Nearly two-thirds (65%) of people admitted to hospital are over 65 years old.¹ All clinicians including surgeons must expect to care for an increasingly older group of patients. Yet sufficient emphasis was not placed on the special needs of older patients in the medical curriculum for undergraduate and medical/surgical postgraduate training.²
Can postgraduate medical/surgical education continue to ignore in its curriculum for training a significant proportion of the patient demographic represented by older patients? Can we continue on a path that seeks to create new subspecialties every time there is a need to improve patient care in a medical or surgical setting? Can we actually afford to run a system where physicians take over or lead surgical units in order to care for the ‘medical needs’ of patients under the care of surgeons? Is this clinically proven to be safe and who takes overall responsibility for the care of these patients if this model were to apply?
For far too long fractionation of hospital units into businesses and directorates with varying budget needs has been allowed to get in the way of patient care. As clinicians we ought to avoid a state of medical utopia that delineates patient care into pure surgical or medical problems. It is increasingly clear that such patients do not exist in view of the increasing age of hospitalised patients, ever increasing list of comorbidities and polypharmacy. All clinicians should embrace a holistic care approach to patient care in their training and practice. A patient-centred humane management approach is an essential skill of being a good clinician whether one is a physician or a surgeon.
There is little doubt that the orthogeriatric model of care of patients after hip fracture and the POPS (Proactive care Of Patients undergoing Surgery) have been a success.³ Does the available medical workforce allow for these models to be rolled out on surgical units across the UK? If not, are alternatives available that can afford district hospitals the opportunity to improve care for frail older patients?
Our experience in a smaller district hospital unit may be easier to deliver in view of available human resource (numbers of trained geriatricians across the UK). A simple criterion (age related) was produced to provide routine medical reviews for a high risk patient group (older patients ≥80) on the general surgical units. This group of patients are most likely to have multiple comorbidities and medications requiring medical review.⁴ The age range for units who may want to trial this model can be adjusted based on local demographics and inpatient numbers. Routine medical assessment is provided for these patients on a twice weekly basis by a physician trained in general internal medicine and geriatric medicine. This also provided the advantage of team working between the physician and general surgeons in identifying other groups of patients in need of medical review, which is delivered on a referral based system through the rest of the working week. This also offers the ability to deliver good care without the risks of deskilling the primary surgical team. There is shared learning and teaching as well.
A recent move by NHS trusts to increase the numbers of working physicians with generalist roles should prompt recognition that we cannot always ‘subspecialise’ clinical practice to negotiate the growing challenge of caring for patients (especially older frail patients) on surgical units. Surgeons should, in liaison with physicians, remain central to caring for their patients. We should all be enablers of good medical practice and shared holistic practice. The introduction of the best practice tariff in hip fracture care is an exemplary model of how better care can be achieved when physicians and surgeons work together. Some of this success can be replicated in older patients on general surgical wards.