Introduction
In 2013, the Future Hospital Commission published a report outlining radical steps required to meet the needs of a changing patient population. This highlighted the need for medical care for all hospital inpatients, not just those on medical wards, stipulating that medical education and training must equip doctors ‘with the knowledge and skills to manage the future demographic of patients.’1 The Shape of Training Review, published in the same year, further emphasised the need for doctors to provide general care in broad specialties across a range of settings; whole patient, whole pathway medicine.2 To achieve this service provision, the review asserted that training should reflect the needs of the changing patient population. This requires training and services to be tailored to an older population where multimorbidity and frailty are frequently observed.3,4
This is particularly true in the case of surgical patients, where the population is ageing faster than the general population (1.8 vs 0.7 years per annum). It is estimated that by 2030, one-fifth of people aged 75 years and older will undergo surgery every year.5 While older patients have much to benefit from surgery in terms of symptom control and improved longevity, they remain at higher risk of adverse postoperative outcomes including postoperative complications, longer length of stay and functional deterioration resulting in institutionalisation.6,7
The emerging specialty of perioperative medicine aims to provide quality care for this high risk population through evidence-based medicine delivered throughout the surgical pathway. The Centre for Perioperative Care, launched in 2019, is a cross-specialty, multidisciplinary partnership led by the Royal College of Anaesthetists, which aims to orientate surgical services to the changing surgical population. One model of care advocated by this initiative involves the use of comprehensive geriatric assessment and optimisation (CGA) methodology employed through multidisciplinary, interspecialty perioperative medicine for older people undergoing surgery (POPS) services.8,9 In addition to clinical care, POPS services offer the opportunity to train clinicians in perioperative medicine tailored to a high-risk older population. Such an initiative is aligned with the perioperative agenda, recommendations from the Future Hospital Commission and the Shape of Training Review.
This article describes an innovative approach to training for foundation doctors in perioperative medicine for older people.
The POPS foundation placement
POPS is a CGA-based, geriatrician-led service at Guy’s and St Thomas’ Hospital, established in 2003. Foundation trainees (doctors in the first and second years of clinical practice after completing their medical degree) have been part of the multidisciplinary team since 2015. The POPS foundation placement follows a modular structure (Table 1) that aims to deliver generic capabilities and cross-specialty competencies (Table 2) based on a curriculum (see supplementary material S1) co-designed with foundation doctors and iteratively modified through weekly-feedback fora.10 The modular structure allows the foundation doctor to focus on inpatient medicine (2 months) and community facing medicine with sessions in outpatient clinic, theatre and community rehabilitee units (2 months). On-call commitment and annual leave is distributed throughout.
Modular structure of the foundation placement in perioperative medicine for older people undergoing surgery (POPS). Adapted from Rogerson A, Partridge JS, Dhesi JK. A foundation programme educational placement in perioperative medicine for older people: mixed methods evaluation. Anaesthesia 2018;73:1392–9.
Perioperative medicine for older people undergoing surgery rotation competencies and generic capabilities/transferable skills
Evaluation of the POPS foundation programme
Following its establishment in 2015, the POPS Foundation programme underwent a mixed-methods evaluation.10 Outcome measures included core foundation competencies, learning objectives in perioperative medicine and quality of training. Over a 2-year period, all POPS foundation trainees (n=68) achieved full portfolio sign off (indicating adequate opportunity to practice and record core foundation competencies). In addition, job satisfaction was also deemed to be higher in POPS foundation doctors compared with foundation trainees in standard surgical posts. The authors concluded that the placement ‘provides effective and enjoyable training in line with national recommendations regarding “whole patient medicine.”’ The learning experiences of two current POPS foundation trainees are illustrated below.
Edward (foundation year 1):
POPS has grown my confidence in decision making and ownership of patient care, which are essential foundations for any medical career. Through regular participation in multidisciplinary meetings, my clinical work is continually evaluated and improved. An invaluable learning opportunity.
Sarah (foundation year 2):
I now see that discussing risk is more than a tick box exercise; it is an opportunity to face realities and for the patient to be able to make truly informed decisions. In addition, I have realised that a key part of the optimisation and recovery process involves empowering and supporting patients to take ownership of their own health.
Conclusions
POPS is an example of a perioperative training programme. The POPS foundation placement not only delivers training on core foundation competencies and specialty-specific learning points, but also promotes key transferable skills that are essential to a cadre of doctors required to deliver ‘whole patient medicine’. POPS instils in its trainees the importance of comprehensive, evidence-based, patient-centred care and clear communication with patients, families and healthcare professionals to inform shared decision making. Juniors are supported to become competent in managing complex, multimorbid patients in a variety of settings across the whole patient pathway. They are also encouraged to appreciate the wider context of their work in relation to demographic trends, national reports and policy drivers. Through their quality improvement work, they have the opportunity to make positive change at the local and sometimes national level. Importantly, it is also enjoyable! Innovative foundation programmes such as this are required to meet the challenges ahead
Supplementary material
Additional supplementary material may be found in the online version of this article at www.rcpjournals.org:
S1 – Curriculum for foundation programme in perioperative medicine for older people
- © 2019 Royal College of Physicians
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