Insights
Reflections of a trainee geriatrician James Fisher Geriatric and General Internal Medicine, Health Education, North East, UK Given the demographic changes in the population, is the argument to provide more elderly-specific teaching not now compelling?
I
t is well recognised that the population of developed countries, such as the UK, is ageing. This changing demographic presents health services with new challenges because of the complex care needs of many elderly patients. This tidal wave of ageing is in fact already upon us: twothirds of acute admissions to hospital are aged over 65 years, and it is hard to think of a specialty (paediatrics excluded) that is shielded from this sea change. Meeting the needs of the ageing population is not, therefore, solely the domain of a geriatrician. The recent UK ‘Shape of Training’ independent review highlighted the changes required in postgraduate training to ensure that doctors gain broader experience and are thus capable of providing more holistic general care.1 Although this was a UK-based report, its findings are of relevance to other developed countries, as their health services are likely to face similar challenges given the demographic shift. It is important that I declare a competing interest at this point – I am a trainee geriatrician who
finds the specialty challenging and hugely rewarding. But this hasn’t always been the case. Whilst an undergraduate I had no inkling that a career in geriatric medicine beckoned: paediatrics was where I saw myself headed. In fact, if I am truly honest, I am not sure that I was even aware that geriatric medicine was a specialty in its own right, until the later stages of my undergraduate training. It has been shown that some students are deterred from undertaking a career in geriatric medicine because of a perceived lack of prestige.2 Furthermore, some students at an early stage in their training were found to hold negative attitudes towards elderly patients.3 These two perceived deterrents didn’t apply to me, but thinking back I struggle to recall specific teaching on geriatric medicine topics whilst I was an undergraduate. Perhaps a lack of exposure to geriatric medicine in the curriculum might explain this? We know that undergraduate curricula are crowded, with each specialty arguing that their domain is the
most important, and that it should have greater representation. But, given the demographic changes in the population, is the argument to provide more elderly-specific teaching not now compelling? Serial survey work has highlighted how the undergraduate teaching of geriatric medicine has in fact expanded in recent years.4 Critically, so too has assessment, as it is well recognised that for many students what is ‘on the exam’ is considered to be the curriculum. Although this increase is encouraging, this survey showed that the proportion of time devoted to teaching on geriatric medicine remained low. This is particularly concerning when you consider that frail older people represent a significant proportion of doctors’ work. So what made me into a geriatrician? Put simply, the power of positive role modelling. A final-year placement on an elderly care ward brought me into contact with a number of inspirational geriatricians. Witnessing a geriatrician implement patientfocused management of a
210 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 210–211
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5/14/2015 7:39:35 AM
condition(s), rather than condition-focused management of the patient, opened my eyes to the essence of the specialty. As the famed medical educator William Osler once said,
‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has’.5 Over time I came to understand that doctors alone couldn’t resolve these patients’ complex problems, and that embracing multidisciplinary teamwork was the key to doing so: my conversion to an aspiring geriatrician was complete. Spreading an understanding of this multidisciplinary process (known as Comprehensive Geriatric Assessment) beyond geriatricians will be essential if the goals set out in the Shape of Training report are to be achieved. At a recent local training day for geriatric medicine trainees, I spoke to a number of fellow trainees about their decision to undertake a career in the specialty. None recalled holding an overwhelming desire to practice geriatric medicine whilst an undergraduate, but all were able to identify a positive role model who had strongly influenced their career preference. In a Canadian cross-sectional study that examined the impact of role models on medical students,6 it was demonstrated that a large proportion of students could identify a role model that they came into contact
with during the later stages of their medical school training. Furthermore, it was recognised that exposure to role models in a particular specialty area was strongly associated with medical students’ choice of clinical field for subsequent training. So, how can a clinical teacher act as a role model for a future generation of doctors? Firstly, having an insight into the power of positive role-modelling is critical, as well as an understanding that negative role-modelling can be an equally potent deterrent. Secondly, teaching skills were highlighted as being one of the most influential factors as to whether a clinician was perceived by their students to be a positive role model.6 Taking proactive steps to improve one’s teaching skills and making time to teach alongside clinical commitments may increase the likelihood of being considered a positive role model. As William Arthur Ward is quoted as saying:
The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.7 In summary, the effects of the ageing global population are likely to be felt across almost all specialty areas, and thus all doctors require better training in how to care for complex elderly patients. Clinical teachers should be mindful that both positive and negative role-modelling can influence students’ career decisions. Those clinical teachers who deliver
high-quality teaching, whilst striving to continually develop their teaching skills, are more likely to be considered positive role models by their students. REFERENCES 1.
General Medical Council. Shape of Training Review: Securing the Future of Excellent Patient Care. Available at http://www.shapeoftraining. co.uk/static/documents/content/ Shape_of_training_FINAL_Report. pdf_53977887.pdf. Accessed on 17 March 2014.
2.
Robbins TD, Crocker-Buque T, Forrester-Paton C, Cantlay A, Gladman JR, Gordon AL. Geriatrics is rewarding but lacks earning potential and prestige: responses from the national medical student survey of attitudes to and perceptions of geriatric medicine. Age Ageing 2011;40:405–408.
3.
Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: a five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group. J Am Geriatr Soc 1995;43:1430–1436.
4.
Gordon AL, Blundell A, Dhesi JK, Forrester-Paton C, Forrester-Paton J, Mitchell HK, Bracewell N, Mjojo J, Masud T, Gladman JR. UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine. Age Ageing 2014;43:293–297.
5.
Bliss M. William Osler: A Life in Medicine. New York: Oxford University Press; 2007.
6.
Wright S, Wong A, Newill C. The Impact of Role Models on Medical Students. J Gen Intern Med 1997;12:53–56.
7.
Fred HL. The True Teacher. Tex Heart Inst J 2010;37:334–335.
Witnessing a geriatrician implement patient-focused management of a condition(s) ... opened my eyes to the essence of the specialty
Corresponding author’s contact details: James Fisher, Geriatric and General Internal Medicine, Health Education, North East, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was not required. doi: 10.1111/tct.12278
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 210–211 211
tct_12278.indd 211
5/14/2015 7:39:35 AM
Reflections of a trainee geriatrician James Fisher Geriatric and General Internal Medicine, Health Education, North East, UK Given the demographic changes in the population, is the argument to provide more elderly-specific teaching not now compelling?
I
t is well recognised that the population of developed countries, such as the UK, is ageing. This changing demographic presents health services with new challenges because of the complex care needs of many elderly patients. This tidal wave of ageing is in fact already upon us: twothirds of acute admissions to hospital are aged over 65 years, and it is hard to think of a specialty (paediatrics excluded) that is shielded from this sea change. Meeting the needs of the ageing population is not, therefore, solely the domain of a geriatrician. The recent UK ‘Shape of Training’ independent review highlighted the changes required in postgraduate training to ensure that doctors gain broader experience and are thus capable of providing more holistic general care.1 Although this was a UK-based report, its findings are of relevance to other developed countries, as their health services are likely to face similar challenges given the demographic shift. It is important that I declare a competing interest at this point – I am a trainee geriatrician who
finds the specialty challenging and hugely rewarding. But this hasn’t always been the case. Whilst an undergraduate I had no inkling that a career in geriatric medicine beckoned: paediatrics was where I saw myself headed. In fact, if I am truly honest, I am not sure that I was even aware that geriatric medicine was a specialty in its own right, until the later stages of my undergraduate training. It has been shown that some students are deterred from undertaking a career in geriatric medicine because of a perceived lack of prestige.2 Furthermore, some students at an early stage in their training were found to hold negative attitudes towards elderly patients.3 These two perceived deterrents didn’t apply to me, but thinking back I struggle to recall specific teaching on geriatric medicine topics whilst I was an undergraduate. Perhaps a lack of exposure to geriatric medicine in the curriculum might explain this? We know that undergraduate curricula are crowded, with each specialty arguing that their domain is the
most important, and that it should have greater representation. But, given the demographic changes in the population, is the argument to provide more elderly-specific teaching not now compelling? Serial survey work has highlighted how the undergraduate teaching of geriatric medicine has in fact expanded in recent years.4 Critically, so too has assessment, as it is well recognised that for many students what is ‘on the exam’ is considered to be the curriculum. Although this increase is encouraging, this survey showed that the proportion of time devoted to teaching on geriatric medicine remained low. This is particularly concerning when you consider that frail older people represent a significant proportion of doctors’ work. So what made me into a geriatrician? Put simply, the power of positive role modelling. A final-year placement on an elderly care ward brought me into contact with a number of inspirational geriatricians. Witnessing a geriatrician implement patientfocused management of a
210 © 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 210–211
tct_12278.indd 210
5/14/2015 7:39:35 AM
condition(s), rather than condition-focused management of the patient, opened my eyes to the essence of the specialty. As the famed medical educator William Osler once said,
‘It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has’.5 Over time I came to understand that doctors alone couldn’t resolve these patients’ complex problems, and that embracing multidisciplinary teamwork was the key to doing so: my conversion to an aspiring geriatrician was complete. Spreading an understanding of this multidisciplinary process (known as Comprehensive Geriatric Assessment) beyond geriatricians will be essential if the goals set out in the Shape of Training report are to be achieved. At a recent local training day for geriatric medicine trainees, I spoke to a number of fellow trainees about their decision to undertake a career in the specialty. None recalled holding an overwhelming desire to practice geriatric medicine whilst an undergraduate, but all were able to identify a positive role model who had strongly influenced their career preference. In a Canadian cross-sectional study that examined the impact of role models on medical students,6 it was demonstrated that a large proportion of students could identify a role model that they came into contact
with during the later stages of their medical school training. Furthermore, it was recognised that exposure to role models in a particular specialty area was strongly associated with medical students’ choice of clinical field for subsequent training. So, how can a clinical teacher act as a role model for a future generation of doctors? Firstly, having an insight into the power of positive role-modelling is critical, as well as an understanding that negative role-modelling can be an equally potent deterrent. Secondly, teaching skills were highlighted as being one of the most influential factors as to whether a clinician was perceived by their students to be a positive role model.6 Taking proactive steps to improve one’s teaching skills and making time to teach alongside clinical commitments may increase the likelihood of being considered a positive role model. As William Arthur Ward is quoted as saying:
The mediocre teacher tells. The good teacher explains. The superior teacher demonstrates. The great teacher inspires.7 In summary, the effects of the ageing global population are likely to be felt across almost all specialty areas, and thus all doctors require better training in how to care for complex elderly patients. Clinical teachers should be mindful that both positive and negative role-modelling can influence students’ career decisions. Those clinical teachers who deliver
high-quality teaching, whilst striving to continually develop their teaching skills, are more likely to be considered positive role models by their students. REFERENCES 1.
General Medical Council. Shape of Training Review: Securing the Future of Excellent Patient Care. Available at http://www.shapeoftraining. co.uk/static/documents/content/ Shape_of_training_FINAL_Report. pdf_53977887.pdf. Accessed on 17 March 2014.
2.
Robbins TD, Crocker-Buque T, Forrester-Paton C, Cantlay A, Gladman JR, Gordon AL. Geriatrics is rewarding but lacks earning potential and prestige: responses from the national medical student survey of attitudes to and perceptions of geriatric medicine. Age Ageing 2011;40:405–408.
3.
Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: a five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group. J Am Geriatr Soc 1995;43:1430–1436.
4.
Gordon AL, Blundell A, Dhesi JK, Forrester-Paton C, Forrester-Paton J, Mitchell HK, Bracewell N, Mjojo J, Masud T, Gladman JR. UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine. Age Ageing 2014;43:293–297.
5.
Bliss M. William Osler: A Life in Medicine. New York: Oxford University Press; 2007.
6.
Wright S, Wong A, Newill C. The Impact of Role Models on Medical Students. J Gen Intern Med 1997;12:53–56.
7.
Fred HL. The True Teacher. Tex Heart Inst J 2010;37:334–335.
Witnessing a geriatrician implement patient-focused management of a condition(s) ... opened my eyes to the essence of the specialty
Corresponding author’s contact details: James Fisher, Geriatric and General Internal Medicine, Health Education, North East, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Acknowledgements: None. Ethical approval: Ethical approval was not required. doi: 10.1111/tct.12278
© 2015 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2015; 12: 210–211 211
tct_12278.indd 211
5/14/2015 7:39:35 AM
