Training and Careers

Introduction

The UK is expanding provision of acute medical care in peoples’ own homes through Hospital at Home (H@H) and virtual wards. Our H@H service is training junior doctors to meet the growing clinical need in this environment. We describe the use of simulation training to improve the H@H induction process.

Methods

From their experiences in H@H, junior doctors identified specific training needs to build relevant competencies. From this feedback, PDSA cycle one involved junior doctors designing a dedicated simulation training (H@H-SIM). Stations addressed clinical, practical and advanced communication skills required in H@H using high- and low-fidelity simulation. PDSA cycle two used post-course evaluation to refine H@H-SIM through introduction of FP10 prescribing stations, point-of-care testing (POCT) and greater emphasis on practical skills. Revisions were evaluated via participant questionnaire before and after the H@H-SIM.

Results

Cycle two of H@H-SIM involved twenty doctors. The clinical scenarios, prescribing and practical skills stations, including POCT and IV administration, were perceived as the most useful parts of training. Overall self-rated confidence in knowledge and skills to work in H@H improved from a mean of 6.9 to 7.7/10. Before H@H-SIM, 60% were ‘not confident’ with recognising end of life (EOL), IV administration or decision-making around remaining at home; 10% with advance care planning (ACP). After H@H-SIM, 10% felt ‘not confident’ with recognising EOL or ACP and 5% with IV administration. Concerns persisted with using equipment, prescribing and availability of senior support. An additional station on recording ECGs was suggested. 

Conclusions

Working in a H@H context and seeing patients in their homes can be daunting for junior doctors. H@H-SIM embedded into induction is one way to prepare doctors for this role, improve their confidence and has potential for wider replication.

Introduction

Despite the UK’s increasing life expectancy, and increase in the elderly population, there is an overwhelming lack of Geriatricians in the UK; as of 2022, there is only 1 consultant Geriatrician per 8,031 individuals over the age of 65 (BGS, 2023). To meet the complex care needs of this population, there must be a focus on increasing the interest that doctors have towards Geriatric Medicine, with the overall aim being to recruit more doctors into the speciality.

Method

The aim of this review was to investigate what factors medical students perceive as barriers to pursuing a career in Geriatric Medicine and then, from identifying these, generate a set of comprehensive suggestions as to how to tackle these barriers at a medical school level to increase the interest and ultimately uptake of Geriatric Medicine. The qualitative review contains literature published between 2003 and 2023 accessed using MedLine.

Results

Six themes were identified in answering our question: (a) high emotional burden, (b) caring for patients with complex needs, (c) negative preconceptions of non-clinical factors (prestige, salary, career progression), (d) negative influence of clinical educators, (e) lack of intellectual stimulation and (f) lack of exposure to the speciality and the elderly.

Conclusion

The barriers perceived by medical students when considering Geriatrics as a speciality are complex and multifaceted; these barriers must be tackled promptly in order to secure the next generation of Geriatricians We suggest that this work can be used as a foundation for further qualitative studies with UK medical students to investigate barriers that are specific to UK students. From this, interventional courses designed to increase Geriatric Medicine uptake could be developed to strengthen the UK Geriatric Medicine workforce.

Background

Understanding human factors involved in patient care is a focus of the Geriatric Medicine Training curriculum including the leadership of and communication within an interprofessional team. Geriatric Medicine Specialty Trainees (ST4+) need advanced communication skills and confidence in managing complex situations. Simulation-enhanced Interprofessional Education (Sim-IPE) can be used to provide insight into other disciplines roles. We hypothesised that the implementation of a Sim-IPE programme dedicated to communication skills could improve confidence.

Method

We organised a one-day Sim-IPE programme for our Geriatric Medicine ST4+. Faculty consisted of doctors, advanced nurse practitioner, social worker, occupational therapist, physiotherapist and speech and language therapist. Communication scenarios, with faculty as simulated participants, were undertaken including establishing a ceiling of treatment, management of delirium, breaking bad news, ethical feeding dilemmas, complex discharge planning and capacity assessment. Debrief discussions followed each scenario. Mixed-method evaluation was used with questionnaires collected from learners’ pre and post session in a 10-point Likert scale to compare confidence levels. Qualitative feedback was collected from learners and faculty.

Results

Ten Geriatric Medicine ST4+ attended plus nine faculty including two facilitators. Positive feedback was received from learners and faculty. There was improvement in confidence across all six scenarios (one being “not at all confident” and ten “extremely confident”). Pre-session average confidence was 7.2, post-session 8.7. All trainees would recommend the programme to a colleague. Common learning themes included gaining feedback from debrief discussions and shared learning from our allied-health professionals. Learners and faculty commented on the enjoyment, usefulness and value of learning within a safe team environment.

Conclusion

Sim-IPE can improve confidence in complex communication scenarios and human factor skills. Feedback highlighted that this programme would be useful for all General Internal Medicine Specialty Trainees.

Introduction

Old age psychiatry wards facilitate patients who have physical health needs alongside mental health needs, deeming them high risk for falls. Following a fall, best practice suggests a doctor should perform a medical review. An audit of this was performed within the Harplands Hospital in-patient elderly care psychiatric ward, which revealed incomplete documentation or the absence of a review. Subsequently, a post-falls proforma was implemented and a re-audit was performed.

Method

Audit cycle one gathered data on post-falls documentation between August and September 2020. A falls proforma was then introduced and cascaded to ward staff. Audit cycle two then gathered data on post-falls documentation between November and December 2021. Information collected included if falls occurred within normal working hours (Monday-Friday, 09:00-17:00), whether witnessed or unwitnessed, if an assessment was documented, whether a head injury occurred, whether anticoagulation status was documented, and whether neurological observations were completed.

Results

The first cycle showed a total of 31 falls. Insufficient documentation was recorded in 5 falls (16.1%), including 2 falls (6.5%) with no documentation of a physical assessment. A head injury was recorded following 25% of falls, with anticoagulation status documented in 100% of cases. The re-audit showed a total of 10 falls. All falls (100%) were reviewed by a doctor with documentation recorded, including a brief history and assessment. A head injury was recorded in 4 cases (40%), with anticoagulant status only being documented in one case (25%).

Conclusion

This audit demonstrated the implementation of a falls proforma improved post fall documentation. It was noted that the falls proforma was not always utilised, which was thought to be due to junior doctor rotational changes alongside lack of communication regarding this tool. Moving forward, this second cycle identified the need for proforma digitalisation and junior doctor education at induction. 

Introduction Older adults are at risk of falls, which increases further in care homes. Due to the complexity of care home residents’ conditions and an increasing ageing population, it is important for care staff to have knowledge and understanding in falls awareness, prevention, and management in order to support their residents. Literature searches identified that barriers to care staff implementing falls prevention strategies included limited knowledge of staff and insufficient resources (including lack of staff training). There is scarce research regarding methods to deliver training to care staff, however emerging research in Virtual Reality (VR) as a training method had promise due to increased knowledge retention, and application into practice. Stakeholder patient and public involvement and engagement determined that VR as a training method had potential value.

Methods The second study as part of a multi-phase project, including two research phases and one technology development phase. The second research study was a mixed methods pragmatic study exploring the feasibility of the VR proof-of-concept, across seven care homes across the North West (n=40).

Results Engagement, immersion and enjoyment were key factors for acceptability of a training method. The training suited the learning styles of care staff, and VR was accepted as a training method. Utilisation of a case study resident increased empathy for the resident experience. Feedback for development included additional locations, scenarios, and interactable items. Barriers and facilitators of acceptability and adoption were identified.

Conclusion Identifying a potentially effective method of training for a complex intervention may influence the creation of future training programmes for care homes: to assist in increasing care staff knowledge, retention of information, and application of knowledge into practice. This in turn may improve the quality of care delivered and resident outcomes. Additional research is required to develop the proof-of-concept further, and feasibility tested further.

Background: The MDTea is a free open access medical education podcast designed for all healthcare professionals caring for older adults. To date there are 120 episodes.

Introduction/Method: The MDTea Podcast has CPD survey logs on its website where listeners who access the website can record their learning and receive a CPD certificate, Listeners provide their professional roles. Listener numbers for episodes were much higher than those recorded in the CPD log, so alternative measures were sought to understand who listens to the podcast. Series 11 was released in January to July 2022 and was themed around ‘A Day in the Life’ of health professionals working with older adults in the hospital environment. The MDTea Podcast Twitter account had 6333 followers before series 11 release and has good discussion and engagement with followers, and is regularly tagged in other geriatrics care from discussion by professionals. Measuring the followership and social network of the account may be useful to understand the MDTea’s place in the social network of UK care of older adults healthcare. Therefore with each episode release the new follower numbers and if available self identified professional roles of each were recorded and counted.

Results: Over the course of the 11th series, the MDTea Podcast twitter account gained 432 new followers, from 22 different self defined professional groups who engaged with our social media.121 followers did not identify their title. In contrast 12 self identified professions were recorded in our series 11 CPD log results from 30 responses.

Conclusion: This work has demonstrated the wide range of professionals that engage with FOAMed resources produced by the MDTea. Given the breadth of professionals working in elderly care roles in both primary and secondary settings, having an understanding content users can enable authors to design content that is appropriate for their audience.

Introduction

The British Geriatrics Society and NHS England recommend that patients aged 65 and over should be screened for frailty when presenting to healthcare services to facilitate early comprehensive geriatric assessment (CGA). Recognition of frailty frequently relies on assessment by FY1s. We sought to assess a) how confident FY1s are in recognising and managing frailty, b) their understanding of CGA, and c) how these change during the year.

Methods

Questionnaires (quantitative and qualitative data) were given to FY1s at induction, 6 months, and 12 months. Teaching sessions on frailty and CGA were delivered. We collated feedback on how frailty recognition and CGA knowledge had altered their assessment of older people.

Results

All FY1 Doctors completed the survey at induction. The 6 months and 12 months surveys were emailed to FY1s. The survey response rate was 100% (31/31), 68% (21/31) and 58% (18/31), respectively. At induction, 23% (7/31) reported they were “quite” or “very” confident in assessing for frailty. This increased to 71% at 6 months and 100% at 12 months. Fifty-two per cent (16/31) of FY1 Doctors were aware of a tool to assess for frailty at baseline, increasing to 100% (18/18) at 12 months. Knowledge of CGA improved less, from 48% (15/31) at baseline to 83% (15/18) at 12 months. There was no association between speciality experience and confidence levels. Feedback from FY1 doctors indicated that frailty recognition allowed identification of patients who may benefit from advanced care planning discussions and triggered early therapy input.

Conclusions

Despite BGS and NHS England recommendations, at induction, FY1s lack confidence in frailty recognition and assessment. Through experiential learning and targeted teaching this improved, not limited to those in geriatric medicine. We recommend final year medical students need increased frailty and CGA specific education to improve their confidence when assessing frail older patients.

Introduction
Timely administration of medication for people living with Parkinson’s Disease (PwP) is critical. Missed or delayed Parkinson’s Disease (PD) medication can lead to motor complications, swallow impairment, and in some cases a neuroleptic malignant type syndrome. This can lead to morbidity and mortality and longer hospital stays. Our local policy on the nil by mouth (NBM) guidance for PwP is available on the intranet. We wanted to audit knowledge of, and adherence to this policy.

Method
An audit tool was used to collect responses from nursing and medical staff in the Clyde sector, including Royal Alexandra Hospital, Inverclyde Royal Hospital and Vale of Leven Hospital. Paper copies and QR code linking to the questionnaire were distributed across the wards between November 2022 to January 2023.

Results
A total of 124 responses were obtained, where 84 were prescribers. The responses showed some pre-existing understanding on the NBM policy for PwP, with 77% agreeing that Rotigotine patches should be considered if the oral or enteral feeding route is unavailable. 67% also knew the frequency for Rotigotine patches to be changed. Of the responses, only 52 (50%) have seen the trust’s NBM policy. Prescribers were also asked on how to calculate the dose for Rotigotine patches, 37 (52%) knew of the online calculator or referring to a guideline, with the remaining unsure or leaving the question unanswered. 41 (33%) knew the location of the emergency stock for PD meds.

Conclusion
Our study has shown a gap in the awareness of the NBM trust policy for PwP and highlights the need for more staff education. Educating medical staff at their weekly teaching and signposting them to the local guidance will be a starting point for our intervention. For the wider hospital staff, further training will be provided during PD awareness week.
 

The Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form is widely adopted to document advanced care plans, including Do Not Attempt Resuscitation (DNACPR) decisions. Communication between clinicians and patients, or next of kin is required for completion. It is widely documented UK medical students have little exposure to these experiences, including being asked to leave whilst they are occurring. During the COVID19 pandemic, Foundation Year 1 (FY1) doctors led discussions with increased frequency and autonomy, with no documented concurrent training. We present a novel learning experience designed to aid these discussions. Students were timetabled to a 1.5 hour workshop, facilitated by a clinical teaching fellow. They were invited to complete a ReSPECT form for a celebrity to familiarise themselves with the layout. They then considered a patient admission scenario in 3 different groups from the perspective of the patient, family and medical team, and used this to contemplate potential, future, emergency treatments. Subsequently a discussion surrounding CPR effectiveness, ways of communicating this, and legal advanced decision documents occurred. The session concludes with scrutinising example ReSPECT forms provided by the Resuscitation Council UK.

Method: Students' confidence levels were measured pre and post session using a Likhert scale questionnaire.

Results: 90 students attended workshops across 6 rotations. 80% students completed post - session questionnaires, of which 100% reported an increase in confidence with having a DNACPR/advanced care planning discussion compared to before the session.

Conclusion: DNACPR conversations can incite anxiety in any seniority of health care professionals. Medical educators need to adequately prepare medical students during their training in advanced care planning and DNACPR discussions. This can be done with simulated workshop experiences, reinforced with opportunistic or organised observational experience. Adequate preparation will lead to increased confidence in discussions, ultimately leading to better experiences for patients and their families.

Introduction

NICE Clinical Guideline CG103 states that adults aged 65 and older should be screened for delirium within 48 hours of emergency hospital admission. The Geriatric Medicine Research Collaborative (GeMRC)'s World Delirium Day data from 2019 showed an average screening rate of 27% nationally. After an inpatient fall on the Medical Assessment Unit resulted in hip fracture for a patient who had not been screened for delirium with the recommended 4 A's Test (4AT), we decided to collect data on screening rates and devised a way of improving these.

Method

Baseline data was collected examining patient notes of adults over 65 years currently on the Medical Assessment Unit who had been seen by a doctor. The intervention was a teaching session on delirium for the junior doctors on the ward, focusing on the adverse prognostic features of delirium and importance of clear diagnosis with onward communication to the patient's GP. Repeat data collection was done following this.

Results

55% of all patients on the ward throughout data collection were over 65 years of age. A total of 79 patient notes were examined. The baseline rate of delirium screening with a completed 4AT pre-intervention was 25%. Post-intervention this increased to 41.3%. Without further education this fell to 26.9%. Most of the unscreened patients showed incomplete 4ATs or only the Abbreviated Mental Test (AMT) section completed.

Conclusion

Integrating delirium teaching into departmental teaching on Acute Medical Units can increase the rates at which delirium is diagnosed, which is important for the patient's clinical trajectory and prognosis, both for their inpatient stay and long term. After this data was presented at a clinical governance meeting, the Emergency Department purchased an electronic patient record including mandatory delirium screening in those over 65 presenting to hospital. Future work may include assessing the rate of documented diagnosis out of those who clinically fit the criteria.