Representatives of the four countries of the BGS met at the the Ark Conference Centre (thank you Dr Gill Turner), in Basingstoke in the summer, for the Annual Study Day

Appropriately the morning session began in a very modern lecture theatre on the subject of “Modernising Medical Careers” (MMC).

Two papers were presented, the first on Foundation Programmes (FP) and the second on MMC post the first two FP years.

Papers were delivered by two hybrids, part- geriatrician part-associate-dean (prize offered for suggestions of a one word description of such a person).

The Foundation Programme will begin August 2005 (correct at time of going to press).

Pre-registration House Officers as we know them will cease to exist, and graduates will all enter a 2-year programme. Initially the first year will be reminiscent of the current situation with time (minimum of 3 months) spent in medicine and surgery, but with an opportunity to use other time in the first year for exposure to less confined aspects of patient care. (Such novel PRHO years already exist around the country, with time spent in general practice, intensive care medicine, paediatrics etc).

Foundation Programme - Year 1
However, the new foundation year 1 (FPY1) concentrates on the acquisition of important competencies which will be mandated to be achieved over a 2-year stretch. The curriculum and competency grids have been drafted by the General Medical Council. The competencies are graded in terms of achievement. Full registration will probably still be achieved at the end of Foundation Programme Year 1, but there is potential for flexility on when registration actually happens.

The competencies will emphasise more than ever, issues such as:

Recognition of the sick patient and full competence in managing acute life threatening illness

Team working

Clinical Governance issues

In depth understanding of National Health Service priorities and National Service Framework objectives

Clearly the necessity for concentrating on the acute illness of the older patient, which constitutes the majority of adult illness attending hospitals today, will be a fallout of Foundation Programmes.

Foundation Programme - Year 2
Foundation Programme Year 2 (FPY2) will build on this approach and provide young doctors with a broader exposure to many other basic specialisms than it has done to date, usually in three four-month blocks.

FPY2 jobs will come into existence with the conversion of stand alone SHO posts (many still in elderly medicine), first year SHO posts, etc., which already exist in general medicine, surgery, A&E, paediatric rotations and so forth.

Choice of FPY2 should be ordained by better quality career guidance at undergraduate and early post-graduate level, but the intention to stream graduates into a much smaller number of basic specialisms following the foundation programme is explicit.

Completed Certificate Training
Basic specialist training thereafter could be completed in three years to achieve a CCT (Completed Certificate Training). It could be argued therefore, that elderly care departments should convert as many posts at SHO level as possible, into FPY2 programmes, to ensure that the majority of doctors get exposure to the speciality early on in their careers.

Foundation schools
Recruitment to a Foundation Programme will be based on new foundation schools, which are slowly acquiring a “virtual” existence and are advertising now for August 2005. The rules of application are well worth reading as students are likely to ask a lot of questions of teachers over the next year.

Three more important points fall out of the principles underlying the development of a foundation programme:

There is a focus for a newly trained doctor to concentrate on patient need for treatment intervention as expressed by their wishes.

Programmes are trainee centred and not dominated by service needs.

“Tasters” of “shortish” specialisms should be encouraged, especially in FPY2 years e.g. histopathology, radiology, psychogeriatrics etc., by engineering in exposure to these disciplines as programmes are designed.

As always, the trainees will have to maintain a portfolio of evidence to show the acquisition of competencies and also to maintain revalidation as medical practitioners.

Basic Specialist Training
David Black then followed with a paper to illustrate what may evolve in August 2007, with the rest of Modernising Medical Careers.

With Post Foundation programmes:

• we will have Basic specialist training (BST)
• Specialist training in medicine will become very general
• Assessments of achievement of competency will be mandatory
• Training will be time limited to, perhaps, 3 years
• A Record of In Training Assessment (RITA) system similar to Calman SpR’s will be introduced

Higher Specialist Training
Following BST will come Higher Specialist Training (HST) which will be entered on a competitive basis; the attributes for the competitor have not yet been explicitly defined.

The rotations that will fall out of MMC must account for flexible working, overseas doctors, returnees to training and remedial trainees.

Entry to BST will be competitive, starting mid- FPY2 and will be informed by the needs of the National Health Service i.e. the NHS does not need 30-40% of its graduates to become surgeons. Once again, the importance of career counselling and manpower information for young doctors in training is highlighted.

The role of the membership of the College of Physicians in BST is still not clear, especially if the assessments are truly competency based.

David then went on to open up the discussion as to what “geriatric” BST might look like, especially in the light of the arrival of the training pathway for emergency physicians, and the disappearance of General Internal Medicine, as we know it, at a higher specialist level.

Acute hospital based model
David illustrated his talk with information from a recent survey of English consultant geriatricians, the results of which seem to favour an acute hospital based model of geriatric care, at least early in one’s career, with an increasing interest in community aspects as the geriatrician “matures”.

However, he pointed out that the model of geriatric care supported by the purchasers may ultimately prevail, and more than ever will be based on chronic disease management principles.

David finished by reminding us that the geriatric consultant of the near future will be a different animal from the one of today :

• They will almost certainly be trained more quickly
• They will be more generalist
• They will need to work in a department with a hierarchical structure of clinical experience and management skills
• They will need to concentrate on developing and delivering chronic disease management programmes
• They will need to develop individual specialist services on behalf of older people, for example falls and orthogeriatrics

Following the two papers a discussion ensued which I believe can be fairly summarised as saying that the principals of MMC are not seen necessarily, as being bad for geriatric medicine, provided that we can maintain recruitment to the discipline. Strong emphasis on high quality education and training, and an excellence in academic geriatric medicine are crucial to the ongoing health of the discipline.

Kevin Kelleher
Study Day
Programme Co-ordinator