Consultant physicians working with patients - Royal College of ...

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2 Specialties Geriatric medicinePromoting health and self careSpecialist elderly services should develop a culture ofhealth promotion alongside disease management andrehabilitation. Geriatricians should discuss healthpromotion and preventative healthcare programmes,which should be regarded as a legitimate subspecialty,with commissioning boards. Health promotion postersand literature specifically directed at this age groupshould be readily available in patient-contact areas.4 Interspecialty and interdisciplinary liaisonConsultants in geriatric medicine pioneered the conceptof interdisciplinary teams, working to ensure thatmedical illness and functional capacity in older peopleare assessed and treated. It is the essence of goodpractice in acute assessment and rehabilitation settingsfor the consultant to lead at least one interdisciplinarycase conference per week. Such teamworking with alliedhealth professionals, social workers and communitystaff, based on multiple individual assessments that leadto comprehensive geriatric assessment (CGA), is thehallmark of a high-quality service. Case conferencesmaybelessfrequentinlong-termcare.5 Delivering a high-quality serviceA high-quality service is defined as early access to anMDT, led by a geriatrician specialising in thecomprehensive assessment of older people. This can bein an acute hospital, day hospital or outpatient setting,with subsequent access to further specialist input whenindicated. Community rehabilitation and crisisintervention teams should be based on aninterdisciplinary model with specialist medicalinvolvement.Quality tools and frameworksRelevant quality standards should be adhered to, such asthe National Institute for Health and Care Excellence(NICE) quality standards in England, and relevantoutcomes measures achieved. Particular attentionshould be paid to stroke, 3,4 dementia and falls;pathways should be in place to assess and addresscontinence and poor nutrition. 5 In addition to nationalpolicies, the British Geriatrics Society (BGS) hasguidelines, policy statements and statements of goodpractice for many aspects of the care of older people. 6Education, training and support programmes fornon-specialist wards and clinicians not specialising inthe care of older people should be available, andorganisations should have a system of quality assuranceto facilitate clinical governance and ensure maintenanceof the highest possible standards.6 Clinical work of consultantsHow a consultant works in this specialtyGeriatricians work in a broad range of settings, withduties differing widely in content and load across theUK, reflecting variations in local supporting services,specialist activity, geographical sites covered andinvolvement in the acute emergency take. No job islikely to be identical to another.In many areas, consultant geriatricians participate in theacute unselected take for adults of all ages. In a growingnumber of hospitals where the main medical take isdelivered by acute physicians, geriatricians are delivering7-day input to provide a rapid, targeted, comprehensivegeriatric assessment to case-find frail people at the frontdoor and prevent unneeded hospital admissions. Suchmodels of care are frequently known as Geriatrician ofthe Day, OPAL teams or Interface Geriatrics. Otherswork alongside specialty-based physicians so they canpreferentially care for older people on an age- orneeds-related basis. In all situations, geriatricians mustensure an appropriate balance between their emergencyrole and other duties, particularly supervision ofrehabilitation and delivery of subspecialty services, suchas falls management, stroke care or orthogeriatrics.Most consultants in geriatric medicine maintain specificsessional commitment to the inpatient core areas ofacute assessment and rehabilitation. In addition, theywill have some community responsibilities throughoutpatient, day hospital and outreach facilities. Thedevelopment of intermediate or post-acute care outsidethe hospital will necessitate increasing cooperation withprimary care.Acute inpatient careModels of care delivery will vary depending on casemix,bed numbers and support staff. Regular consultantward rounds should take place at least twice per week,and be combined with frequent multidisciplinary‘board rounds’. A ward round of 25 (+/−5) patientsshould take a programmed activity (PA); therefore thiswork would be equivalent to 2–3 PAs per week.Involvement of relatives is vital in the ongoing care andrecovery of this complex group of patients, and aC○ Royal College of Physicians 2013 121
Consultant physicians working with patientsfurther 3–4 hours per week (1 PA) should be consideredto allow for meeting with next of kin.Within a department there should be sufficient capacityfor consultants to provide prospective leave cover forcolleagues, including being able to do a ward round oftheir patients.RehabilitationNumbers of rehabilitation patients looked after by aconsultant geriatrician, with supporting medical staff,will vary depending on where the rehabilitation istaking place. In a traditional hospital setting with directsupervision (either acute or community), this could beexpected to be an average ward ie 24–30 patients. In a‘virtual ward’ or intermediate-care setting, this numberwould vary depending on the expertise of the leadstaff, and complexity of the patients. A consultantnormally would be expected to complete at least onerehabilitation ward round per 20 patients eachweek, and this would include a meeting of themultidisciplinary team (MDT).In addition, the consultant is likely to require onefurther PA for meeting relatives, reviewing unstablepatients, special case conferences and troubleshooting.Community workDepartments of geriatric medicine should expect to playa significant role in the community, including workingin teams to deliver intermediate care; reviewing patientsin care homes (NHS and private sector) – often inconjunction with community matrons or other expertallied health professional colleagues; assessing patientswho require long-term care; and providing homeassessments at the request of colleagues in primary care.These duties of community geriatricians may beundertaken in partnership with social services, byGPwSIs in older people and perhaps by nurse ortherapist consultants.Continuing careWhen continuing care work is undertaken, a consultantgeriatrician would be expected to have directresponsibility for around 30 continuing care beds andwould normally be expected to review the needs of thepatients at least once every two weeks.Referral work including interspecialty andinterdisciplinary liaisonA consultant would expect to deal with around five to10 referrals per week. Absolute numbers will depend onconsultant numbers and local provision of specialistliaison services within an acute hospital.Outpatient workTable 2 considers the requirements of outpatient clinicsfor general geriatric medicine and general internalmedicine (GIM).Table 2 Requirements of outpatient clinics for general geriatric medicine and GIM with indicative timings forconsultationsTime (minutes)Type of patientNewconsultation ∗Follow-upconsultationAdministration †(per patient)Training andpatient discussion(per patient)Consultant and ST4–7Complex elderly care patient ‡ 45–60 20 10 10General medical patient (young or old) § 15–25 10 5 10ST1–3Complex elderly care patient ‡ 60 30 10 10General medical patient (young or old) § 45 15 5 10ST = specialty trainee.∗ A new consultation would cover patient history, an examination, discussion of findings, reviewing or ordering investigations and a management plan.† Administration may be during clinic or at another time and includes dictation, reviewing results, phone calls, electronic correspondence, etc.‡ Complex conditions such as multiple problems, memory loss, Parkinson’s disease, falls and incontinence.§ General conditions such as transient ischaemic attacks, weight loss, anaemia, gastrointestinal problems and ischaemic heart disease.122 C○ Royal College of Physicians 2013
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AcknowledgementsWe would like to th
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AbbreviationsA&EAACsAMUsARCPCCGsCCS
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2 Specialties Clinical geneticsClin
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2 Specialties Clinical genetics6 Cl
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