What is meant by “Frailty” in the context of undergraduate medical education?

Rebecca Winter is a ST6 in Geriatric Medicine and a Research Fellow at BSMS. Her thesis uses creative research methods to explore the current perceptions of and approaches to frailty in undergraduate medical education. She tweets on @rebeccawinter27.

“And of how the snail, so small and frail,

With her looping, curling, silvery trail,

Saved the life of the humpback whale”

- Taken from the Snail and the Whale, Julia Donaldson and Axel Scheffler
 

I talk about frailty a lot. I hear the word ‘frailty’ a lot. In the clinical environment, across academic literature, in the media to describe weakened politicians and even from my 3-year-old son (courtesy of the snail). I cannot recall being taught about frailty as a medical student, and as a geriatrician-in-training, a person passionate about teaching and learning about frailty, and as a person who has spent more than two years reading and writing about frailty, do I find it easy to teach about frailty to medical students? The answer is no.

People living with frailty account for 20% of hospital inpatients and half of all hospital bed days in the UK¹. Medical students will encounter patients with frailty, across a breadth of clinical specialities, which therefore requires an in-depth understanding of this topic. The 2018 General Medical Council (GMC) Outcomes for Graduates document reflects this, with a requirement that medical schools include frailty in their curriculum². However, little is known about what it means to teach and learn about frailty in practice. A systematic review in postgraduate education found no relevant publications addressed the evidence of educational programmes for frailty prevention and/or frailty management⁷. This gap in training of healthcare professionals has been highlighted as a main barrier towards identifying and managing frailty⁸. There is some evidence to suggest that with teaching, the perceived importance of frailty and competence in assessing, diagnosing and managing frailty can improve⁹.

Some of the challenges associated with teaching and learning about frailty include negative perceptions, lack of a universal definition and a variation in the interpretation among healthcare professionals^3–6. This is partly due to the differing discourses between the medical construct of frailty introduced in the literature two decades ago to advance understanding of the heterogeneous health status of older people and the lay use of the word, which can be traced back to at least 2500 years ago.

How do medical students perceive frailty?

Work from our group, led by McCarthy¹⁰, aimed to explore medical student attitudes towards both older people and frailty over an entire UK medical school cohort. The study used a mixed-methods approach using validated questionnaires^11,12 and the creation of word clouds about older people and frailty. Participants (n=187) reported generally positive attitudes towards older people and frailty. The most positive attitudes towards both older people and frailty were held by year one students, and most negative by students in years three and four. The most negative attitudes towards older people were towards their reduced functional ability. The qualitative word clouds for older people and frailty differed noticeably from one another. Medical students associated positive qualities far more with older people whereas frailty was associated with more negative words. The five most common terms when students were asked to think about frailty were vulnerable, old, weakness, dependence, and illness, compared to experienced, wise, old, kind, and grandparents for older people.

How do medical schools perceive and approach frailty?

All UK medical schools were invited to complete an electronic survey in 2019¹³. Schools described educational strategies used to teach and assess frailty and provided frailty-related learning outcomes. Learning Outcomes (LOs) were grouped into categories and mapped to the domains of Outcomes for Graduates (knowledge, skills and values). 25/34 Medical schools (74%) participated. The interpretation of what frailty is varied widely between schools and the diversity of teaching strategies reflects this. Some provided LOs that represented frailty as a long-term condition within general medicine  (the concept of frailty, frailty assessment tools such as the Clinical Frailty Scale- CFS) and others considered frailty to equate to the whole of GM (chronic conditions in the older patient, social impact of ageing, gerontology). The most common learning outcomes about frailty are about the concept of frailty, Comprehensive Geriatric Assessments and Roles of the MDT.

Frailty teaching was widely delivered through ward rounds and clinical placements, commonly opportunistically. Simply being present in a clinical environment, however, does not guarantee that students will recognise or understand the concept of frailty. A number of schools discussed that students learn about frailty by completing or observing the CFS. The assessment examples and descriptions most commonly described Objective Structured Clinical Examinations (OSCEs) scenarios, including a history or communication station involving a frailty syndrome (fall, episode of delirium) or prescribing stations demonstrating polypharmacy.

What next?

The background work of my thesis has started to set the scene of frailty in medical education but there is much work to be done at individual, institutional and national levels to optimise teaching and learning about frailty for generations to come. I have included some suggestions below (a selection from a longer list) but in the spirit of the responsibility we all share for preparing medical students to meet the needs of future generations, please do comment below with your thoughts.

1. Expert consensus should be reached regarding the core areas to include about the topic of frailty. This could be included in future versions of the undergraduate curriculum produced by the BGS.
2. In view of the variation in frailty-related educational strategies, it would be good to further explore which strategies enhance student learning around frailty.
3. Medical schools should ensure that frailty-related learning outcomes are taught and assessed to follow the educational principles of constructive alignment. Furthermore, there should be careful consideration as to which/how frailty assessments feature within the national Medical Licencing Assessment (MLA).
4. In view of the fact that frailty teaching and learning currently is largely opportunistic by students being present on the ward, further research is required to understand how medical students and clinical teachers across specialties perceive frailty and how these perceptions impact what students learn in the clinical environment – watch this space for these results.