education, geriatrics

A Whole New World

Three exciting things happened this week – I hosted my first ever Journal Club on Twitter, I attended the BMA Women in Medicine event and also presented at the Geriatrics for Juniors conference in Newcastle.

All very different but all with one thing in common – bringing people together.

My feeling over the past few months is that within healthcare there has been a creeping return to silo working. Whether it’s staffing on a ward area, the rota or teaching it all feels like people are in self preservation mode. It was nice to be pulled out of that for a while and see what was going on in the wider world

I’m not sure how many of you still run journal clubs at work?  They’re something that seem to have fallen out of fashion. I’ve got to be honest, in the past I didn’t like them.  For those who are unfamiliar, the premise was that some unfortunate soul was nominated to present a ‘topical’ paper at a lunchtime meeting.  This paper would then be dissected by the audience.  It was an opportunity for scientific ‘show pony-ism’ for the statistically minded. Usually I forgot to read the paper and when I did there seemed to be far too many statistics which I didn’t understand. I learnt nothing.

Years later I have come to appreciate their value in appraising evidence which is clinically relevant to my day to day work. I am still not keen however on the traditional design of a Journal Club.

What the @GIMJClub guys have done is take the same principal – ‘have paper, now discuss….’ and refreshed the format for a wider social media audience (#genmedjc)

In the week leading up to the Journal Club the paper and its supplementary links were shared across several social media platforms.  This allowed people the time and the flexibility to read it on a device of their choosing.  I must admit though, I still printed it off and sat with a pink highlighter pen – old habits!

The discussion was fast paced and hugely interesting. I learned loads!  The bonus part was it allowed people from all over the UK to take part from the comfort of their own home.

Using Storify, I was able to capture the main points reflecting a happy couple of hours of educational community.

https://storify.com/Sparklystar55/iqcode-journal-club

This energy followed me to the Women in Medicine BMA event a couple of days later (#BMAWomenMedicine). The workshops I found the most useful were those on Less Than Full-Time (LTFT) working.  It struck me that people were somewhat left to get on with it when it came to LTFT working.  As someone who has trained and currently works, correction, is paid less than full time it is a subject close to my heart.  We are seeing a change in the workforce with more people choosing to work flexibly where possible.

The BMA have recognised this and have introduced the concept of ‘LTFT Champions’. An informal go-to person to ask advice on the practicalities of LTFT working and to also  provide local guidance.  It’s something I’m looking to introduce to Forth Valley in the coming months.

To round off the week I was asked to present at the Geriatrics for Juniors conference (#G4J17).  The guys at @AEME are heroes of mine. Not only have they advanced Geriatric education they have raised the profile of the speciality a million fold.

On a cold Saturday in Newcastle ~200 mostly junior doctors attended a day of very entertaining presentations on the different facets of Geriatrics. To my mind this reflects the growing interest in our speciality, which I hope ultimately translates into more people training as Geriatricians.

What continues to impress me most about @AEME is that they not only recognised the need for a different way to deliver Geriatric teaching but they went out and did it.  They also managed to attract like-minded individuals to give up their time and contribute too – whether through a Connect event, a Podcast or their newly formed Mentor network.  Silo working just does not exist in their world.

Now of course you don’t have to go to these lengths to get out and talk to people. Pick up the phone, email (yes, I said it; its still a convenient communication tool), grab a coffee together or meet up with other specialty colleagues before a lunchtime meeting. One of my colleagues is trying to do this very thing by booking an area next to the lecture theatre.

Either way just get out there, people. You’ll be amazed by what you find….

geriatrics, nhs

Free, free, set them free

 

This week I’m in Nashville for the American Delirium Association Conference (#ADS2017).  Day one was heavy on education and although I was familiar with most of the content I always find it interesting to hear how others interpret and explain things. One session on delirium in the Intensive Care got me thinking:

Screen Shot 2017-06-04 at 19.30.04

Now when you mention restraints to people in healthcare they will generally think about the kind that have people strapped to a chair or cot side.  Thankfully these types of restraints are no longer routinely used in the NHS.

There are some kinds of restraint that can be a good thing for example, the plaster cast that stops a fracture becoming displaced.

However what about the restraints we use by proxy?

As I sat in the lecture I got to thinking about what happens to a person when they are in hospital.  Last week I talked about the role of the environment in particular how it can be damaging to the person with delirium or dementia.  By making simple changes there is evidence that the person will get better more quickly, so of course the environment was number one on my list.

The #endpjparalysis campaign on social media also highlights it.  I recently had a patient comment she would like to get dressed but unfortunately her family had only packed her a nightdress. Most equate a hospital admission with serious illness however the aim is to get the person better as quickly as possible so we do need to see beyond that.  One could argue that a person’s dignity is restrained by having them rehabilitate (walk, eat etc) only in nightwear.

Which brings me on to 7 day access to a multi disciplinary team (MDT).  We know that early access to physio and occupational therapy can have huge benefits not only on the physical but also cognitive health of a person.  Could limited access to the MDT be a restraint by proxy?  I’m not so sure.  I do think they are spread far too thin.  I also think that some of the tasks could be done by others, in particular, our healthcare assistants.  I just wonder if they perhaps need to be more empowered to do so instead of just doing unto the patient….?

One thing that does not help in the early mobilisation of a person is the use of sedation.  It’s not just an issue for ITU, many of our older people are on medications that actively sedate them e.g. the ‘little sleeping tablet at night’, strong painkillers even some antihistamines.  I would argue that Geriatricians in conjunction with our pharmacy colleagues are good at trying to rationalise medications.  The community, especially care homes are not quite as good.

So coming back to the hospital setting both in acute and rehab here are a few other things that could be considered restraint by proxy;

  • urinary catheters
  • hearing aids that don’t work or are not fitted
  • no glasses
  • buzzers that are out of reach
  • empty water jugs and cups
  • inappropriate walking aids
  • no walking aids
  • no ‘getting to know me’ or ‘what matters to me’ discussions

Most would be horrified at the idea of going back to the use of physical restraints but I wonder if we realise all the other ways we achieve the same effect? Perhaps we ought to reframe the discussion so that as with straps, belts etc other restraints by proxy can become a thing of the past….

geriatrics

True Colours

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Our lunchtime meeting this week featured a talk by George (@ilovehermind), one of our junior doctors on health issues in older LGBT people.  It was incredibly thought provoking.  It’s rare that a presentation makes me want to immediately go and learn more. However as I soon discovered there was very little to find.

First up I went to the British Geriatrics Society website and typed ‘LGBT’ into the search facility. No results.  Hmmmm…. disappointing.  I then tried typing ‘Gay’ – nothing again.  In fact despite typing an array of acronyms and looking amongst the various headings I couldn’t find anything.

I tried Health Improvement Scotland. They’re bound to have something I thought.  Eh, that’s a no too.

I was starting to get annoyed….

Eventually I was able to find the articles that George had referenced in her talk.  What I hadn’t really appreciated until now was the range of issues that our older LGBT community faces.  More over how little attention or recognition they receive.

I am also slightly ashamed to say the issues raised had never really crossed my mind.  I guess I have always considered myself to be the type of person who doesn’t pay all that much attention to perceived differences. I will treat people the same whoever they are.

That said over the next couple of days I began to reflect on my own practice.  To my knowledge I have looked after only a few older LGBT people.  I have never asked nor have I made assumptions.

Is this wrong?

I’m beginning to wonder if it is.

I have been corrected on many occasions by the women who I have said hello to as ‘Mrs’ only to be told ‘it’s Miss’.

Then there was the man who I looked after years ago with the low impact hip fracture.  He told us some weeks later that in fact he had been born female but had been brought up and identified as being male.  This was told to us in confidence and I’m very honoured that he felt he could share that.  However when a well intentioned Healthcare Assistant shaved the beard he had been trying to grow for months the devastation felt by all was awful.  He never said not to and she just assumed he would want to look well groomed.  Now I appreciate that’s a very specific story but it has stayed with me.  What could we have done differently?  Each time I come up blank…. The story came back to mind when I read this quote:

‘Coming out’ is an on-going, dynamic process. Every unfamiliar person and place (such as a hospital or nursing home) demands yet another decision about disclosure. (Age UK)

So as we talk about frailty and all the other conditions that occur in old age I don’t recall any conversation about the needs of the LGBT community in old age.

Are they any different?  In some respects yes but in ways I hadn’t really considered before.  There is a higher proportion who drink alcohol and/or take drugs.  We are also now seeing approximately a third of newly diagnosed HIV cases in the over 50yrs and 5% are >65yrs.

However what I hadn’t appreciated was the issue around social care and loneliness. The combination of family estrangement and/or no children leading to social isolation and lack of support network. Some good news and an attempt to address this lies in Manchester City Council opening the first LGBT care home:

https://www.theguardian.com/world/2017/feb/21/manchester-city-council-to-create-uks-first-lgbt-retirement-home

To be honest George’s talk was a real eye opener for me. I became a Geriatrician because I believed that older people were largely the forgotten mass who got a rubbish deal from the NHS. I wanted to be their advocate. I now realise that I have been somewhat blind to a group of people within this. I am delighted that Geriatrics is now front and centre in the NHS.  However I feel we may have some way to go to ensure that all older people receive the care they deserve and are entitled to.

For more info:

http://www.stonewallscotland.org.uk/sites/default/files/LGB_people_in_Later_Life__2011_.pdf

http://www.tht.org.uk/our-charity/Facts-and-statistics-about-HIV/HIV-in-the-UK

http://www.ageuk.org.uk/health-wellbeing/relationships-and-family/lgbt-information-and-advice/lesbian-gay-bisexual-or-transgender-in-later-life/

http://www.ageuklondonblog.org.uk/2017/05/19/dementia-care-lgbt-community/?utm_content=buffer57b6c&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer