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Training in Geriatric Medicine in the E.U.
Introduction:
In Chapter 6 of the Charter on Training of Medical Specialists in the E.U., the requirements for the speciality of Geriatric Medicine are laid down. The Geriatric Medicine Section of the UEMS will be the Monitoring Authority in the E.U. National Authorities are responsible for the selection and approval of training institutions and teachers in accordance with national rules, EU legislation and recommendations from the UEMS Geriatric Medicine Section. Quality assurance of training programmes, training institutions and teachers also are the responsibility of the National Authorities in accordance with the same proviso.

General Aspects of Training in Geriatric Medicine
Selection of trainees should be in open competition and on an equal opportunities basis for doctors qualified in Medicine. At least a 2 year period of training in a common trunk in general internal medicine in a recognised programme, longer periods being up to National Authorities, would normally precede the 4 year period of specific training in geriatric medicine, which may include 1 year in research. Training would be based in the hospital sector and should be predominantly clinical, but would involve the community and other institutions in providing care. Established training programmes would be approved by the National Authorities and would include the biological, social and medical psychological aspects of diseases in older people. It is the duty of the National Authorities to regularly review the quality of the training centres the trainers and the trainees. The opportunity should be available for trainees to be trained in recognised training programmes in other UEMS member countries with the approval of the country of origin.

Requirements for Training Institutions
It is the responsibility of the National Authorities to lay down the criteria and monitor/supervise them. Training in an institution or group of institutions should offer the full range of geriatric medicine and should be in a setting which offers a high quality of service, audit and quality assurance and have established Research Ethics and Therapeutics Committees. Inspection visits by the National Authorities should be structured. The trainee must have space, opportunities for research and study and access to national and international professional literature.

Requirements for Teachers (Trainers)
The Head or Chief of training should be a practising specialist in Geriatric Medicine for at least 5 years. In centres where this is not possible then short term solutions need to be sought with the help of governing bodies and specialist societies. Trainers should produce a training programme which complies with national rules, EU directives and UEMS recommendations. There requires to be close monitoring of both trainee and their training programme. Each trainee should have an educational supervisor/mentor, who will be able to advise the trainee but who the trainee will not necessarily be working for, for the whole period of training.

Requirements for Trainees
The trainee should gain adequate experience of inpatients and ambulatory care patients. Trainees should have the ability to communicate with patients, their carers and to study the international literature including communication with foreign colleagues. The trainee must keep a personal logbook or equivalent up to date and in accordance with national rules, EU directives and UEMS recommendations.

Attaining Competency Trainees should be aware that to obtain competency they require to have knowledge, objectives and skill objectives which once acquired can be evaluated .

Knowledge, Objectives --> Behaviour and Skill Objectives -->
Evaluation --> Acquisition--> Competency

Skill objectives include acquiring communicative, diagnostic, therapeutic, rehabilitative, academic, teaching and research, and administrative skills.

Curriculum for Training in Geriatric Medicine
The curriculum needs to be broad and flexible and to include clinical practice, educational techniques, research and administration.

a) Basis of Care and Provision of Appropriate Services
The ability to understand the basis of care of all aspects of geriatric medicine and the provision of the appropriate service requires knowledge of:
  • the process of ageing, age-related diseases and its effects on the central nervous system and the major organs, the immune and homeostatic systems, and locomotor function and mobility
  • ageism
  • adaptive changes with ageing effects e.g. effects of exercise, chronic disease
  • the demographic features of ageing both nationally and internationally
  • epidemiology of diseases seen in old age
  • prevention of illness in old age
  • the result and interaction between disease and disability e.g. stroke, hip fractures
  • the principles of care in a patient's own home and provisions for day care.
  • the principles of palliative and terminal care
  • the principles of medical ethics
  • basic pathology relating to ageing, and diseases of old age and the value of autopsy.

b) Assessment and Treatment The ability to provide assessment and treatment of patients referred for specialist geriatric medical opinion of acute medical problems and chronic disabling illness requires knowledge of:
  • the presentation of multiple problems and complex disability sometimes in an atypical manner
  • functional impairment
  • disorders such as stroke, Parkinson's disease, epilepsy
  • ischaemic heart disease, heart failure, hypertension, postural hypotension, arrhythmias and peripheral vascular disease
  • falls and dizzy turns
  • respiratory disorders such as chronic obstructive pulmonary disease, asthma, infections including tuberculosis, respiratory failure, neoplasm and pulmonary vascular disease
  • gastro-intestinal disorders such as peptic ulcer, malignancy, motility disorders, jaundice, faecal incontinence and constipation
  • genito-urinary disorders such as incontinence, prostatic disease and infection
  • locomotor disorders such as the arthritides (osteo and rheumatoid arthritis), metabolic bone disease including osteoporosis, and connective tissue disorders
  • endocrine and metabolic disorders such as diabetes, thyroid disease
  • renal disease and electrolytic disorders and dehydration
  • haematological disorders such as anaemia, lympho- and myelo - proliferative disorders
  • visual, hearing and dental disorders
  • dementia, delerium, depression, acute psychosis and management of behavioural disorders
  • cutaneous disorders such as pressure sores, leg ulcers and foot care
  • nutritional and feeding disorders.
  • drugs, their actions, adverse effects and interactions.
(The above list is by no means exhaustive but covers the disorders in which the trainee should become competent to manage).

The trainee would also be expected to have knowledge of the appropriateness of investigation, treatment options, drug interactions, adverse effects of drugs and compliance problems in this age group. The trainee should develop skills in the prognosis of specific illness and in assessing and treating older patients in their home, as inpatients and as day patients. The trainee should have knowledge of the role of the interdisciplinary team, the supervision and deployment of junior medical staff, and the provision of a service for older patients in other hospital departments.

c) Rehabilitation Service
The ability to provide a rehabilitation service for older people requires the knowledge of:
  • the expectations and limitations of rehabilitation
  • the contribution of the other members of the interdisciplinary team including nursing, physiotherapy, occupational therapy, speech and language therapy, dietetics, social work etc.
  • the selection of the most appropriate environment for rehabilitation as inpatient, day patient, or in community measures of assessment of functional status and outcome.
  • It also requires the management skills to promote team development and leadership qualities. The trainee should be aware of the role of informal support, carer strain, elder abuse and the involvement of carer in goal setting and clinical decision making.
d) Discharge Planning:
The ability to undertake effective discharge planning requires knowledge of:
  • the determinants of discharge including functional level, environment, social support, financial support and the role of the voluntary sector, assistive devices and adaptations to the home, the different types of accommodation and the various levels of care in the community
  • the expectations and limitations of social relief/respite
It also requires skills in:
  • utilising interdisciplinary assessment
  • developing links with primary healthcare and social services
  • counselling
  • integrating packages of care, including social relief/respite which may be planned or acute
e) Assessment for Long Term Care
The ability to make appropriate medical assessment for those older people needing long term care requires knowledge of:
  • current national guidelines on responsibility for long term care
  • the determinants which indicate the appropriate institution
  • the medical, nursing, psychological and social needs of these patients
  • the ethical issues relating to highly dependent individuals
Skills are required in counselling patients, relatives and carers.

f) Research
The ability to undertake research depends on the knowledge of:
  • the principles of clinical research
  • the ethical issues of undertaking clinical research
  • the evaluation of medical literature and the presentation of a critical literature review.
Trainees should be able to promote, supervise or participate in appropriate research and should present or publish a project or programme.

g) Medical Education
The ability to contribute to medical education requires knowledge of:
  • the educational objectives set locally for undergraduate teaching
  • the educational needs of other training grades
  • the educational needs of other health care workers
  • the basic educational methods to develop communication skills
h) Development of Geriatric Service
The ability to contribute to the development of geriatric services requires knowledge of:
  • the demography and population projections in the area
  • the service provision and resources required
  • alternative models of geriatric care
It also requires the demonstration of interpersonal skills with professional colleagues and management.

i) Administrative Duties
The ability to carry out administrative duties relevant to a consultant function requires knowledge of:
  • junior staff employment including on-call commitments and study and holiday leave
  • medico-legal matters such as complaints, and testamentary capacity
It also requires the acquisition of skills in:
  • interviewing techniques
  • communicating with general practitioners
  • committee work
j) Contribute to the Nation's Health Service
The ability to contribute to the running of the health service requires the knowledge of:
  • national government health strategies
  • the structure and funding of the health care system
  • the structure and funding of the social care system
Skills require to be developed in applying the above to the local geriatric service, and the ability to inform Public Health and planners of the necessary requirements.

k) Clinical Audit
The ability to undertake and contribute to clinical audit requires the knowledge of:
  • the principles of clinical audit
  • the principles, expectations and limitations of performance indicators
  • the different methods of audit which apply to geriatric medicine
l) Professional Development
The ability to ensure personal professional development requires knowledge of:
  • personal continuing medical educational needs
  • the requirements for continuing medical education and its organisation for career development
Skills should be developed in:
  • dealing with complaints and the handling of mistakes so that there is learning from them.
  • utilising resources available for continuing medical education
  • the needs and management of the trainee: own department
With the completion of the curriculum, it is expected that the trainee will demonstrate competence to allow appointment to a consultant/specialist in geriatric medicine.






Last modified: 2009-01-14