My life as a Geriatric consultant

What stage of your training are you in?

Having completed my SpR training, I’m just finding my feet as a newly appointed consultant in Geriatric medicine. I work as a frailty consultant in-reaching to the emergency department. It’s busy and challenging, but enormously rewarding. My sub-specialist interests are in palliative care and falls.

What region are you working in?

Merseyside – where I went to medical school and completed my CMT and SpR training.

When did you decide on Geriatric medicine? What else were you considering?

As an FY1 I wanted to be a surgeon. However the reality was duller than I’d hoped.

Following that I thought about cardiology, as I trained as a cardiac physiologist prior to going to medical school. However, I didn’t have a cardiologist’s mindset. As a CMT I considered diabetes and Endo and ITU, but they didn’t feel right to me. Finally I did a stroke and geriatrics job at Aintree and I just knew.

What helped you decide?

Being a dour, acerbic Yorkshireman, I have always been painfully pragmatic and realistic. I often felt we did too many tests and procedure that added little value to patient care. This meant I clashed with many of the other specialities that I worked in. However, when on call, I always enjoyed working with the care of the elderly SpRs as they shared the same values regarding patient care that I did. They were the type of doctor I wanted to be.

How have you found the exams so far? How did you revise for them?

Despite failing all my GCSEs, I have actually found my postgraduate exams tough but not impossible. I was fortunate enough to pass them all in succession.

For the MRCP1, I did around fifty random questions a day, and then upgraded to the passtest. MRCP2 was similar – but I did some extra reading around conditions I hadn’t encountered before.

With PACES, it was similar reading as MRCP2. I got a daily flogging on the wards by my eagle-eyed consultants, which certainly helped me sharpen my exam and communication skills! Knowing guidelines and some of the current NICE stuff helped, too.

For SCE, I did a lot of multiple choice questions from the book, and read around the core topics of geriatrics. Henry Woodford’s books are an excellent resource, but a lot of it came from day-to-day practice and talking to the consultants.

How is your day job split up – when you’re not on-call?

Very different from being an SpR!

Mornings are either family meetings, admin/SPA time or ward rounds. Afternoons are dedicated to Emergency department frailty in reach. Often I have meetings or I’ll be teaching. The exciting part of the job is service development. Seeing real change in the workplace and patient care happen as a result of your efforts is immensely rewarding.

What aspects of being a Medical Registrar have you enjoyed the most? What has been hard?

Initially I loved being medical registrar. It was a truly unique experience to be involved in the medical care of all manner of patients. As time wore on I found it dreary and tiresome, being the hospital’s whipping boy for medicine.

As I got older and had kids, I found the nights and long days on a weekend challenging. Mainly because I was ready to finish my training, but also because I’d rather have spent time with the kids at that point.

What’s the best thing about being a Medical Registrar?

The variety. Seeing all types of medical problems across a vast age range.

What’s the worst thing about being a Medical Registrar?

Being everything to everyone. The calls from random juniors about random things that really bear no relevance to the patient at stupid o’clock in the morning. Running cardiac arrests particularly used to aggravate me, as the vast majority are wholly inappropriate but ceilings of care haven’t been broached for some unfathomable reason.

Could you share with us your most challenging moment as a Med Reg?

The first time I saw a patient in multiorgan failure from sepsis who was not an ITU candidate owing to several severe comorbidities. Having to make that call and speak with the patient was harrowing to say the least. Fortunately I had supportive colleagues and ITU colleagues who supported the decision.

How do you deal with an ever-growing medical take list? What advice would you have for managing all the medical referrals?

Tons:

• Work to your strengths – I grew to realise I could plough through the frail elderly patients with ease but got bogged down in bizarre chest pains for example, however – you are better off sending the SHO who currently works in cardiology to see them.
• Take your breaks. You cant be effective if you are knackered.
• Ask for help from colleagues – you aren’t alone.
• Learn to delegate – you don’t have to see everyone yourself.
• Don’t be afraid to be true to your gut feeling. If a patient is telling you they have had enough or you think they are deteriorating but shouldn’t be for resuscitation, then make the call, the patient’s wishes are a vehicle for delivering the care they need and want, including ceilings of care. Patients’ care and wishes are more important that any medical treatment. In a time where standards seem to be squeezing the common sense out of medicine, it is important to deliver your own values of care, simpler, kinder and more pragmatic care are what come first for my patients.
• Don’t take shit from anyone. Being belittled or demeaned is unacceptable. Escalate and report- it’s the only way to change culture.

What do you think are the most critical personality traits that a doctor should possess for a career in medicine?

Decisiveness. Common sense. Patience.

The RCP recently published a report on the welfare of junior doctors which made for harsh reading; what needs to be done to make medical training fit for purpose?

Actually training the juniors. 9-5 on the ward and 9-9 clerking patients on your own isn’t training. We need to be inspirations to the juniors, make an effort to grow and develop them, support them in their examination efforts, and get them into clinics regularly. Show them why your speciality is the best and why you chose it.

A concern of many trainees applying for medical training is the work-life balance; how do you cope with incessant nights and weekends?

It doesn’t last forever. Find something outside of work to do with regularity that takes you away from the challenges of work. Sleep is vital, get loads of it. Eat well and stay active. Take your holidays. The nights and weekends can really grind you down, organise your leave so you can get some downtime after your on calls.

Some rotations or trusts you just end up hating – having experienced this myself, it took me to a pretty dark place on more than one occasion. However, speak to you supervisor, your TPD or even colleagues. Don’t suffer alone. Having spoken to other trainees to find they hated and were struggling too gave me some solace and we worked out ways to make it less grim for us as a group.

With medicine and training becoming increasingly specialised – is the General Physician dead?

To an extent. Geriatric Medicine is one of the last bastions of general medicine and is appropriately positioned to do this. We look after some of the most complex and multimorbid patients that pose a major challenge for specialities that tend to be more single organ focussed.

I find a lot of colleagues and juniors get lost in the patients complex problems and forget to ascertain what the patient wants. I always challenge the notion of doing tests because that’s the culture – if the result is uninterpretable or not going to change the patient’s management, then don’t do it. A lot of medical interventions are indiscriminate and protocol-driven. It’s easy to put a patient through something that only devalues their care, or at worst contributes to a bad death, because there has been a failing to see the patient in the overall trajectory or context of their illness.

What’s your number one piece of advice to junior doctors who are considering applying for medical training?

Do the speciality that fits with you and your personality. Do it because it interests you and you are passionate about it. Being a physician is literally the best job in the world. Don’t do something because it’s easy, because there is no reward in it.