Training in Geriatric Medicine and the Curriculum Dr Oliver J Corrado

Training in Geriatric Medicine
and the Curriculum
Dr Oliver J Corrado
Consultant Physician and Chair
SAC in Geriatric Medicine

• Background information
• The Training Pathway in Geriatric Medicine
• The Higher Training (Registrar) Curriculum in Geriatric
Medicine
• The Specialist Certificate Examination (SCE)
in Geriatric Medicine

The Start of Geriatric Medicine
• 1936 Dr Marjory Warren
• Isleworth workhouse, with
rehab and equipment
discharged many residents
• Advocated creating the
specialty ‘Geriatrics’
• 1948 NHS appointed first
consultants

Consultant Numbers in UK by Specialty (2009)
Specialty
Consultants in UK
Geriatric Medicine 1205
Gastroenterology 995
Respiratory 859
Cardiology 856
Haematology 843
Diabetes and Endo 742
Rheumatology 640
Neurology 633

Registrar Numbers in UK by Specialty
Specialty
Registrars in UK
Cardiology 685
Respiratory 624
Geriatric Medicine 607
Gastroenterology 555
Diabetes and Endo 405

Training Pathways in Medical Specialties
• 2005 major change in UK postgraduate training
‘Modernising Medical Careers’
‘Old System’
1 year : Pre-registration House Officer
(6 months medicine and 6 months surgery)
2-3years: Medical SHO training obtain MRCP
Then
: Registrar Training (variable period, 5 years
for dual training in Geriatric and GIM)

Training Pathways in Medical Specialties
‘New System’
2 year mandatory:
Foundation Training before GP or specialty training.
(6 posts of 4 months, different specialties and settings)
Work place based assessment of competence
2-3 years: Core Medical or Acute Care Common Stem
trainee (similar to SHO) obtain MRCP (at least
Part 1)
Then:
Specialty Registrar training 5 yrs to complete for
Geriatric and GIM and obtain CCT

The Curriculum
• Foundation (generic not specialty specific)
• Core Medical (for all medical specialties)
• Higher Specialist (Registrar) Training
(specialty specific)

The Geriatric Medicine Registrar Curriculum
Aim of the curriculum is to provide the trainee with
necessary, knowledge, skills and behaviours to
practise as a specialist in geriatric medicine in any
clinical setting:
• Undertake comprehensive assessment of an older
person, including mood, cognition, gait and nutrition
• Diagnose and manage acute illness in old age
• Diagnose and manage patients with chronic disease
and disability
• Supervise older patients’ rehabilitation with a
multidisciplinary team

The Geriatric Medicine Registrar Curriculum
• Discharge planning
• Provide appropriate care to those in long term (continuing care) in
the NHS or community
• Have the skills to manage patients in a community or intermediate
care setting
• Assess and manage older patients presenting with common
geriatric problems including
• Falls with or without fracture
• Delirium
• Incontinence
• Poor mobility

The Geriatric Medicine Registrar Curriculum
• To demonstrate competence in the following topics:
• Palliative care
• Orthogeriatrics
• Old Age Psychiatry including dementia and depression
• Stroke care (acute and rehabilitation) and TIAs
• Movement disorders eg Parkinson’s disease
• Understand principles of health promotion, nutrition, tissue
viability, homeostasis and thermoregulation
• Generic skills: Medical Leadership, team working, communication,
Patient Safety, medical ethics

Assessing Competence: Work Place Based
Assessments (WPBAs)
Trainees’ competence assessed using a variety of work place based
assessments:
• Multi-source feedback (MSF)
Assesses generic skills such as communication, leadership and team
working. Feedback of a trainee’s performance from different health
professionals.
• Mini-Clinical Evaluation Exercise (Mini-CEX)
Evaluates a patient clinical encounter to assess competence in skills
such as history taking, examination. Can be used in any setting.
• Direct Observation of Procedural Skills (DOPS)
Evaluate ability to undertake practical procedures, not as relevant in
Geriatric Medicine)

Assessing Competence: Work Place Based
Assessments (WPBAs)
• Case-based Discussion (CbD)
Assesses competence in areas such as clinical reasoning,
decision-making and application of knowledge to patient care.
• Acute Care Assessment Tool (ACAT)
Assesses a doctor's performance during their practice on the
Acute Medical Take.
• Patient Survey (PS)
• Audit Assessment (AA)
• Teaching Observation (TO)
WPBAs entail a lot of work for consultants!

Specialty Certificate Examinations (SCEs)
• SCEs introduced by the Federation of Royal Colleges of
Physicians for larger medical specialties in 2008
(Cardiology organising its own exam)
To ensure that certified specialists have sufficient
knowledge of their specialty to practice safely and
competently as consultants
• SCE is taken after MRCP (UK) generally 3 rd /4 th year of
Registrar training
• Gastroenterology first specialty to hold exam in 2008,
Geriatric Medicine the second March 2009

Specialty Certificate Examinations (SCEs)
• The SCE is ‘blueprinted’ against the Curriculum in
Geriatric Medicine
• The SCE is a computer-based two-paper test with a total
of 200 questions. Each paper contains 100 questions
and lasts three hours. Questions are based on the
MRCP(UK) ‘best of five’ multiple choice question format.

SCE Sample ‘Best of Five’ Questions
Sample questions for many specialties available free
via MRCPuk.org site
http://www.mrcpuk.org/SCE/Specialties
Free online educational resource with Geriatric Medicine
questions (Educational Resource on Ageing (ERA)) hosted
by University of Dundee
http://www.dundee.ac.uk/learning/era/eraindex.htm

SCE Example ‘Best of Five’ Questions
An 82-year-old woman had a 3 year history of urinary frequency, with a
sudden desire to urinate at times associated with incontinence, but no
dysuria. She was on no medication and there were no abnormal
findings on examination. Mid stream urine specimen was negative.
The most likely cause for her symptoms is:
A atonic bladder
B autonomic neuropathy
C overflow incontinence
D overactive bladder syndrome
E pelvic floor weakness
Answer: ?

SCE Example ‘Best of Five’ Questions
An 82-year-old woman had a 3 year history of urinary frequency, with a
sudden desire to urinate at times associated with incontinence, but no
dysuria. She was on no medication and there were no abnormal
findings on examination. Mid stream urine specimen was negative.
The most likely cause for her symptoms is:
A atonic bladder
B autonomic neuropathy
C overflow incontinence
D overactive bladder syndrome
E pelvic floor weakness
Answer: D

SCE Example ‘Best of Five’ Questions
An 84-year-old man had a 3 year progressive decline in memory. His
wife was now having to help him dress and said that for 2 years he had
seen ‘animals and people which were not there’ and that his gait had
become ‘shuffly’. He had slight rigidity in his upper limbs and his
Mini Mental State Examination MMSE was 19/30.
Routine bloods, CXR, ECG and MSU were all normal.
What is the most likely diagnosis?
A Alzheimer’s disease
B Lewy body dementia
C Low pressure hydrocephalus
D Neurosyphilis
E Vascular dementia
Answer: ?

SCE Example ‘Best of Five’ Questions
An 84-year-old man had a 3 year progressive decline in memory. His
wife was now having to help him dress and said that for 2 years he had
seen ‘animals and people which were not there’ and that his gait had
become ‘shuffly’. He had slight rigidity in his upper limbs and his MMSE
was 19/30. Routine bloods, CXR, ECG and MSU were all normal.
What is the most likely diagnosis?
A Alzheimer’s disease
B Lewy body dementia
C Low pressure hydrocephalus
D Neurosyphilis
E Vascular dementia
Answer: B

SCE Example ‘Best of Five’ Questions
Human progeria syndromes are considered to represent a human
model of accelerated ageing
What is the most characteristic feature observed in this condition?
A cardiovascular disease in teenage years
B cataract formation
C cognitive decline
D normal weight gain in infant years
E osteoarthritis
Answer: ?

SCE Example ‘Best of Five’ Questions
Human progeria syndromes are considered to represent a human
model of accelerated ageing
What is the most characteristic feature observed in this condition?
A cardiovascular disease in teenage years
B cataract formation
C cognitive decline
D normal weight gain in infant years
E osteoarthritis
Answer: A

Thank You and Questions?