Frailty is a state of vulnerability resulting from a cumulative decline in reserve and function over a lifetime, until a minor stress event triggers a disproportionate change in an individual’s health status. Using an example of pneumonia as the stressor, people with frailty can present typically (with a cough and shortness of breath) with their frailty status identified through routine screening tools, or could present with subtle symptoms and signs that are not classical of the underlying pneumonia, where instead the pneumonia triggers a frailty syndrome (12). Frailty syndromes include falls, delirium, immobility, incontinence and susceptibility to the side effects of medication (12), meaning that mobility problems or behavioural changes are often the only signal that a new disease episode of different organ-origin occurred (13).

The impact of frailty on clinician decision-making and management-planning is complex. Clinical trials and national guidelines often do not include older patients with frailty, which necessitates pragmatic decision-making based on clinical experience (13), and clinicians must also consider increased susceptibility to iatrogenic complications and uncertain prognosis (14). Frailty is often considered a more elegant way than chronological age to justify making management decisions that stratify resources, yet despite being clinically ubiquitous it remains difficult for many to comprehend and factor into practice (15, 16). It is important for HCPs to look beyond survival as the only relevant outcome, as people with frailty often favour quality over quantity of life (13), and medical students can struggle to understand this (17).

Clinical reasoning is the cognitive process that underlies diagnosis and management (18), comprising both subconscious pattern recognition (system one), and conscious step-by-step analysis (system two) (19). The recurrent use of system two eventually leads to processing through system one, and this decision then becomes intuitive when it recurs (19). The clinical reasoning around an acute decompensation in a person with frailty is challenging, in that it does not fit into a discrete illness script, nor is frailty easy to deduce analytically. It is likely to cause challenges in formulating differential diagnoses and in deciding appropriate management strategies for medical students who lack experience and exposure, seeing only a brief ‘snap shot’ of each patient’s medical journey. It is our recommendation that HCPs convey their uncertainty surrounding the identification, prognosis, and management of frailty to students, and attempt to verbalise the cues they have used to inform these decisions.

Frailty spans multiple systems and patients with frailty are looked after across different healthcare environments and clinical specialities (20). In view of this, and the challenges in clinical reasoning, it is difficult to know how, where and at which stage of training, to introduce the concept to medical students. Currently, most UK medical students are taught in a modular manner, with healthcare broken down into body systems or clinical specialties, which is arguably inadequate to address the complexity and ubiquity of frailty. Thus, it is our recommendation that patients with frailty should be encountered by medical students longitudinally over the course of several units across several years of medical school, and not in a single module or specialty. Longitudinal weaving of such complex themes may widen the scope of reference on which students can build their clinical reasoning skills, to ‘see’ frailty in different contexts, with opportunity to understand the roles of the wider multidisciplinary team. Furthermore, seeing people with frailty over time enables medical students to view frailty as a spectrum that is dynamic in nature, which can help to reframe unhelpful ‘snap shot’ perceptions of older people with frailty (21). Longitudinal clerkships have been trailed with success across geriatric medicine and dementia (3, 22), and are recommended by the British Geriatrics Society (5). The community has been found to be a particularly rich environment for learning about and with patients with frailty (20).