Shona Bell  -  25 August 2023

I first started seriously considering a career in geriatrics when I was in third year of medical school. I was on a general medical ward, and I went with a geriatrics registrar to see a lady in her late 80s with dementia who was a ‘social admission’. Although it would have been easy to have just written ‘medically fit for discharge’ in her notes and moved on, the doctor I was with helped her sit up in bed, refilled her water jug and drew her attention to the beautiful view out of the window. This was the first time I had seen that medicine could be like this and it excited me about medicine in a way that I had not experienced since I started university.

It was a little while after that that I first came across the field of community geriatrics and the Hospital at Home movement.  For me, it made perfect sense, an opportunity for elderly patients to receive quality medical care whilst staying in their own homes and avoiding the pitfalls of a hospital admission. It was in the British Geriatrics Society (BGS) magazine AGEnda that I first heard about the West Kent Home Treatment Service; I read an article from Dr Amy Heskett about her experiences working as a SAS doctor in the community and realising that that Home Treatment Service is down the road from where I grew up, I reached out to Dr Amy and we arranged a week of shadowing.

I did not really know what to expect and I was quite nervous that I might not actually like community geriatrics after having told everyone that that was what I wanted to do! I needn’t have worried though; I found a deep satisfaction from caring for older adults in the community. The balance of managing acute medical issues in the context of frailty, with the added twist of being in people’s homes and juggling dysfunctional key safes, narrow country lanes and enthusiastic dogs! It was certainly a challenge and required more flexibility and willingness to cope with uncertainty than with hospital as you can never be fully sure what you are walking into. Furthermore, although having access to point of care tests helped to quickly rule in and rule out differentials to aid in decision making, not having imaging meant relying more on the clinical picture and accepting a higher level of risk that the diagnosis might not be correct and also that patients might deteriorate at home. It is a fine line to walk but one I found exciting and stimulating.

Although I found that doing home visits across half a county meant a lot of time spent on the road and this could be frustrating and draining (particularly for someone who gets car sick!), I found it so rewarding simply seeing the look on people’s faces when we said that they did not have to go into hospital. Although some elderly patients may feel more comfortable being cared for in hospital, for a large proportion, it is a place that they fear that they will go into and never come out again. Not an unreasonable fear, particularly in the wake of the COVID pandemic. It was satisfying to be able to care for them at home and to put measures in place to ensure that anyone looking after them in future would know what their wishes are. It was also affirming just how happy everyone tended to be to see you! One of my favourite memories was of a lady in her eighties with mild cognitive impairment who lived alone and had had a fall, I did all the history, examination and investigations (very exciting for a medical student, my normal role on placement being to open and close curtains!) and she was delighted to have someone to talk to and so pleased when she could do something correctly and help me with the examinations. She kept telling me ‘what a lovely lady’ I was and told me to ‘drop in for a cup of tea’ any time!

Although working in the community can be daunting, I felt that I learnt a lot about pragmatic, caring decision making which is defined by the patient and their needs and that the community is not a controlled environment and you have to be prepared to accept a bit of chaos!