Journal of the Royal Society ofMedicine Volume 71 October 1978
711
The state of British medicine - 10
The teaching of geriatrics F I Caird DM FRCP University Department of Geriatric Medicine Southern General Hospital, Glasgow G51 4TF
In the past thirty years there has grown up, particularly in Great Britain, a body of knowledge about the skills required for the effective management of the medical problems of the elderly. This is now sufficiently large and detailed to require both time and instruction if it is to be acquired. Indeed, even the recent report of the Royal College of Physicians of London (1977) clearly, if somewhat half-heartedly and grudgingly, acknowledges the existence of the specialty of geriatrics, with as valid claims as any within the family of medical specialties. There follows a need to teach and to learn. The fact that geriatricians do not at present treat all conditions in all elderly patients cannot be used as evidence against the existence of a true specialty, any more than the equally obvious fact that not all cardiac or renal disorders are treated by cardiologists or nephrologists argues against the existence of these organ specialties. Geriatric medicine may be defined as 'that branch of medicine that deals with the clinical, psychological, rehabilitative and social problems of the elderly' (Anderson 1976). Many physicians maintain that because they are 'all geriatricians now' the diagnosis and management of disease in old age cannot require any special knowledge or expertise (Leonard 1976).-In fact the skills needed for proper geriatric practice are both clinical, in the widest sense, and managerial or administrative. The clinical skills include an appreciation, based on extensive practical experience, of the differing presentations of illness in old age (Caird & Judge 1973, Hodkinson 1976), of the confusing pictures produced by the almost universal occurrence of multiple pathology in the elderly, and of the problems presented by true age changes in human physiology (Shock 1968). A confident knowledge of the clinical psychiatry of old age is vital (Slater & Roth 1969, Pitt 1974, Whitehead 1974), because neuropsychiatric disorders are the commonest cause of disability in the elderly (Akhtar et al. 1973), and because psychological factors colour all the manifestations of disease in old age, and even m-ore its management. An understanding of the similarities and differences between the findings on haematological, biochemical, radiological and other investigations in the elderly and middle-aged is also essential, to allow a rational approach to such investigations and their interpretation (Caird 1973, 1978, Hodkinson 1977). Thus for instance, to regard an iron-deficiency anaemia in an old person as necessarily highly likely to be of nutritional origin may be to deny the patient gastrointestinal investigation, and so perhaps the diagnosis and treatment of an eminently remediable neoplasm. Conversely, to undertake detailed investigation of an abdominal mass in an elderly patient with advanced dementia may entail the opposite error, since the outcome of the investigations could not reveal a condition more serious than the already apparent mental
disorder. In the field of treatment, a knowledge ofthe special problems of drug therapy in the elderly is vital. The indications for and doses of many drugs are radically altered in the elderly, and
712
Journal of the Royal Society of Medicine Volume 71 October 1978
almost all side-effects more frequent (Judge & Caird 1977, Caird 1977). The avoidance of iatrogenic disease is imperative. Equally important are the clinical and organizational aspects of rehabilitation, particularly of the patient with stroke (Adams 1974). It may be that geriatricians should not be especially concerned with stroke rehabilitation, but the fact is that they are, partly because the incidence of stroke increases exponentially with age, but largely and regrettably by default of any other deeply interested parties. It is not enough for the geriatrician to know that 'physiotherapy and rehabilitation should be started as soon as practicable' (Marshall 1977). The scope and limitations of physiotherapy, occupational therapy, and speech therapy (Williams et al. 1977) require time and experience to learn, and there is little doubt that most geriatricians have learnt more of practical value from their paramedical colleagues than they might care to admit. Practical experience in simple medical administration and a grasp of the skills required to organize services both for the individual elderly patient and for the large number of beds under the geriatrician's care are further essentials, since these are not matters that can be safely left entirely to others. The close contact between the geriatrician and both local authority services for old people and voluntary bodies concerned with the welfare of the elderly necessitate an appreciation both of the scope of their activities and of the factors that limit their effectiveness. The range of skills needing to be learnt is thus considerable, and extends well beyond those conventionally taught to most doctors in training. Yet the increasing numbers of old people, particularly the very old, and the increasing demands they inevitably make, and will continue to make, on the health and welfare services make it essential that all doctors should now be aware of these skills. To whom then should they be taught, and how, and when? There can be no doubt that an introduction to the principles of modern geriatric medicine must be a part of the education of all medical students. That this is so has been recognized by the institution of Chairs of Geriatric Medicine, of which there are now 10 in medical schools in the United Kingdom, and by the active participation of geriatricians in the undergraduate curriculum in most of the remainder. There may be argument about how this participation should be organized, and what are the main points that require to be taught. The first principle is undoubtedly the difference between the medicine of old age and that of middle age, in the presentation of disease, in its management with special reference to drug therapy, and in its psychological and social aspects, together with a clear indication of what geriatric units and geriatric services have to offer their patients, and thus what should be the reasons for referring a patient to the geriatrician. These topics can be covered in a lecture-demonstration course, but standard bedside clinical teaching is also invaluable. There is no difficulty in making the medicine of old age as interesting as cardiology or neurology, especially as most students have a natural aptitude in communicating with and relating to the elderly. There may also be debate as to the most satisfactory time in the undergraduate curriculum for the participation of geriatricians. Considerable knowledge of clinical medicine may be regarded as a prerequisite, but experience in Glasgow, where geriatrics has for six years been taught in the first clinical year, shows that this is not necessarily so. The wide range of problems presented by the elderly and the fact that the needs of many of them require commonsense solutions rather than a detailed knowledge of clinical and investigational minutiae, make it appropriate to expose students to them at an early rather than a late stage in their undergraduate career. Gale & Livesley (1974) have clearly shown how students tend to be diverted from an interest in the problems of the elderly in their later clinical years. Though undergraduate instruction is undoubtedly the most important single part of the teaching of the specialty, because some knowledge at least is needed by all doctors, there are four groups who require postgraduate instruction and experience. These are: (1) those intending to specialize in geriatric medicine, whether as 'pure' geriatricians or 'physicians with an interest'; (2) physicians in general, because unless they are paediatricians the majority of their work for the remainder of their professional lives will inevitably be concerned with the elderly; (3) general practitioners, for the same reason; and (4) community physicians. The training of the specialist geriatrician remains a matter of some controversy. Most
Journal of the Royal Society ofMedicine Volume 71 October 1978
713
geriatricians currently in practice have experienced training based on Squeers' apprenticeship principles'; these perhaps have more to recommend them than is ordinarily credited to that maligned pedagogue. The most satisfactory training for a newly qualified doctor who sees his future in geriatric medicine is not greatly in doubt. He should take a senior house officer post in an active geriatric unit, to make certain that he is temperamentally fitted to work with old people. He should then gain experience in general medicine, and there acquire the basic clinical expertise, and then return to geriatrics as a senior registrar, to learn in particular the skills in rehabilitation and management that have been outlined above. But other paths leading to the same goal should never disqualify. There can be no doubt that all physicians of the future will need a knowledge of modern geriatric practice, if their patients are to receive optimum treatment., Rotational schemes at registrar level would seem a natural and relatively simple method of ensuring this, but it may well be that the most effective single way of ensuring at least a book knowledge of the subject would be the introduction into the MRCP examination of a reasonable number of questions in geriatrics. It is much to be hoped that this will soon happen (Royal College of Physicians 1978). The requirements of general practitioners are somewhat different. Some vocational training programmes include a period spent in a geriatric unit, but there may be difficulties in integrating the trainee into the working of the unit. What needs to be taught is what the specialist geriatric unit, and the facilities it contains, has to offer to the general practitioner and his patients. The reasons for referral of patients by general practitioners to geriatric units remain unclear (Kennedy & Acland 1976) and it seems probable that the main reason for this uncertainty is a lack of a clear knowledge of the type of problem presented by their elderly patients that is most likely to be helped by such referral. The community physician similarly requires knowledge of what services are available to the elderly population under his care, of what the implications of the demographic state of that population are for the planning of such services, both now and in the future, and of the administrative and practical aspects of collaboration between geriatric and psychiatric services, and between health and local authority services. A community physician who does not know how many old people's homes there are in his district, and indeed has never been inside one, would seem lacking in training in an important aspect of his specialty. The conventional clinical methods of teaching, at the bedside, in outpatient clinics, in day hospitals, and most importantly in patients' homes, can all be effectively used in both undergraduate and postgraduate teaching. A number of centres in the United Kingdom have for several years run formal courses in geriatric medicine. These may attempt a wide coverage of the field, or concentrate on one particular aspect. They have been of value especially to general practitioners and community physicians. National and regional meetings of the British Geriatrics Society also play an important part, particularly for the specialist. In addition, there are now a considerable number of books at a variety of levels dealing with a variety of topics in geriatrics. They include a major multi-author textbook (Brocklehurst 1973), a number of student and introductory texts (Anderson 1976, Brocklehurst & Hanley 1976, Caird & Judge 1973, Hodkinson 1975, 1976, Coni et al. 1977, Adams 1977), and monographs dealing with particular aspects of the medicine of old age (Harris 1970, Thomas & Powell 1971, Verbov 1974, Adams 1974, Caird et al. 1976, Willington 1976, Devas 1977, Hodkinson 1977). The latter should be considered of interest to geriatrician and organ specialist alike, since their aim is to set out both the present state of scientific knowledge and the practical details of management of elderly patients in their respective fields. Geriatrics involves many workers in the health care field in addition to doctors, and there are thus many others who are in need of teaching in the principles and practice of modern geriatric medicine. These include, first and foremost, nurses, and also physiotherapists, occupational ''We go upon the practical mode of teaching, Nickleby; the regular education system. C-l-e-a-n, clean, verb active, to make bright, to scour. W-i-n, win, d-e-r, der, winder, a casement. When the boy knows this out of book, he goes and does it.' (Dickens C, 1838, Nicholas Nickleby; Ch. 8)
714
Journal of the Royal Society of Medicine Volume 71 October 1978
therapists, and social workers. The absence of a compulsory period of geriatrics in the course of nursing training in recent years (Committee on Nursing 1972) is evidence of a remarkable narrowness of vision. This must derive from a fundamental misapprehension of the realities of modern health care, since there can be no doubt that the nursing of the elderly is the real nursing of both the present and the future, and presents challenges which cannot be ignored and will not disappear. Not only is a large part of the nursing profession already engaged in geriatric nursing (and a greater part will be in the future), but the majority of all patients in hospital are elderly, and the major part of the time of nurses in the community is taken up with the elderly. Yet all geriatricians will have experience of nurses trained in the best schools whose appreciation of the practice and rewards of geriatric nursing is slight, and who recognize their lack of training in this important field. Though there is no substitute for practical experience, there are now a number of excellent textbooks of geriatrics for nurses of all grades, and of specialized geriatric nursing (Irvine et al. 1970, Rudd 1970, Schwartz et al. 1964). There is a similar tendency to regard exposure to the problems of the elderly in geriatric units as unsuitable for physiotherapists and occupational therapists in training (Peach 1978). Yet, as with nursing, the involvement of both these therapists in the care of the elderly is already large, and continues to increase. A greater appreciation of reality, and of the central place of physiotherapy and occupational therapy in modern geriatric rehabilitation, must lead to a recognition of the need for formal teaching of geriatrics in this vital field. The 'generic' social worker may also be denied any formal exposure to teaching in the social problems of the elderly. Luckily social workers with experience in these matters have not entirely disappeared from the hospital service, and there must be some hope that in the next few years the need for specialists with real knowledge of particular problems, such as those of old age, will become sufficiently apparent to be acted upon. There are few more difficult, more interesting, or more rewarding aspects of social work than that for the elderly, and it remains for teachers to make this plain to their students. Finally, many others concerned with the elderly are in need of teaching, not perhaps in geriatrics (except to demonstrate that the word does not deserve the reputation it acquired in the workhouses of thirty years ago, and has not yet altogether lost) but more in understanding the needs of the elderly. These include home help supervisors and home helps themselves, and workers in old people's homes, all of whom need to be able at least to recognize the warning signs of remediable physical and psychological disorders in the old people with whom they come into contact. In conclusion, if the body of knowledge and the particular skills involved in the modern health care of the elderly are recognized as being the foundation of a true specialty, then its teaching is a matter of growing importance to all concerned with medicine in its broadest sense, and should be a part of the basic education of all doctors, and of many others, in addition to the need of many for detailed, indeed truly specialist training. References Adams G F (1974) Cerebrovascular Disability and the Ageing Brain. Churchill Livingstone, Edinburgh Adams G F (1977) Essentials of Geriatric Medicine. Oxford University Press, London Akhtar A J, Broe GA, Crombie A, McLean W M R, Andrews G R & Caird F 1 (1973) Age and Ageing 2, 102-111 Anderson W F (1976) The Practical Management of the Elderly. 3rd edn. Blackwell Scientific, Oxford Brocklehurst J C (ed) (1973) Textbook of Geriatric Medicine and Gerontology. Churchill Livingstone, Edinburgh Brocklehurst J C & Hanley T (1976) Geriatric Medicine for Students. Churchill Livingstone, Edinburgh Caird F I (1973) British Medical Journal iv, 378-381 Caird F I (1977) British Journal of Hospital Medicine 18, 610-613 Caird F 1 (1978) Medicine (Oxford), 3rd series 1, 15-19 Caird F 1, Dall J L C & Kennedy R D (1976) Cardiology in Old Age. Plenum, New York Caird F I & Judge T G (1973) The Assessment of the Elderly Patient. Pitman Medical, London Committee on Nursing (1972) Report of the Committee on Nursing, Cmnd 5115. HMSO, London Coni N, Davidson W & Webster S (1977) Lecture Notes on Geriatrics. Blackwell Scientific, Oxford Devas M (ed) (1977) Geriatric Orthopaedics. Academic Press, London Gale J & Livesley B (1974) Age and Ageing 3, 39-43
Journal of the Royal Society of Medicine Volume 71 October 1978
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Harris R (1970) The Management of Geriatric Cardiovascular Disease. Lippincott, Philadelphia Hodkinson H M (1975) An Outline of Geriatrics. Academic Press, London Hodkinson H M (1976). Common Symptoms of Disease in the Elderly. Blackwell Scientific, Oxford Hodkinson H M (1977) Biochemical Investigation in Diagnosis and Treatment of the Elderly. Chapman & Hall, London Irvine R E, Bagnall M K & Smith B J (1970) The Older Patient. 2nd edn. English University Press, London Judge T G & Caird F 1 (1977) Drug Treatment of the Elderly Patient. Pitman Medical, London Kennedy R D & Acland S M S (1976) Health Bulletin 34, 320-324 Leonard J C (1976) British Medical Journal i, 1335-6 Marshall J (1977) Medicine (Oxford), 2nd series 34, 2018-2033 McKeown F (1965) Pathology of the Aged. Butterworths, London Peach H (1978) Age and Ageing 7, 57-61 Pitt B (1974) Psychogeriatrics. Churchill Livingstone, Edinburgh Royal College of Physicians (1977) Medical Care of the Elderly. Report of a Working Party. London Royal College of Physicians (1978) British Medical Journal i, 217-220 Rudd T N (1970) The Nursing of the Elderly Sick. 6th edn. Faber and Faber, London Schwartz D, Henley B & Zeitz L (1964) The Elderly Ambulatory Patient. Macmillan, New York Shock N W (1968) In: Surgery of the Aged and Debilitated Patient. Ed. J H Powers. Saunders, Philadelphia; pp 10-43 Slater E & Roth M (1969) Clinical Psychiatry. 3rd edn. Bailliere Tindall & Cassell, London Thomas J H & Powell D E B (1971) Blood Disorders in the Elderly. Wright, Bristol Verbov J (1974) Skin Diseases in the Elderly. Heinemann Medical, London Whitehead J M (1974) Psychiatric Disorders in Old Age. Harvey Miller and Medcalf, Aylesbury Williams B 0, Walker S & Dall J L C (1977) Age and Ageing 6, 96-103 Willington F L (ed) (1976) Incontinence in the Elderly. Academic Press, London
711
The state of British medicine - 10
The teaching of geriatrics F I Caird DM FRCP University Department of Geriatric Medicine Southern General Hospital, Glasgow G51 4TF
In the past thirty years there has grown up, particularly in Great Britain, a body of knowledge about the skills required for the effective management of the medical problems of the elderly. This is now sufficiently large and detailed to require both time and instruction if it is to be acquired. Indeed, even the recent report of the Royal College of Physicians of London (1977) clearly, if somewhat half-heartedly and grudgingly, acknowledges the existence of the specialty of geriatrics, with as valid claims as any within the family of medical specialties. There follows a need to teach and to learn. The fact that geriatricians do not at present treat all conditions in all elderly patients cannot be used as evidence against the existence of a true specialty, any more than the equally obvious fact that not all cardiac or renal disorders are treated by cardiologists or nephrologists argues against the existence of these organ specialties. Geriatric medicine may be defined as 'that branch of medicine that deals with the clinical, psychological, rehabilitative and social problems of the elderly' (Anderson 1976). Many physicians maintain that because they are 'all geriatricians now' the diagnosis and management of disease in old age cannot require any special knowledge or expertise (Leonard 1976).-In fact the skills needed for proper geriatric practice are both clinical, in the widest sense, and managerial or administrative. The clinical skills include an appreciation, based on extensive practical experience, of the differing presentations of illness in old age (Caird & Judge 1973, Hodkinson 1976), of the confusing pictures produced by the almost universal occurrence of multiple pathology in the elderly, and of the problems presented by true age changes in human physiology (Shock 1968). A confident knowledge of the clinical psychiatry of old age is vital (Slater & Roth 1969, Pitt 1974, Whitehead 1974), because neuropsychiatric disorders are the commonest cause of disability in the elderly (Akhtar et al. 1973), and because psychological factors colour all the manifestations of disease in old age, and even m-ore its management. An understanding of the similarities and differences between the findings on haematological, biochemical, radiological and other investigations in the elderly and middle-aged is also essential, to allow a rational approach to such investigations and their interpretation (Caird 1973, 1978, Hodkinson 1977). Thus for instance, to regard an iron-deficiency anaemia in an old person as necessarily highly likely to be of nutritional origin may be to deny the patient gastrointestinal investigation, and so perhaps the diagnosis and treatment of an eminently remediable neoplasm. Conversely, to undertake detailed investigation of an abdominal mass in an elderly patient with advanced dementia may entail the opposite error, since the outcome of the investigations could not reveal a condition more serious than the already apparent mental
disorder. In the field of treatment, a knowledge ofthe special problems of drug therapy in the elderly is vital. The indications for and doses of many drugs are radically altered in the elderly, and
712
Journal of the Royal Society of Medicine Volume 71 October 1978
almost all side-effects more frequent (Judge & Caird 1977, Caird 1977). The avoidance of iatrogenic disease is imperative. Equally important are the clinical and organizational aspects of rehabilitation, particularly of the patient with stroke (Adams 1974). It may be that geriatricians should not be especially concerned with stroke rehabilitation, but the fact is that they are, partly because the incidence of stroke increases exponentially with age, but largely and regrettably by default of any other deeply interested parties. It is not enough for the geriatrician to know that 'physiotherapy and rehabilitation should be started as soon as practicable' (Marshall 1977). The scope and limitations of physiotherapy, occupational therapy, and speech therapy (Williams et al. 1977) require time and experience to learn, and there is little doubt that most geriatricians have learnt more of practical value from their paramedical colleagues than they might care to admit. Practical experience in simple medical administration and a grasp of the skills required to organize services both for the individual elderly patient and for the large number of beds under the geriatrician's care are further essentials, since these are not matters that can be safely left entirely to others. The close contact between the geriatrician and both local authority services for old people and voluntary bodies concerned with the welfare of the elderly necessitate an appreciation both of the scope of their activities and of the factors that limit their effectiveness. The range of skills needing to be learnt is thus considerable, and extends well beyond those conventionally taught to most doctors in training. Yet the increasing numbers of old people, particularly the very old, and the increasing demands they inevitably make, and will continue to make, on the health and welfare services make it essential that all doctors should now be aware of these skills. To whom then should they be taught, and how, and when? There can be no doubt that an introduction to the principles of modern geriatric medicine must be a part of the education of all medical students. That this is so has been recognized by the institution of Chairs of Geriatric Medicine, of which there are now 10 in medical schools in the United Kingdom, and by the active participation of geriatricians in the undergraduate curriculum in most of the remainder. There may be argument about how this participation should be organized, and what are the main points that require to be taught. The first principle is undoubtedly the difference between the medicine of old age and that of middle age, in the presentation of disease, in its management with special reference to drug therapy, and in its psychological and social aspects, together with a clear indication of what geriatric units and geriatric services have to offer their patients, and thus what should be the reasons for referring a patient to the geriatrician. These topics can be covered in a lecture-demonstration course, but standard bedside clinical teaching is also invaluable. There is no difficulty in making the medicine of old age as interesting as cardiology or neurology, especially as most students have a natural aptitude in communicating with and relating to the elderly. There may also be debate as to the most satisfactory time in the undergraduate curriculum for the participation of geriatricians. Considerable knowledge of clinical medicine may be regarded as a prerequisite, but experience in Glasgow, where geriatrics has for six years been taught in the first clinical year, shows that this is not necessarily so. The wide range of problems presented by the elderly and the fact that the needs of many of them require commonsense solutions rather than a detailed knowledge of clinical and investigational minutiae, make it appropriate to expose students to them at an early rather than a late stage in their undergraduate career. Gale & Livesley (1974) have clearly shown how students tend to be diverted from an interest in the problems of the elderly in their later clinical years. Though undergraduate instruction is undoubtedly the most important single part of the teaching of the specialty, because some knowledge at least is needed by all doctors, there are four groups who require postgraduate instruction and experience. These are: (1) those intending to specialize in geriatric medicine, whether as 'pure' geriatricians or 'physicians with an interest'; (2) physicians in general, because unless they are paediatricians the majority of their work for the remainder of their professional lives will inevitably be concerned with the elderly; (3) general practitioners, for the same reason; and (4) community physicians. The training of the specialist geriatrician remains a matter of some controversy. Most
Journal of the Royal Society ofMedicine Volume 71 October 1978
713
geriatricians currently in practice have experienced training based on Squeers' apprenticeship principles'; these perhaps have more to recommend them than is ordinarily credited to that maligned pedagogue. The most satisfactory training for a newly qualified doctor who sees his future in geriatric medicine is not greatly in doubt. He should take a senior house officer post in an active geriatric unit, to make certain that he is temperamentally fitted to work with old people. He should then gain experience in general medicine, and there acquire the basic clinical expertise, and then return to geriatrics as a senior registrar, to learn in particular the skills in rehabilitation and management that have been outlined above. But other paths leading to the same goal should never disqualify. There can be no doubt that all physicians of the future will need a knowledge of modern geriatric practice, if their patients are to receive optimum treatment., Rotational schemes at registrar level would seem a natural and relatively simple method of ensuring this, but it may well be that the most effective single way of ensuring at least a book knowledge of the subject would be the introduction into the MRCP examination of a reasonable number of questions in geriatrics. It is much to be hoped that this will soon happen (Royal College of Physicians 1978). The requirements of general practitioners are somewhat different. Some vocational training programmes include a period spent in a geriatric unit, but there may be difficulties in integrating the trainee into the working of the unit. What needs to be taught is what the specialist geriatric unit, and the facilities it contains, has to offer to the general practitioner and his patients. The reasons for referral of patients by general practitioners to geriatric units remain unclear (Kennedy & Acland 1976) and it seems probable that the main reason for this uncertainty is a lack of a clear knowledge of the type of problem presented by their elderly patients that is most likely to be helped by such referral. The community physician similarly requires knowledge of what services are available to the elderly population under his care, of what the implications of the demographic state of that population are for the planning of such services, both now and in the future, and of the administrative and practical aspects of collaboration between geriatric and psychiatric services, and between health and local authority services. A community physician who does not know how many old people's homes there are in his district, and indeed has never been inside one, would seem lacking in training in an important aspect of his specialty. The conventional clinical methods of teaching, at the bedside, in outpatient clinics, in day hospitals, and most importantly in patients' homes, can all be effectively used in both undergraduate and postgraduate teaching. A number of centres in the United Kingdom have for several years run formal courses in geriatric medicine. These may attempt a wide coverage of the field, or concentrate on one particular aspect. They have been of value especially to general practitioners and community physicians. National and regional meetings of the British Geriatrics Society also play an important part, particularly for the specialist. In addition, there are now a considerable number of books at a variety of levels dealing with a variety of topics in geriatrics. They include a major multi-author textbook (Brocklehurst 1973), a number of student and introductory texts (Anderson 1976, Brocklehurst & Hanley 1976, Caird & Judge 1973, Hodkinson 1975, 1976, Coni et al. 1977, Adams 1977), and monographs dealing with particular aspects of the medicine of old age (Harris 1970, Thomas & Powell 1971, Verbov 1974, Adams 1974, Caird et al. 1976, Willington 1976, Devas 1977, Hodkinson 1977). The latter should be considered of interest to geriatrician and organ specialist alike, since their aim is to set out both the present state of scientific knowledge and the practical details of management of elderly patients in their respective fields. Geriatrics involves many workers in the health care field in addition to doctors, and there are thus many others who are in need of teaching in the principles and practice of modern geriatric medicine. These include, first and foremost, nurses, and also physiotherapists, occupational ''We go upon the practical mode of teaching, Nickleby; the regular education system. C-l-e-a-n, clean, verb active, to make bright, to scour. W-i-n, win, d-e-r, der, winder, a casement. When the boy knows this out of book, he goes and does it.' (Dickens C, 1838, Nicholas Nickleby; Ch. 8)
714
Journal of the Royal Society of Medicine Volume 71 October 1978
therapists, and social workers. The absence of a compulsory period of geriatrics in the course of nursing training in recent years (Committee on Nursing 1972) is evidence of a remarkable narrowness of vision. This must derive from a fundamental misapprehension of the realities of modern health care, since there can be no doubt that the nursing of the elderly is the real nursing of both the present and the future, and presents challenges which cannot be ignored and will not disappear. Not only is a large part of the nursing profession already engaged in geriatric nursing (and a greater part will be in the future), but the majority of all patients in hospital are elderly, and the major part of the time of nurses in the community is taken up with the elderly. Yet all geriatricians will have experience of nurses trained in the best schools whose appreciation of the practice and rewards of geriatric nursing is slight, and who recognize their lack of training in this important field. Though there is no substitute for practical experience, there are now a number of excellent textbooks of geriatrics for nurses of all grades, and of specialized geriatric nursing (Irvine et al. 1970, Rudd 1970, Schwartz et al. 1964). There is a similar tendency to regard exposure to the problems of the elderly in geriatric units as unsuitable for physiotherapists and occupational therapists in training (Peach 1978). Yet, as with nursing, the involvement of both these therapists in the care of the elderly is already large, and continues to increase. A greater appreciation of reality, and of the central place of physiotherapy and occupational therapy in modern geriatric rehabilitation, must lead to a recognition of the need for formal teaching of geriatrics in this vital field. The 'generic' social worker may also be denied any formal exposure to teaching in the social problems of the elderly. Luckily social workers with experience in these matters have not entirely disappeared from the hospital service, and there must be some hope that in the next few years the need for specialists with real knowledge of particular problems, such as those of old age, will become sufficiently apparent to be acted upon. There are few more difficult, more interesting, or more rewarding aspects of social work than that for the elderly, and it remains for teachers to make this plain to their students. Finally, many others concerned with the elderly are in need of teaching, not perhaps in geriatrics (except to demonstrate that the word does not deserve the reputation it acquired in the workhouses of thirty years ago, and has not yet altogether lost) but more in understanding the needs of the elderly. These include home help supervisors and home helps themselves, and workers in old people's homes, all of whom need to be able at least to recognize the warning signs of remediable physical and psychological disorders in the old people with whom they come into contact. In conclusion, if the body of knowledge and the particular skills involved in the modern health care of the elderly are recognized as being the foundation of a true specialty, then its teaching is a matter of growing importance to all concerned with medicine in its broadest sense, and should be a part of the basic education of all doctors, and of many others, in addition to the need of many for detailed, indeed truly specialist training. References Adams G F (1974) Cerebrovascular Disability and the Ageing Brain. Churchill Livingstone, Edinburgh Adams G F (1977) Essentials of Geriatric Medicine. Oxford University Press, London Akhtar A J, Broe GA, Crombie A, McLean W M R, Andrews G R & Caird F 1 (1973) Age and Ageing 2, 102-111 Anderson W F (1976) The Practical Management of the Elderly. 3rd edn. Blackwell Scientific, Oxford Brocklehurst J C (ed) (1973) Textbook of Geriatric Medicine and Gerontology. Churchill Livingstone, Edinburgh Brocklehurst J C & Hanley T (1976) Geriatric Medicine for Students. Churchill Livingstone, Edinburgh Caird F I (1973) British Medical Journal iv, 378-381 Caird F I (1977) British Journal of Hospital Medicine 18, 610-613 Caird F 1 (1978) Medicine (Oxford), 3rd series 1, 15-19 Caird F 1, Dall J L C & Kennedy R D (1976) Cardiology in Old Age. Plenum, New York Caird F I & Judge T G (1973) The Assessment of the Elderly Patient. Pitman Medical, London Committee on Nursing (1972) Report of the Committee on Nursing, Cmnd 5115. HMSO, London Coni N, Davidson W & Webster S (1977) Lecture Notes on Geriatrics. Blackwell Scientific, Oxford Devas M (ed) (1977) Geriatric Orthopaedics. Academic Press, London Gale J & Livesley B (1974) Age and Ageing 3, 39-43
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