For our Year 4 electives, we signed up for the Geriatric Surgical Service (GSS) elective, which was part of the Learning Oriented Teaching in Transdisciplinary Education (LOTTE) programme at Khoo Teck Puat Hospital (KTPH). Through exposure to general surgery, geriatrics and other disciplines, we had the chance to appreciate the value of transdisciplinary, patient-centric care.
The GSS in KTPH was first established in 2007, with the aim of developing more holistic care for elderly patients undergoing surgery. It was recognised that this subset of patients had more complex needs that could not be managed by merely one physician but required the assistance and input of multiple disciplines. They also often had more individualised goals that needed to be carefully discussed for their care. The GSS hence aims to bring together various members of the healthcare team (such as the general surgeon, geriatrician, nurse, anaesthetist, cardiologist, dietitian and physiotherapist), to work together in caring for geriatric surgical patients. While the idea of multidisciplinary care is not new, it may result in fragmentation of care when different disciplines work separately. The GSS was borne out of the hypothesis that a model with one dedicated transdisciplinary team, working together and committed to patients' goals of care, would produce better healthcare outcomes.
The journey begins
On the first day of our posting, we joined a family conference with a general surgeon and a geriatrician, as well as the patient Mr T and his family. Mr T was an elderly nursing home resident presenting with impending intestinal obstruction secondary to a colorectal tumour. The case was a complex one, as Mr T had significant comorbidities and was cognitively impaired. A clinical decision for "Do Not Resuscitate" had been made previously. There were many considerations regarding the next steps in his management – Mr T's comorbidities, poor baseline function and the new problem of a cancer with impending obstruction needed to be put into context. We saw how both the surgeon and geriatrician constantly brought the focus of the conversation back to Mr T and his goals of care. Mr T enjoyed eating good food, and that never failed to bring him joy. With that in mind, the decision was ultimately made for him to undergo a surgical procedure with the primary goal of allowing him to be able to eat without performing any overly invasive intervention. This was to be achieved with a diverting loop colostomy for symptomatic relief of the intestinal obstruction. The family conference set the tone for our elective – the holistic, transdisciplinary nature of care which was centred upon the patient and his/her goals of care.
We had a multifaceted experience over the course of this elective posting. In addition to attaching ourselves to transdisciplinary ward rounds, clinics and the OT, we had opportunities to follow the specialty and advanced practice nurses in doing the geriatric assessments for patients, and to sit in on team meetings involving the dietician, physiotherapist and case manager in evaluating their respective care goals and needs for the patient.
We also spent time speaking with the patients before and after their surgery. Besides gaining a keener understanding on their symptoms and post-operative concerns, we learnt a great deal about their unique and individual life stories as well. This collective experience embodied the spirit of the GSS ideology of journeying with the patient "from start to finish", which enabled us to better empathise with the patient's experience holistically at various time points as well as to further our understanding of the perspectives of our allied healthcare team members.
Frailty was a new concept we grew to appreciate during our elective; the reduced functional reserves an elderly patient has leaves him/her more vulnerable to insults. While many of us were familiar with the concept of post-operative rehabilitation, our mentors introduced us to the concept of "prehabilitation" – optimising a patient's functional status pre-operatively. We saw how an individualised prehabilitation programme to improve a patient's functional reserves could make such a profound difference in the post-surgery outcome. As we journeyed with our patients and reflected on some of their pre-operative and intraoperative considerations, our mentors constantly reminded us that the goal of simply reducing the mortality and morbidity of the peri-operative journey was inadequate. What was even more important was to empower patients to lead meaningful lives even after surgery.
During our time with the GSS, we also realised first-hand the improvements a transdisciplinary model of care has made to current standards of multidisciplinary care. This was demonstrated to us in numerous ways, from the collaborative approach in engaging a patient's family, to seeing a surgeon perform geriatric assessments, and sitting in on team meetings involving allied health professionals collaborating to form a comprehensive picture of the patient's care needs. It was impressed upon us that the dissolution of silos between disciplines is pivotal in providing integrated unfragmented care, while reducing ambiguities and points of inefficiencies. On a meta level, this also means that the patient can truly be cared for as a unique individual, as opposed to a loose collection of medical and surgical issues to be addressed separately by different specialists. In other words, a transdisciplinary model enables the delivery of a more humanistic form of care, with the patient at its centre.
The many lessons learnt
The primary focus of our training as students has been to build a foundation of medical knowledge, amass clinical experience, and refine our clinical acumen and reasoning skills. Experiencing an elective posting with the GSS, however, has shown us the value of going beyond developing our skills as future doctors, to examining and rethinking the processes in the provision of care for patients.
From understanding the philosophy and growth behind the GSS, we learnt the importance of thinking from the perspective of the patient in his/her journey within the healthcare system, identifying unmet needs and potential solutions from the systems level. Re-engineering the patient's journey from the reorganisation of logistics and resources can also go a long way in improving outcomes for the patient. Even at the time of our posting, we were heartened by the efforts of the GSS team in furthering knowledge to improve current protocols, such as the identification of sarcopenia among patients as a prognostic factor for surgery, allowing for a more informed decision in proceeding with surgical treatment.
Our time with the GSS has challenged our perspectives on the way care should be provided for our patients. The unit's outcomes are a testament to what can be achieved by putting the patient first. As students, we are deeply encouraged to apply these lessons in our future practice.
Acknowledgements
We would like to express our heartfelt gratitude to A/Prof Tan Kok Yang, Dr Daniel Lee, Dr Priscilla Ng, the transdisciplinary team at the GSS, the LOTTE programme, as well as every patient we have encountered in our short elective journey for this very fruitful learning experience.