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For more than a year, I have been learning about the practice of geriatric medicine in England. My experience has provided an interesting contrast with the specialty as practised in my own country, Thailand.
As is well known the population worldwide is ageing. In developing countries, the growth rates of the proportion of elderly people in the population are much faster than those of the developed countries. It is projected that 13 years from now, 11 million out of the 65 million people in Thailand, almost 17%, will be aged over 60 years. The move towards the ageing society in Thailand is the result of a decrease in the birth rate and the increase in life expectancy as has already occurred in most developed countries. The life expectancy for Thais is 68 and 75 years for men and women respectively. Men and women can, respectively, expect that 19% and 24% of their life after the age of 60 will be spent in a disabled state, but may expect only about 10% of this later stage of life to be spent unable to manage basic self-care activities of daily living.
Social issues for the Thai population
Almost three-quarters of Thai elderly live with their spouse and children. Sixteen percent live with their spouse only. Only 6.3% live alone. However, the change in the lifestyle in the modernised cities has resulted in the family structure becoming more nuclear-family orientated, with increasing disintegration of the extended family, so important in the past. The main source of income for older Thai people is from working (40%), family member (35%), savings and interest (18%), and pension (4%).
Health care service for the elderly
The health problems associated with the ageing Thai population have changed from the infectious diseases and malnutrition of previous years to more chronic degenerative diseases. Four fifths of the young elderly (60 – 80) and nine tenths of the very old suffer from at least one chronic disease. The disability rate is around 15% in the young elderly climbing to 30% in the octogenarian population. Thailand launched the first “Elderly health care project” in 1960 and the “Geriatric clinic” one year later. Despite this it still lacks a nationally organised scheme since most of the geriatric clinics were in the district general hospital or medical schools. Two years ago, the plan to develop geriatric clinics in every community hospital was started. The inpatient ward specifically dedicated for the elderly is still in short supply as most hospitals still pay attention to short-term acute treatment rather than chronic diseases requiring rehabilitation, possible resettlement and longer term care. The long term care institutions are mainly in the form of nursing homes. There are 20 homes run by the government and 30 private-run homes. The main discharge destination for the disabled elderly person is their home and their family members are the primary carers. Traditionally, the main carer in the family is a woman. However, the tendency for women to work outside the home and the increase in the dependent elderly in the family often makes it necessary for a trained carer to be hired to look after the elderly person, either at home or in an institution. Moreover, the change in family structure, the potentially higher number of unmarried people, and the style of modern work means that increasing numbers of elderly people either live alone or live with their spouse only.
Geriatricians in Thailand
There is still a shortage of geriatricians in Thailand. There are less than 10 who have been trained or have spent some time training in geriatric medicine. The first generation of specifically trained geriatricians appeared in the early 1990s. There is no formal training in geriatric medicine in Thailand at the moment as the number of centres which can provide the training is still limited. Most Thai geriatricians are in medical schools but some medical schools do not have geriatricians. In Siriraj medical school in Bangkok, there are 6 consultant geriatricians for a 2500 inpatient bed hospital, while most other medical schools may have none or only one. Those working in medical schools have to work simultaneously as a university lecturer and as a full time consultant. The average work hours of doctors in Thailand are 94 hours per week and may be up to 128 hours per week in a community hospital. This does not include time spent in preparing teaching material, writing articles away from direct care contact with patients or teaching time with students. The average time spent for each patient in the outpatient clinic is 4 minutes, which includes time spent in writing notes and prescribing medications. There are, however, quite a few of doctors who have a special interest in elderly medicine. These include those from related sub-specialties in medicine (neurology, cardiology etc), family medicine, and rehabilitation medicine. They gain their experience by seeing the elderly patients and doing research in the field of geriatric medicine. At Siriraj medical school, there are two geriatric clinics per week and one of them, which sees 80 patients at every clinic, concentrates on health promotion and disease prevention in the more active elderly. The other clinic serves the more disabled elderly which is attended by 20 patients each week. Elderly patients are admitted in the integrated wards and most Thai geriatricians work in general medicine and geriatric medicine. Patients who have acute strokes and Parkinson’s disease are looked after by neurologists. Dementia patients may be under the management of neurology, geriatric medicine or psychiatry departments depending on the clinical style of the medical school. Patients suffering a subacute stroke, Parkinson’s disease, and/or dementia may be looked after by either neurologists or geriatricians. Formal multidisciplinary meetings are still in the process of development. The overwhelming work load and inpatient bed time is invested in dealing with patients referred with established disease. However, there are a number of projects focusing on health promotion and disease prevention in the elderly, in particular in the community settings.
Training in Geriatric Medicine
At the present there is no formal training to become a specialist in geriatric medicine in Thailand. In the near future we expect a postgraduate course in geriatrics to be established and this may be in the form of a diploma course, a master’s degree or a clinical fellowship. Thai medical students and junior doctors have little interest in pursuing a career in geriatric medicine. This may be due to a lack of role models as a result of the limited number of geriatricians in the medical schools or because geriatricians also function as general physicians so that their role in geriatric medicine is not clear. Furthermore, the image of geriatric medicine probably does not appeal to medical students and junior doctors, who usually prefer to look after patients in acute medicine or look after younger patients. Finally, the income of geriatricians is less than it is for other medical specialists.
At present in Thailand it cannot be guaranteed that doctors will have further education in geriatric medicine. Hence, the undergraduate curriculum is designed to ensure that all graduates have the essential knowledge and ability to manage the basic problems of elderly people. The undergraduate curriculum varies depending on the availability of geriatricians in that medical school. For example, in Siriraj medical school, the teaching of geriatric medicine grows from the second year to the sixth year of the curriculum. This teaching is provided in various ways including seminars, lectures, integrated teaching, problem-based learning, community-based education, and elective programmes. The curriculum encourages students to think about the prevention of illness in elderly health care since this is a key element of geriatric medicine. The clinical exposure of students to the elderly patients is in their fourth to sixth year.
Trainees in internal medicine (the second or the third year of their training) rotate to the division of geriatric medicine for four weeks. The training is conducted by Departments of Preventive and Social Medicine, General Medicine, and Rehabilitation Medicine. Each week there are three bedside teaching sessions, two geriatric clinics, one core lecture, one geriatric grand round, one topic review, and a journal review. Trainees have to see referral patients from other departments everyday and meet with the on-call consultant.
Trend
Geriatric medicine in Thailand is now being pushed along by the increase in the number of older people as a porportion of the population. Though there is no formal training in geriatric medicine at the moment, the curriculum that is being developed for undergraduate and junior doctors is functioning well. The national health care service for the elderly still needs much improvement to serve the complex changes happening in Thai society. The year 1990-2020 is and will be the critical period for the country to develop its health care personnel and service for delivering health care to the elderly. This is because it is the time of “population dividend” when the dependency ratio is stable and comparatively low. After this, Thailand will become an ageing society. The Thai Society of Gerontology and Geriatric Medicine and the Thai Medical Council are cooperating to provide formal training in geriatric medicine and need to play a key role in geriatric medicine becoming a valued specialty in the whole country.
Weerasak Muangpaisan
Prasert Assantachai
Siriraj Hospital, Mahidol University, Thailand
BGS Newsletter, December 2007
Issue 14 ISSN 1748-6343 14