S4E9: EM fellowships and the Role of the GEM Specialist - GEM bonus
Ever wondered how to pursue an EM fellowship after finishing your SpR training? Is it worth it, and if so what are the benefits of doing a fellowship? We’re very excited to welcome back a familiar voice to our bonus episode this week to answer these questions and more!
TCR alumnus Dr Deirdre Breslin joined Geriatric Emergency Medicine (GEM) lead Dr Conor O’Gara to chat all things fellowships, frailty and finding out what to do with your interest in GEM.
Dr Breslin is an EM consultant in the Mater Misericordiae University Hospital (MMUH). She has a special interest in GEM, having worked as the TCR production lead in GEM and completed a GEM fellowship prior to taking up her consultant post. Her insights and tips make this both an interesting and important discussion.
Coffee in hand? Right then, let’s get to it!
Why Geriatric EM?
Like many tempted by Emergency Medicine (EM), Dr Breslin had many avenues she was interested in pursuing. Ultimately a combination of her personal and professional experience led her down this path. Increasingly GEM is being recognised as a fundamental area in EM, and after witnessing the benefit to patients of receiving quality GEM care and finding good career opportunities within the sub-specialty, her course was set. Providing comprehensive GEM care can enormously improve patient outcomes, and in this growing area there are tons of measures that can be taken to make further improvements.
Fabulous Fellowships
While she makes it clear that fellowships are optional, Dr Breslin delves into the advantages she’s found of completing one. There are a few options, both abroad and in Ireland. Leicester in the UK is a hotspot for GEM training, while many also jump on a plane Down Under. Dr Breslin began her Geriatric Emergency Medicine fellowship in the Mater Hospital through the Aspire programme - fellowships that are released by different departments in Ireland each year with different focuses.
For SpRs thinking of following in Dr Breslin’s footsteps in seeking out an Aspire Fellowship, she recommends talking to the relevant department early to show interest and maybe even have input into the specific focus of the fellowship before funding is sought.
The GEM Fellowship was just what Dr Breslin needed after her SpR training to decide her aims and focuses going forward as a consultant. Working under the supervision of Dr Vinny Ramiah (Silver Trauma and EM Consultant) and Dr Colm Byrne (Consultant Geriatrician), she spent time working in a variety of GEM services. Rotating through the Frailty Intervention Team (FIT), the Silver Trauma Review Clinic, Integrated Care Team in the community and other areas such as Psychiatry of Old Age, Dr Breslin got a comprehensive picture of the GEM services available and how they can help improve patient outcomes.
Emergency fellowships in Ireland tend to be around 1-2 years long depending on the area of interest. While many opt not to complete one, Dr Breslin highly recommends it as a time to get involved with non-clinical work on various projects, as well as getting a clearer picture of what you want your work to look like to help you hit the ground running as a consultant.
More on GEM
The Silver Trauma Review Clinic in MMUH is a unique service allowing a comprehensive patient-centred review of frail or pre-frail elderly patients after a non-operative traumatic injury a week or two post discharge from the Emergency Department (ED). Run by consultants in geriatric medicine and EM, a physiotherapist and advanced nurse practitioner, it goes beyond injury assessment, recovery and function, and looks into optimising the patient overall. From assessing the cause of falls (commonly associated with orthostatic hypotension requiring medication review), to investigating the need for bone protection going forward, it looks at preventing further events and helping patients to live less limited lives. From there, they can be linked with relevant services, or get set on the right injury pathway e.g. early MRI for vertebral compression fractures.
Pearls for GEM: a note on Frailty
Frailty is a common comorbidity in elderly patients. Dr Breslin discusses the challenges in managing these patients and the importance of early identification of the frail patient to allow targeting of the 5 Ms of Geriatrics: Medications, Mind, Mobility, Multi-complexity and what Matters most. In the Mater Hospital, patients are screened at triage with the VIP score, allowing for early referral to the FIT (Frailty Intervention team). Frailty assessment is also vital for all clinicians to determine goals of care and the appropriateness of interventions.
Frailty Intervention Teams (FIT)
FIT teams are multidisciplinary groups aimed at providing comprehensive and patient-centred care and support to frail elderly patients coming through the Emergency Department. The team is led by a consultant geriatrician and made up of Physiotherapy, Occupational therapy, Speech and Language therapy, Pharmacy, Dietetics, and Social work. From Monday to Friday, a member of the team will perform a Comprehensive Geriatric Assessment (CGA) on most frail patients in the ED, and collaborate with the rest of the team to meet the needs of the patient while they receive emergency care and treatment. Those presenting outside of this timeframe will be invited to a Frailty Review Clinic for their CGA.
Optimising care for geriatric patients
How can EM physicians provide good quality GEM care for their patients? Dr Breslin discusses tips that we should all know when caring for these patients. Non-pharmacological measures to maximise patient comfort and minimise the chances of developing delirium are key, such as ensuring adequate nutrition/hydration, using appropriate lighting and making their sensory aids available to them. Clinical Frailty Scores should be used to guide treatment goals and prognosis, and to communicate the patient’s status while making referrals. Luckily, Dr Breslin knows of an App to make this more straightforward!
Click here for the app for iphone
Click here for the app for android
GEM Magpies
Interested in GEM? Good thing we have an expert on side. Dr Breslin directs us to GEM special interest groups in EUSEM and IPHEM that she recommends joining. They provide research, education (with workshops and events) and opportunities to get involved with teaching.
TCR did a 7 episode GeriEM collaboration series from EUSEM with corresponding posters covering topics all the way from the Comprehensive Geriatric Assessment to palliative care in the ED - they’re definitely worth a listen and you can find the link to all the individual Spotify episodes and posters here.
If you’re lucky enough to work in a hospital with a Frailty Intervention Team, go talk to them! Get to know the system and how to navigate it, as well as learning from their approach to CGA. Another easy way to get involved is to speak with other doctors interested in the same specialty. Seek out consultants involved in the area to discuss all things GEM, and why not start a discussion on our socials with other like minded people tuned in to the episode! With more and more focus being put on improving outcomes for these patients with advancements in GEM care, it’s an exciting time to be a part of this community.
