Friday, November 29, 2013

Gamechanger V: Training....where's the patient?


It's simply astounding how disconnected NHS structures can be, how poor future workforce planning can be, how out of sync training can be with modern healthcare demands...there seems to be a lag period..and by the time training curriculums catches up, the NHS and its healthcare needs have moved on, the priorities have changed, the needs of the patients have change.
Lets start with this new fangled love all policy makers now have...it's called "Long term conditions".No longer is it about single disease such as diabetes, COPD, heart failure but no, as the patient has multiple comorbidities, we need to have multiple disease specialists. As a plan? Fabulous. Execution? Not surprisingly....slow. Why? because immaterial of how you brand it, that "multiple disease specialist" a few years back used to be called the general physician. I still recall doing general medicine clinics...all disbanded gradually as we needed to champion specialism. Who used to come to those clinics? Yep, you guessed it, patients with multiple problems, and a GP asking you to join the dots together, get a few disease processes sorted in 1 go. Now as time has phased, and finances squeeze, sending the same patient to a diabetes clinic, then a heart failure clinic and finally a COPD appointment doesn't look right, either from a patient experience or a financial one.

So where do we find these "long term conditions experts?" I can assure you they are a rare breed in the hospital, in fact as lots of junior doctors will testify, early mornings are spent trying to cherry pick specialists patients and wondering who to hand to or grumbling about the "general medicine patients" on the list.
So where are these specialists? Have we now managed to narrow them down only to elderly medicine physicians, the only ones who still look at the patient as a whole? But we only have so many of them..and the demand for them grows exponentially every day. Is it then the GP who does this role? Then again, the pressure on time for them is well documented too. Thus as evident,we have problem with the present...but a bigger problem brews with the future.

We are planning these models but training still is delivered in specialist silos. Long term conditions? Don't be silly. It's only about diabetes, only about heart failure.General Medicine training? You learn what you do on the wards, attend a few conferences, try your best to get to a few regional training days but always takes second preference to your own specialty..not always due to choice of the juniors but also pressure from their own Consultants. It maybe the priority of the Policymakers and even the patients, certainly not in the training cycle though.
Another example? End of Life care.  I read about Elin Roddys passionate plea to improve this area and with an ageing population, multiple morbidities, increased malignancies..he need to have the skills or even the mental inclination to spend those extra minutes with the family and patient is paramount. what about training though? Is it responsive to the needs of the patients? Is it adapting to the changing population?

So what can be done? Forget the present for a minute and invest some time in the future. There is little point in talking about models for which we are not training our juniors. The Royal college of physicians talks about how they want to bring general medicine back...my suggestion would be to stop talking in waffle and actually get something robust in place. We have specialties who duck out of any general medicine commitment as they don't have   General medicine accreditation. cardiology is a prime example..and Gastroenterology is  trying their utmost to follow suit. I know so as the local college tutor as the cardiology trainees don't attend sessions on end of life care, COPD management...as "there isn't a training requirement". Not their fault, just pressures of time make them choose appropriately. The sadness of that is compounded by the fact that in my training years, some of the best general physicians I met were actually cardiologists. Up and down he country, those who have been left to pick up the baton of patients with multiple problems ( cue Respiratory physicians, elderly medicine physicians etc) feel the heat of this, day in, day out and ask for all to share the load but unfortunately training continues inexorably targeting a single specialty disease process.

So want to change the game? Then tackle training NOW. Do we need more single disease specialists? Debatable. Do we need more up skilled GPs, do we need better trained practice nurses, pharmacists...well..that question is on the same level of is the Pope a catholic? If you want better general physicians or multiple disease specialists in the hospital, then make it mandatory part of training and job plans, not an option. Stop waffling about with polices and do it. And if you don't have the muscle or know how then come to the conclusion that we need more elderly care physicians as long term conditions specialists, up skill GPs and give them quick, fast access to single disease specialists.

Maybe we need to accept that we need to invest a lot of education money into upskilling GPs, use the fourth year of training for targeted LTC training rather than continuing as is...maybe its time to invest in training of specialists to be educators, develop the importance of being there for primary care as a support...how many trainees are specifically taught about teaching skills? Accept elderly medicine physicians are turning into the last bastions of general medicine..and train appropriately rather than force folks to do something they don't.

Either way, a fundamental change needs to happen NOW. No more time for endless meetings of educational gurus mulling over nuances of the curriculum, we don't have the time left for things to happen 5 years later...while the patient needs have changed now.

The worry I suspect is that as trainees we saw this coming 8-9 years ago when specialists started to pull out citing their super specialist skills...the rot had set inside the hospitals..and now its cascaded to the wider community. You reap what you sow...and in case you do want to tackle the future and the multi morbidities conundrum ( which incidentally I see as a success of the NHS way of working) then the time to act is now....Royal College of Physicians/ Health Education England..are you listening closely enough..and more importantly are you ready to tackle the issues head on?
I am sure there are a lot of physicians with a wry smile looking at this attempted resurrection of the general physician in a new garb. The circle of life is nearly complete.

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