Description
As I write this editorial it is hard to believe in global warming, what with hailstones in June. Nonetheless, I remind my trainees that attention to 5 day weather forecasting is an important aspect of caring for frail older people. Anticipating heat waves should remind us to: recommend reductions in diuretics; omission of ACE-inhibitors or NSAIDs in those who may have difficulty maintaining adequate fluid input (probably all on our acute wards, most on our rehabilitation wards, most care home residents and all on the case-load of community matrons); anticipate increased incidence of constipation in the same cohort; and remember that these same groups of frail elders will also have problems with thermoregulation. I recall the words of my emeritus colleague, Nick Coni, There is no such thing as the National Health Service . but there is a National Crisis Intervention Service. Nicks wisdom influenced me to consider ways that I might pre-empt the crises and plan ahead, not quite what is usually meant by preventative medicine but that is what it is. The metaphor I use with my trainees is that a mini driver can only see the rear of the car ahead and can only plan their journey according to the distance between the two cars, whereas a long-distance lorry driver can plan their journey based on their observations of the flow of traffic over several miles ahead; this is a simple metaphor for understanding the trajectory of disease and being aware of other factors that might alter that trajectory. Good driving to you all and may both you and your patients suffer fewer crises!
In this volume of the journal I have included the first in a series of articles themed around education and learning. These articles do not lend themselves particularly to best of five MCQs and so the authors have been denied the pleasure of producing these. I hope that this series will be of interest to the readership, trainees and trainers alike and would value hearing you views.
The article on osteoporosis is something of a tour de force and although rather long does not readily lend itself to sub-division in to two separate articles. If, like me, you occasionally have to fall back on the diagnostic shorthand SDSD (Some D***ed Skin Disease) hopefully Liddle and McDonaghs article will widen your diagnostic skills. Biju and OMahony remind us of the important changes in pharmacokinetics and pharmacodynamics with ageing. It never fails to amaze me that, when I frequent the pubs of my home town (Manchester), the average Northerner understands that they can not drink as much in older age as they could in their youth, yet many doctors appear unable to translate this common knowledge of age-related changes in drug metabolism in to their prescribing habits!
Finally, the government has announced that increased funding for the NHS runs out in 2010. There surely has never been a more important time for fragile services such as Geriatric Medicine to ensure they can justify their service by robust data gathering through audit, clinical governance and cleaning up hospital data-sets to accurately reflect what we do. However, if your unit is being benchmarked with comparator Trusts do ensure that this is not a comparison of bananas and mangoes. Know who you are being compared with and check that this comparison is reasonable; failure to adjust for differences in case-mix (admission criteria), community support services (early supported discharge), differences in local populations, ethnicity, frailty, standardized mortality rates, and so on may result in your Chief Exec seeking efficiency gains, reductions in length of stay from your unit that are unrealistic based on false comparisons. As for your everyday ward work may I commend to you what are becoming known locally as the Forsyth Ws for directing the multi-disciplinary team discussions:
Why is this patient here (what is wrong with them)?
What do WE need to do about it (treatment and investigation plan)?
When will it be done?
Who is going to do it?
What do we hope to achieve and when do we expect to achieve it (goal setting and predictive discharge dates)?
Why cant they be managed elsewhere (do they have to be in this setting, what of the above could be done elsewhere and where is the elsewhere)?
Why have we not done what we agreed needed doing (where does the problem lie)?
