NASGP member Eva Kalmus describes how she became co-chair of the new GeriGP group of the British Geriatrics Society (BGS), and why being a portfolio GP has never been boring.
When I did my GP training, about half of the GP trainees undertook a self-made rotation of approved jobs, followed by a year in general practice to qualify. Some studied for MRCGP towards the end, and many transferred from other medical specialities.
If I had stayed in hospital practice it would have been geriatrics for me. I was a geriatric SHO for an extra nine months with some wonderful, knowledgeable geriatricians and later held a clinical assistantship on long-stay wards, the NHS’s equivalent to today’s nursing homes. During my first FY1 job I had been inspired by a compassionate and wise consultant geriatrician, appreciated and admired by patients and staff alike.
Years later, as a salaried GP, my practice manager forwarded me an advertisement seeking medical cover for community hospital beds; he said that the practice was not interested, but what about me?
I continued with some GP sessions but had a wonderful 10 years as part of a multi-disciplinary team looking after mostly older people and learnt so much about rehabilitation, pragmatic discharge planning and cross-organisational working.
I also worked in virtual and community wards, providing enhanced care in their own homes to patients at risk of admission to hospital and even dipped my toe in commissioning waters – discovering that I definitely got more satisfaction from patients than meetings!
We can spend more time, and focus on these complex patients as well as developing services offering more proactive and holistic care, than is possible in traditional general practice.
The community hospital moved onto the acute hospital site for a few months’ rebuilding work and I rediscovered my curiosity about the best that specialist medicine could offer to older people. The clinical director offered me an unfilled post for a community geriatrician.
So my job title of Interface Medicine GP was invented, and I have had a rollercoaster four years managing moderate and severe frailty around an acute setting. These patients de-compensate significantly in response to a minor stressor and so are admitted and treated aggressively, but then take a long time to recover – if they do at all – and are often confused, de-conditioned and institutionalised by their prolonged hospital stay. For some, a team – of which I was part – could prevent the admission, but much of the work is smoothing the path to a rapid and effective discharge when hospital no longer offers a net benefit.
It was from these experiences that I felt the need for mutual professional support. Some geriatricians expressed unease that a “mere GP” can undertake some of their role successfully, albeit differently. And some GPs are not aware of the complex issues involved for people with greater degrees of frailty who particularly need continuity of care, advanced care planning and the necessity of good communication with them, their carers and other professionals coming into contact with them.
Over time I’ve probably learnt more than the average GP about the geriatric giants summed up recently as the 5Ms—mind, medication, mobility, multi-complexity and matters most. My knowledge of acute medicine has been updated, but I am not keeping entirely up to date with the latest guidance on contraception, child health etc because I do not think there is enough space in my brain or time to cover it all thoroughly.
However, I reject the concept of being a second-class geriatrician: through conferences, following up leads from appraisers and some good luck, I have now met a growing number of GPs working in a variety of new models of care. We can spend more time, and focus on these complex patients as well as developing services offering more proactive and holistic care, than is possible in traditional general practice.
We have borrowed and modified some geriatric tools-of-the-trade such as multi-disciplinary team working, and merged this with the primary care team model with which we are already familiar.
One of the most striking observations for me returning to an acute care environment after many years’ break was noticing how differently hospital doctors communicate with patients. I started taking a folding chair with me on ward rounds so as not to stand over patients, and resented the lack of privacy in multi-bedded bays separated only by a fabric curtain from the next patient and their visitors.
I have come to love the simple, cheap communicator boxes provided by audiology departments, operable by arthritic hands whose eyesight may also be failing, unlike the miniature hearing aids of today. The patient has a chance of stating preference and even refusing unwanted interventions!
I’ve also developed a reputation for taking on “difficult patients and families”. I had the advantage of greater control over my time than some other doctors, but mainly observed that apart from a small, consistently dissatisfied minority, these “difficult” individuals wanted time, honesty, clear communication and respect. Caring (well) for someone with multi-morbidity, frailty and/or cognitive impairment is tough.
Guidelines do not currently adequately cover most of these medical situations, but providing good personalised and palliative care for patients with significant frailty is possible. The subtitle to my job has been inaccurately described as “shall we just not” when another blood test, MRI scan, clever diagnosis and prolonged hospital stay will not benefit the patient.
So just over a year ago a handful of GPs, including me, decided to form the GeriGP group within the BGS, which has been wonderfully supportive. We are going from strength to strength: we have been consulted by national bodies on policy, and are conducting a survey of our members on how they are working to support older people with frailty. We have also given presentations at BGS conference and are working on appraisal, qualifications and professional development opportunities in this area.
And if you are a GP who has other medical interests, there may be surprising opportunities and interesting possibilities to counter the prevailing despondent mood in primary care. If you are particularly jaded, a few of the GeriGPs have been able to turn an interest into their main employment, preventing some from leaving medicine altogether.
It has been an interesting journey, and an amazing opportunity to follow a medical discipline for which I have a special fondness, especially being able to apply many of the nuances of my practice as a sessional GP.
Eva Kalmus
evakalmus@doctors.org.uk
@DrEvaJK
