Tuesday, 24 March 2015

Community Geriatrics - an opening salvo

As I was contemplating my return to blogging, I remembered a story I once heard: following his release after a 4 year detention by the Spanish Inquisition, Luis de Leon opened his comeback lecture with the words, ‘As we were saying yesterday….’

18 months ago, when I all but stopped blogging, I wasn’t interrupted in quite the same manner as Leon, but things did change: I went from being a geriatrician in a North London DGH, to a community geriatrician in West Dorset. I suspect that some people thought I was crazy, but I had a sneaking suspicion that it would turn out to be a fabulous move. It has been, and I’d quite like to tell you a bit about it.
I’m not going to hark on about life in Dorset. I don’t want to irritate you. But allow me to set the scene: we live in Bridport, where Broadchurch was filmed. It is a lovely place, where people ask you ‘Where’s that to?’, when they mean ‘Where is that?’ It is rural community, fuelled by farming, agricultural industries, and tourism. It is a place people retire to. We swapped a two-up, two down terraced house in Maida Vale for a 17th Century farmhouse, with all the accoutrements to horrify the parents of a toddler: it has a well, a pond, and an Aga. Sometimes when I get home, I stand outside my house and just stare at the night sky – it is like God has shaken his dandruff.

But my aim is not to convince you of the merits of rural life. Instead, I would like to share with you what I have learned about the scope and potential for community geriatrics. My radio silence on these pages has been borne of a number factors (ibid move, house purchase, new job), but only one really counts as a legitimate excuse: I have been learning a new trade. Community geriatrics is different to hospital geriatrics. My out-patients clinics take place in patients’ homes, one of my community hospitals has an x-ray machine, the other does not; my patients are different, my working patterns are alien, the nature of decision-making outside of hospital is dramatically different. The nearest geriatrician to me is 16 miles away.
I came into this job with the skill-set of any other geriatrician, forged and honed in acute hospitals, and have had to learn how to adapt to a totally different environment of practice, where the nature of risk-management is harder, where the access to diagnostics and expert opinion is harder, and where the goal for the patient is different.

I am an introverted thinker (remember your Myers-Briggs) – this means I take my thoughts and experiences, and put them inside my head, where I let them swirl around, until there is some order, and then I share them with the world. So if you are wondering where I have been for 18 months, you have your answer – I have been right here, trying to make sense of this new world I find myself in.

And I have finally reached a point where I not only have questions, but I have some answers as well, and I would like to begin sharing them with you. Of course, the question of how you care for an ageing population more effectively within existing funding streams is a question that can never be ticked off as complete, but my experiences may help to start finding answers to questions like this.

Over this series of blogs, I would like to outline to you what I have learned about caring for the elderly in the modern health service, and what community geriatrics can contribute to the solution. There is a lot to cover, and I would test your patience to attempt it all in one go. And even now, I suspect that I am reaching the limits of your tolerance, so let me end with a final consideration.

Does the structure of geriatric services we have now correspond with what we think the goal of geriatric services should be?

Let me fuel the discussion a little. Towards the end of my registrar training, out of the swirl on my introspective thinking came the realisation that as a hospital physician, I met patients when they were sick, learned about them, about how their illnesses responded to treatment, and tried to get them better. When patients were discharged, I would have nothing to do with them until they got sick again. All that I had learned about them and their collection of illnesses went untapped until their health deteriorated.
I don’t know what geriatric training was like 30 years ago, but I do know that current training has become enmeshed within the acute pathway. Very little time is spent with GPs, or with community services. Virtually no time is spent in the patients’ homes.

The most striking aspect of being a community geriatrician is how much more you can find out about a patient from assessing them in their own home. You are flying blind as a geriatrician until you find out about how a person manages day to day in their own environment. The problems I assess are the same ones I used to assess in my hospital clinics, but my response is often very different. My tests are more considered, my understanding of what the person needs is sharper, and more of it is organised around the needs of the person in front of me, than the demands of the particular disease process we are dealing with.

Over this series of blogs, one of my overarching themes will be the idea that geriatrics is the specialty of managing a constant state of poor health in the elderly, derived from multiple medical problems and acquired frailty. I will make suggestions about how community services, and changes in the way that geriatricians manage their local patients can contribute a better experience of care from the people we serve.

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