Specialty career profile: geriatric medicine

Dr Sally Jones shares her experience of what influenced her choice of geriatric medicine, what training involves, and what it's like to work in the specialty.

What influenced you in choosing geriatric medicine?

Many things. Firstly, I love general medicine and geriatric medicine is one of the last truly generalist specialties. There are so many clinical challenges – from knowing when it is right to stop investigations and simply to palliate, to managing complex comorbidity, to the challenge of atypical presentations of illness, to championing for a group of patients whose voice is not always heard. The two most inspiring physicians I have ever met were both geriatricians which certainly helped to inspire me, not to forget that the specialty was founded by a woman!

I also read a copy of Survival of the Unfittest by the late Bernard Isaacs, one of the best known geriatricians in the UK. The book is about the problems facing the elderly in areas of social deprivation in 1960s Glasgow and opens with the story of an elderly lady who fell and lay all night, cold and alone, with the resulting medical and social problems that sadly are still familiar to us now, 40 years later. I want to work in a specialty where these things matter.

I always enjoyed elderly care and considered it a possibility once I’d completed my junior house officer jobs (old F1 equivalent). However, I enjoyed everything I did and actually found it rather difficult to decide for sure, particularly as some (non-geriatrician) senior doctors were very negative when I said I was considering a career in elderly care. It wasn’t until some months after I’d completed my MRCP and I had a chat with some geriatricians whom I greatly respect, that I made the decision to apply for a SpR rotation in geriatric medicine. I have never regretted this.

I work with fantastic patients and really do feel part of a much wider multidisciplinary team, a feeling that not all doctors experience

What training do you have to do to get into geriatric medicine?

In order to gain an ST3 post in geriatric medicine, candidates should have completed core medical training (CMT) and their MRCP. Within the CMT training, it certainly would be preferable to have spent a period of time working within geriatric medicine, since although elderly patients can form a substantial proportion of patients on the acute medical take and on other medical wards, the approach and focus can be different than those of single specialty wards.

Once in specialty training (ST3 and above), there are 5 years of specific training within geriatric medicine, often five rotations of 12 months each in different hospitals, depending on the individual deanery. During these 5 years, the trainees must gain experience in various sub-specialties of geriatric medicine such as stroke medicine, Parkinson’s disease and movement disorders, falls and syncope, orthogeriatrics and community geriatrics. Most candidates will choose to obtain dual accreditation in general internal medicine at the same time and will form part of the acute medical rota. There are opportunities nationally to spend a further year to gain a specific CCT in stroke medicine, although this is not currently necessary in order to take up a consultant stroke post.

Do you work closely with other specialties?

We work very closely with other specialties, providing help and advice to surgical, orthopaedic, primary care and other medical colleagues. There is also considerable overlap between us and that of old age psychiatry, palliative care and neurology (Parkinson’s and stroke).

What are the best things about working in geriatric medicine?

I can really say that I see something different every day. I’m currently developing a new service where we have a geriatrician available in A&E to see the frail elderly as they present - exciting opportunities during challenging political times. I work with fantastic patients and really do feel part of a much wider multidisciplinary team, a feeling that not all doctors experience.

And what are the main challenges?

The main challenge to face our specialty will be the huge demographic shift occurring in this country leading to a massive increase in the numbers of patients we will see, particularly the oldest old. Currently, inter-agency working can often be challenging, most commonly the interface between health and social care, but it’s also exciting to be part of the generation that will hopefully succeed in improving this – we have to, or else neither agency will cope with the increased demands that will be placed on our services over the next couple of decades.

In addition, the attitude of those from different specialties can sometimes be negative and dismissive – but that is slowly changing for the better.

Are there opportunities for teaching or lecturing?

Yes - many!

Are there opportunities for research?

This depends on which region you’re working in and your own personal interest. Some areas of the country have a really strong interest in research within geriatric medicine (for example, Dr Simon Conroy in Leicester). Other areas of the country are less well set up, and the opportunities for research will depend largely on the drive of the trainee – this is something that the trainees section of the British Geriatrics Society (BGS) is trying to address. There is certainly no requirement to do research.

There are also several MSc courses in geriatric medicine and gerontology nationally in addition to other relevant part time masters degrees. I did a masters degree in medical ethics and law.

Do you work closely with other healthcare colleagues or groups?

Very much so; nurses, specialist nurses (Parkinson’s and stroke), physiotherapists, occupational therapists, social workers, dieticians, community teams, speech therapists and others.

Does your job involve decision making?

Again, very much so. My current role is as a geriatrician within the A&E department, assessing the frail elderly as they present to hospital, not only guiding treatment, but also decisions to admit and decisions to discharge (which can be difficult for an inexperienced junior doctor for this frail group of patients). As geriatricians, we’re frequently helping to make decisions with potentially huge consequences for the patient and family – end-of-life decisions, decisions regarding ceiling of care, place of care, appropriateness of invasive investigations, and decisions about mental capacity.

How competitive have you found working in your specialty?

At the moment, trainees in geriatric medicine are lucky in that there is less competition than for many other specialties, and that due to changing demographics it is one of the specialties most likely to expand over coming years. That said, certain types of consultant posts within the specialty tend to be more competitive than others and the current financial and political climates make it difficult to be certain about what will be the case 5 years from now in terms of workforce planning – but this is true for all specialties.

What advice would you give to someone considering a career in geriatric medicine?

Try it out as a senior house officer, if possible with at least two different geriatricians. Speak to senior colleagues that you respect. Try to get involved in something over and above the usual CMT experience…is there a specialist Parkinson’s clinic or falls clinic you can become involved with or an interesting audit? Finally, be honest – if you are somebody that gets frustrated by social problems, difficult histories and chronic diseases, then the specialty is probably not for you. However, if you’re someone who is interested in all this, loves a challenge, and enjoys working as part of a much wider team - go for it.