Professor of Medicine and Old Age Neuroscience (Nuffield Department of Clinical Neurosciences)
Consultant Physician (Oxford University Hospitals NHS Foundation Trust - OUHFT)
Tell us a bit About your role
I am a Consultant Physician at Oxford University Hospitals NHS Foundation Trust (OUHFT) and Professor of Medicine and Old Age Neuroscience at the University of Oxford. I studied pre-clinical medicine at Cambridge followed by clinical medicine at Oxford and was a junior doctor in London and on the respiratory unit in Grenoble, France, where I worked on the chest unit and completed a research project on obstructive sleep apnoea. I returned to Oxford in 1995 and completed my DPhil in 1999 in MR imaging in stroke recovery before returning to clinical work in acute medicine and geratology. I had three daughters, 2002-2006 and in between periods of maternity leave, I worked three days a week in acute medicine becoming a locum consultant in 2005. In 2008, I was appointed to a part time NIHR Oxford Biomedical Research Centre consultant physician post.
I now work 4.5 days a week still at 50/50 in clinical and research work. My clinical duties include stints of acute internal and complex medicine as well as specialist clinics in memory and multi-morbidity. I am OUHFT Clinical Lead for Dementia and Delirium working closely with the Electronic Patient Record (EPR) Team to implement changes to the process of care for older and frail patients. My research is largely integrated into my clinical work and is focused on the short- and long-term cognitive impacts of acute (systemic) illness and cerebrovascular disease with a substantial translational component. I have supervised numerous junior doctors, medical students and visiting fellows as well as clinical, non-clinical and nursing doctoral candidates. I am a member of the editorial boards of several leading journals, lead author of several books, and senior editor of a series of case-based learning books covering medical/surgical specialities. I have participated in TV, radio and newspaper features on dementia and delirium in the hospital setting.
I see my role as bridging the gap between the clinical coal face of acute medicine and the often more rarified world of medical research. Studies on older frail patients and acutely unwell in-patients are challenging and require a cross disciplinary approach but are key to planning services and improving care as well as understanding mechanisms. I have links with researchers in neuroscience, psychology, imaging, population health, informatics and health economics as well as with clinicians across a broad range of specialties including not only general medicine and geratology, but also stroke, infectious diseases, palliative care, and general surgery. This facilitates a broad research programme encompassing service development, quality improvement, and technological developments through to understanding the role of acute illness, multimorbidity and frailty in cognitive and functional decline.
What is the most meaningful aspect of your work?
The most meaningful aspect of my work is in seeing the improvements to the process of care for older patients over the last 10 years as a result of research, audit and service improvement. In 2010, almost none of our older patients had an assessment for cognitive problems or for aspects of physical frailty which meant it was difficult to individualise care. Many patients were discharged without the appropriate help for medication administration or were asked to sign consent forms for procedures when unable to give informed consent owing to (unrecognised) cognitive impairment. Now nearly 90% of OUHFT in-patients aged 70 years or above have a cognitive assessment and we have demonstrated a six-fold improvement in identification of delirium between 2010-2018. Robust embedding of cognitive screening into routine clinical practice means that it has been possible to build our delirium risk score as an algorithm in the electronic patient record to flag patients at-risk in real time.
Can you tell us about something you’ve done, contributed to that you’re most proud of?
I am most proud of developing, validating and implementing the OUHFT cognitive screen into the routine assessment of older OUHFT in-patients and those undergoing emergency assessment in the ambulatory care units. The cognitive screen is now performed in more than 20,000 patient episodes per year and has informed communication with patients and families, discharge planning, assessment of decision making capacity and consent processes and communication with primary care colleagues. Since 2015, the screen results have been recorded in the electronic patient record (EPR). I am now extracting these data to form the Oxford Cognitive Comorbidity, Frailty and Ageing Research Database (ORCHARD) which also contains data on illness severity, comorbidities and investigations including laboratory results and brain imaging. Studies using ORCHARD data are planned with the help of a Patient and Public Involvement (PPI) group and will be used to improve the care of older and frail patients. Studies include the speciality specific burdens of cognitive and physical frailty in the acute hospital in-patient population and impact outcomes, the accuracy of administrative diagnostic coding for frailty syndromes including delirium and the prediction of delirium and longer-term dementia risk.
What changes would you most like to see in the Medical Sciences in the next 100 years?
I would like to see a greater focus on clinical research with the greatest relevance to the population as a whole including ageing associated diseases and the ageing process including the development of frailty. I would like to see the intelligent use of artificial intelligence to support the work of clinicians bit not to replace them, for example, in the use of automated tools to aid standardised reporting of CT brain scans to aid clinical interpretation and risk prediction.