxication.

New ways of delivering high quality care, especially consultant-led assessment and management within the first few hours of admission, must be supported. However, it seems to have been forgotten that the majority of emergency admissions are of elderly patients with multiple pathology, and that disease can present atypically in an older person. The recent sub-specialty qualification in Acute Medicine is a missed opportunity to re-establish the value of geriatric medicine at the “front door”of the hospital.

How can we modernise training for all physicians to improve the quality of care for frail elderly people admitted as medical emergencies? One response is ask the Colleges to introduce a Specialty Question Group for geriatric medicine at the MRCP(UK) diploma examination, and to enforce a minimum of four months attachment to a Department of Geriatric Medicine for all Basic Medical Trainees and for SpRs in G(I)M. However this may not be agreed, or be the most appropriate solution. For many years geriatricians have taken on greater roles in the acute unselected take for patients of all ages. They have developed sub-specialisms such as continence, stroke, or orthogeriatrics (to name a few), taken on sessions related to organ-based medicine (endoscopy for example), and in some forward-thinking areas intermediate care and community practice. We may push for changes to the way in which basic and higher training in G(I)M is delivered and assessed (this is being done), but in addition should we be lobbying commissioners to fund additional geriatricians - and should our specialty move closer to the “front door” to take up the challenge of assessing all elderly patients within a few hours of admission?

Tim Hendra
Physician and Geriatrician (Sheffield)
Chair Specialist Advisory Committee (Geriatric Medicine)