Download AN INTERNAL MEDICINE GERIATRIC MEDICINE CURRICULUM

FAMILY PRACTICE RESIDENCY PROGRAM
GERIATRIC MEDICINE
CURRICULUM
Oleksandr Pishchalenko, MD, PhD.,
University of Hawaii at Manoa
John A. Burns School of Medicine
2003
A FAMILY PRACTICE RESIDENCY GERIATRIC MEDICINE CURRICULUM AND
LITERATURE REVIEW AND NEEDS ASSESMENT
Literature Review
Geriatric Medicine has become increasingly more important in the education of Family Practice
residents. The aging of the American population brings new challenges to all areas of health
care. Since the turn of the century, the population 65 and older has grown from 4% to 12%, with
that 12% using one third of all healthcare dollars. (31) The proportion of the total population
aged 65+ was 11% in 1980, and it is projected to reach 20% by year 2030. Because of Hawaii’s
long life expectancy, the longest of any state in the U.S., the proportion of people 65+ in Hawaii
is expected to reach 20% much sooner, currently projected at year 2010. The impact on society
with one in five people being aged 65 and older will be enormous, affecting the social fabric of
the state, and of the country. For family practitioners, interested in intergenerational issues, this
means that more families will have four, or perhaps five generations. More grandparents and
great-grandparents will survive to anchor children in the histories of their own families.
Current changes in demographics include a dramatic increase in the numbers of older people in
the United States, particularly in the group aged over 85 years. The number of individuals over
age 85 rose from 370,000 in 1940 to 2.3 million in 1980, and it is estimated to grow to 12.8
million in 2040. Further, older people represent a disproportionately large part of all medical
consumers. Individuals over age 65 use hospitals at 2.8 times the rate of those under 65 and
account for 29% of all health care expenditures in the United States. (13) The over-85 age group
uses hospitals twice as frequently as those aged 65 to 69, although the total costs per individual is
less that those aged 65-74. Although only 5% of people aged 65 and older reside in nursing
homes, those over age 85 have a one in four chance of spending some time in one, either for
rehabilitation post-hospitalization or for permanent placement. Approximately one-third of all
Americans will reside in a long-term care facility before they die, and many who require
palliative care may reside there during the final weeks and months of their lives. (27) When
considering all types of healthcare services, it is predicted that by the year 2020, those who are
65 and older will use nearly half of the nation’s health care services. (13)
Counter to popular belief, and counter-intuitively, over the age of 75 the average costs of
healthcare per person decreases in the two years prior to death, with the lowest costs attributable
to those 85 and older. The highest utilization of healthcare services are in the last 2 years of life,
regardless of the age of death. This is true across the age spectrum, from pediatrics to geriatrics.
The highest costs are in the group aged 65-74. (32) Family Practice can have a significant role to
play both in keeping people healthy across the age spectrum and in reducing costs. Those aged
65-74 with the highest health care costs are those who are most likely to continue to be cared for
by the family practitioners who have been caring for them and for their family for most of their
adult years. The opportunity to apply the principles of preventive medicine and secondary
prevention are great.
Over the last decade, there have been remarkable advances in the understanding of the aging
process and in the approaches to the management of frail older persons in the United States. (4,
14). The field of geriatric medicine focuses on the whole person by dealing with multiple,
complex, and interrelated conditions that can ultimately result in functional decline and the loss
of independence. Geriatric medicine promotes wellness and preventive care, with an emphasis on
maintaining functional independence and improving overall quality of life.(5)
Many problems emerge after the age of 75, when prevention, risk-factor modification, atypical
presentation of disease, multiple chronic conditions, and intervention run counter to traditional
principles of internal medicine used in caring for middle-aged adults. Social isolation, emotional
vulnerability, and poverty complicate these problems and make interdisciplinary care mandatory
for optimal treatment. Older patients react differently to medications, and it is common them to
be taking multiple drugs and nutritional supplements.
Too frequently, illnesses in older people are misdiagnosed, overlooked, or dismissed as a part of
the normal process of aging, leading to needless suffering for the patient and family and higher
costs to health insurance providers. Lack of proper training of physicians of the geriatric
population results in more hospitalizations, more visits to specialists, preventable nursing home
admissions, and higher costs to the healthcare system. Few physicians today would provide
medical care for children without proper training. The care of older people is similarly distinct.
While geriatric medicine has a core of specialized internal medicine, it also includes knowledge
of a wide range of other fields, such as family medicine, neurology, pharmacology, psychiatry,
psychiatry, urology, and others that make it a true age-based specialty of its own.(5)
As educators of tomorrow's doctors and as providers of health care services, medical schools and
teaching hospitals are very aware of how society's needs are changing. The nation's population is
aging. Older Americans are now living healthier, better quality lives as we have become more
adept at forestalling the onset of disease through scientific interventions. However, there are
identifiable groups of older persons who are frail and more vulnerable and require significant
resources and access to services.
Medical education is a complex and long process. There are no "quick-fix" solutions to shifting
the medical education paradigm, but medical educators are taking steps to ensure that newly
trained physicians are well-schooled in providing high quality health care for our senior
Americans.
Medical education takes place along a continuum, starting with four years of undergraduate
medical education. In these years of medical school, students learn content, that is the
knowledge, skills, values and attitudes needed for the practice of medicine and are exposed to
clinical practice. They graduate as "undifferentiated" physicians. Medical school generally is
followed by three to seven years of graduate medical education (GME) in a clinical setting. In
their residency years, new physicians apply the content of undergraduate medical school to
patients in clinical settings and specialize in their chosen discipline. As practitioners, physicians
evolve their style of practice based on clinical experience and ongoing formal and informal
education. Physicians are keenly aware of the need for continued learning, and participate in
programs of continuing medical education (CME). The concepts of independent lifelong learning
and continuous adaptation of new knowledge and techniques to medical practice define what it
means to be a physician.
By the year 2030, it is estimated that the need for geriatrics-trained physicians will be around
36,000 to provide primary care for frail elders and for academic positions (5) However, the
projected number is anticipated to be far less, making Geriatric Medicine a critical shortage
specialty. The challenge of providing health care to this ever-increasing segment of the
population has heightened the need to teach geriatrics in medical schools so that every medical
student will be better prepared to care for people in their practice. (13)
Multiple factors are contributing to problems in adequate education in Geriatric Medicine. Thus
far, efforts to provide specific geriatrics courses or rotations for all physicians-in-training have
had fallen far short. In the 1988-89 the American Association of Medical Colleges (AAMC)
Curriculum Directory, only 13 medical schools required courses or clinical experiences in
geriatrics or aging with the estimates that 75% of all medical students will have a significant
proportion of older people in their practices, regardless of which specialty they choose. (24, 5)
With older people providing an increasing amount of care for children, even pediatricians will
need to recognize common serious geriatric syndromes to avoid inadvertently child abuse and
neglect.
Medical education, for its part, made significant changes to meet the need for training in geriatric
medicine. Gerontology and geriatrics are becoming to be increasingly represented in U.S.
medical school curricula: in the year 2000 already 122 of the nation's 125 medical schools
required at least some elements of geriatrics as part of their regular course work (33). The
AAMC also called upon the Congress to provide adequate funding for a number of federal
initiatives, including the Title VII geriatrics education centers (GECs) and other geriatric training
programs, the VA's Geriatric Research, Education and Clinical Center (GRECC) program, and
student loan repayment programs such as the National Health Service Corps.
The AAMC's statement outlined some of the activities underway at the undergraduate and
graduate levels to increase the number of geriatricians being trained. The statement highlighted
an initiative of the John A. Hartford Foundation in New York City, working with the AAMC,
that has awarded in the last two years a total of $4.8 million to 40 medical schools to enhance
their gerontology and geriatrics curricula. Each institution has received up to $50,000 a year,
totaling $100,000 over the course of the two-year grant. Each school offers a fully integrated
curriculum spanning the four years of undergraduate medical school education. This is critical
because it reinforces the relevance and importance of geriatrics and the care of the elderly
throughout the curriculum, rather than limiting such information to a single course. The
institutions provide medical students with the necessary skills to deliver high quality,
compassionate care to the nation's burgeoning elderly population, and to handle effectively the
complex issues associated with end of life care.
Geriatrics training is beginning to be seen not as a luxury, but as a necessity for the survival of
all of us in our practices. One of the major obstacle preventing the widespread incorporation of
geriatrics training has been the lack of faculty who are able to teach the appropriate knowledge,
skills, and attitudes. Those faculty who currently control the medical curriculum and department
heads may resist changes in the existing curriculum. All medical educators will agree, however,
that gerontology and geriatric medicine must be included in medical education.
The plan proposed makes efficient use of time by both integrating longitudinal didactic and
clinical experiences into the existing curriculum, making better use of the current time allotment,
and greatly strengthening the existing clinical rotation in geriatrics for Family Practice residents.
Studies indicate that students and residents can be influenced significantly by their clinical
rotations and role models in the medical school and hospital settings, and the potential for
communicating positive orientations toward the treatment of the elderly and toward chronic
illnesses does exist.
Although training in Geriatric Medicine and Geriatric Psychiatry is expanding and interest in
geriatric programs is increasing, the demand for well-trained physicians will be even greater in
the future. (6) Within the field, discussion about the degree of primary care versus
“subspecialty” orientation has dominated the professional agenda. The perceived
unattractiveness of the field, the dearth of faculty with interest and expertise in geriatrics at all
levels of training, and the levels of funding for training and research have been cited as major
constraints on the growth and excellence of the field. (20)
Patients of all ages desire to establish themselves with one primary physicians. This is especially
true for those with severe disabilities and chronic conditions. The inability to choose one’s own
doctor is frequently the single most important factor that discourages managed care enrollment.
(7)
For physicians, pursuing careers in Geriatric Medicine presents several barriers. One is the
perception that geriatrics is uninteresting and clinically unrewarding. They may define the work
as managing chronic complex diseases, rehabilitation, and functional assessment, which may
seem less compelling than curing acute illness. Some may avoid the field because they feel
uncomfortable with the elderly or because nursing home patient care is not “high tech”. An
additional reason is the scarcity of physician role models in Geriatric Medicine, restricted and
diminishing budgets for training, poorly supervised training at primary care sites, lack of funding
for training in Medicare Part A, and the fact that department chair and deans rate geriatrics as
low priority are additional obstacles to pursuing geriatric careers. (3)
Also, many competent and compassionate physicians, whether primary care providers or
specialists, may not understand that caring for an older person requires a special body of
knowledge and formal training. By the age of 75 most adults have three or more medical
conditions, both chronic and acute. In addition, they have symptoms that often differ from those
of younger persons with the same illness.
By ensuring that academic geriatricians are on the faculty of every medical school and residency
programs, to teach all medical students and residents about geriatrics, these problems will be
minimized, our health care system will save money, and quality of care will improve.
It will promote healthy aging as physicians make early and more accurate diagnoses, initiate
more appropriate treatments of illness, effectively manage chronic conditions, and minimize the
problems of inappropriate medications and dosages.
In addition, when medical students and residents experience the whole range of health care needs
of older persons, from healthy individuals through those requiring end-of-life care, they will not
only have a more sophisticated and empathic view of their patients, but a knowledge of how
modest interventions can dramatically improve the quality of a patient’s life. Most importantly, a
geriatrics faculty development initiative will result in better health and quality of life for one of
the most vulnerable segments of our population. (11)
The impact of some earlier programs to involve medical students in the different type of geriatric
training and care for elderly showed mixed results. Awareness of geriatrics and comfort with
older people was increased, but there was little change in career aspirations. But students in the
program increased their awareness of physical decline on old age, setting the stage for teaching
them about the physician’s role with regard to assessment and function. (1) At the University of
Arkansas, a rotation in which geriatrics training was carved out of an existing Internal Medicine
rotation failed, largely because the Internal Medicine faculty resented the time taken from their
curriculum and denigrated the new requirement in geriatrics to the students. (34) Rotations in
Geriatric Medicine without competing pressures to be elsewhere are far more successful. UCLA
reported success in attitudes, knowledge and clinical skills as a result of focused experiences for
medical students in geriatrics. (35)
Required training in geriatric care must also be included in the basic training of residents in
general surgery, the surgical subspecialties, gynecology (which is both a surgical and a primary
care specialty), and other relevant specialties, such as anesthesiology, emergency medicine, and
physical medicine and rehabilitation. By improving their current didactic and clinical teaching,
surgical and medical residents can learn the principles of good geriatric care with a modest
addition to their already bulging residency-training curriculum. The basic principles are
straightforward and well supported by research findings and clinical experience. Application of
these principles creates a positive feedback loop because the initial result is favorable enough to
reinforce their adoption and dissemination. Further, as curricular emphasis on geriatrics in
medical schools increases, specialty residents are likely to enter training with some of the
necessary knowledge in hand and with more receptive attitudes. (25)
Geriatrics can apparently be taught in many settings, but it must be required experience.
Techniques to improve attitudes about caring for the elderly need further development and
evaluation. (2)
Training programs in internal medicine and family practice are now required to have a formal
written curriculum and experience in geriatrics. Of the total number of questions on the
American Board of Internal Medicine certifying examination, 12% are specific to geriatric care.
The Council on Graduate Medical Education 1992 report recommended “increased geriatric
training for all resident level physicians, a view endorsed by internal medicine residency
program directors. Currently, only 30% of Internal Medicine residency programs have a required
geriatrics rotation; an additional 25% have an elective experience. Less than half report teaching
some of the fundamentals of geriatric care. Longitudinal rotation with a half day of geriatrics per
week throughout the 3-year curriculum was proposed as a teaching model and can also be highly
effective. Although most program directors believe that residents need more geriatric training,
they cite a number of important barriers: lack of trained faculty, insufficient clinical time, and
inadequate money. (19)
The relationship of geriatrics to primary care/ family practice is central to curriculum
development. Herein, “curriculum” can be defined as a planned educational experience that
encompasses behavioral goals, instructional methods, and the actual experience of the learners.
(15). The goal is for family practice residency programs to have adequate faculty and curricula in
geriatrics so that graduates can give the same quality of care to older patients as they do to the
young and middle-aged. (4)
Geriatric Medicine as practiced in the United States will be both a primary care and a specialty
effort, part of the continuum of adult primary care with general internal medicine and family
practice. Specialist geriatricians will provide some primary care, but for the most part Geriatric
Medicine is developing as a consulting, research, academic, and administration specialty.
Family physicians and general internists who have not done fellowships in Geriatric Medicine
will deliver nearly all geriatric primary medical care. To an increasing extent, specialty and
subspecialty geriatric care will be by referral from generalists. The goal of the geriatric
curriculum and of faculty development is that all adult generalists should be sufficiently trained
in excellent clinical care of the elderly within their 3-year core residencies to serve the needs of
the burgeoning elderly population. (17)
All generalists will be trained to a standard of excellence in geriatrics. Goals were previously set
that 16% of residency education by 1996 and 25% by 1999 in Family Practice and Internal
Medicine would be in geriatric care. (16) Surveys of current training show that residency
programs are currently very far from those goals. To make the best use of available faculty, it is
important to review the most successful training methods. The most useful training strategies
have been through interactions between subspecialists and geriatricians supervising residents in
their direct patient care. Other mechanisms, including lectures, discussion groups, symposia led
by geriatricians and readings were also successful as adjuncts to direct patient care. (18)
Because family physicians and general internists provide most primary care for older adults, we
must implement effective curricula in these residency programs.
Integrated model - geriatric curriculum can be combined with an existing curriculum, but this
requires that all faculty include relevant aspects of geriatric medicine in existing rotations. For
example, during a general medical ward rotation, residents can explore such geriatric topics as
dementia versus delirium, and methods to reduce the use of restraints and Foley catheters.
Unfortunately, this approach is often insufficient because of a lack of interested and qualified
faculty.
Longitudinal programs may include both conference series and having residents follow patients
in community or institutional settings for 6-24 months.
Block rotations provide shorter longitudinal experience but allow residents to concentrate
exclusively on geriatrics for a required period of time, usually 1-2 months. This permits trainees
to master a significant amount of material and apply it throughout the rest of their training
program.
Interdisciplinary teams have great educational value. Residents can learn a great deal about
patients and benefit from the expertise of practitioners in other disciplines in addition to
exploring clinical management, ethical problems, and functional issues.
Home visits can teach residents about the reasons for institutionalization and the limitations of
community-based home services. They can examine the home environment and gather more
accurate nutritional and medication history. Many residents feel anxious before their first home
visit, which can be a barrier to understanding their older patient. (30)
Home care experiences should be one component in a comprehensive geriatric medicine
curriculum. With limited faculty and resident time for home visits, well-defined curriculum
content may also be taught through case discussions, problem-solving conferences, discharge
planning rounds, and meetings with community agency staff (e.g., visiting nurse groups,
community social workers).Home visits to patients well known to residents (e.g., patients
discharged from the resident’s acute medical service and continuity clinic patients) are effective
educational strategies. (28)
Consultations can build the geriatrics educational program. Prompt and effective consultations
can help build the geriatric educational program by focusing on difficult management issues or
complicated patients. Common consultation problems include comprehensive assessments before
a decision can be made on institutionalization, and dementia, depression, multiple medical
problems, or preoperative assessments.
Nursing Homes: Although older people are not in nursing homes, those who are have especially
challenging care problems, so residents must became competent in this setting. The nursing
home experience can be longitudinal, with a resident following four to eight patients over several
years, or an entire block rotation can be based in a nursing home (30).
Family Counseling: Family Practice deals with the care of the individual in the context of their
family and social network. The intergenerational issues that form the background of a person’s
health and well-being are important to the understanding of the individual. Family issues in
geriatrics are extremely important as elders consider their historical and financial legacy, and
contemplate the value of their lives in a social and spiritual context. Physicians must learn how
to handle the family dynamics of emotionally charged issues such as moving to an assisted-living
facility, moving in with relatives, permanent placement in institutional care, naming a designated
surrogate or power of attorney, and making advance directives. Serious unresolved sibling
rivalries may resurface when siblings become involved in decisions regarding their parents.
Compassionate Care-giving: Patients suffer not only physically but also emotionally and
spiritually. It should be the obligation of physicians to respond to, as well as attempt to relieve,
all suffering, if possible. Compassionate care-giving is essential to the practice of medicine and
that it should be taught in medical school. (22).
Residency and fellowship training programs that involve primary or consultative care of elderly
patients should be required to have scheduled clinical and didactic experience in geriatrics. The
full spectrum of healthcare settings should be utilized for training.(10)
In order to improve the health care of elderly patients throughout our care systems, the body of
knowledge on aging must be assimilated by all practitioners who care for older persons. Optimal
care of elderly patients should not depend on referral or consultation by geriatrics “experts”
alone but needs to be in the mainstream of all specialty care of the adult. Geriatric medical
education should expand into ambulatory, home, and long-term care settings, to parallel the
increasing utilization of these sites in geriatric care. Emphasis should be placed on teaching the
scientific body of knowledge regarding the coexistence of the aging process and disease states,
as well as the skills necessary to promote healthy aging and provide for comprehensive,
interdisciplinary assessment and management of older adults with functional impairments
throughout the continuum of care.
Continuing Medical Education: Practicing physicians who provide substantial care to older
adults should be strongly encouraged to gain continuing medical education in geriatrics. All
sectors of the healthcare market place, including both the for-profit and not-for-profit arenas
should be penetrated. (10)
Effective and economical systems of care for older adults with functional disabilities will involve
professionals from an array of disciplines working together to achieve a coordinated system of
care that meets these needs both collectively and on an individual basis. An educational program
in geriatric medicine must be organized to provide a well-supervised experience at a sufficient
level for the resident to acquire the competence of a physician with added qualifications in the
field. Goals will be to provide formal training in geriatrics interdisciplinary team care to all
internal medicine and family practice residents as a component of the geriatrics curriculum.
Residents should be provided with specific learner objectives that will prepare them for the
provision of effective geriatrics interdisciplinary team care. (8, 9, 21)
Potential challenges:
- the assumption is that faculty already know the material; the fact is that formal faculty training
is needed before a sound geriatrics training program can be developed. Perpetuation of
misinformation is to be assiduously avoided.
- access to the judicious use of medical technology will be needed to provide efficient care to
complex patients.
- it is important to teach residents about the care of relatively well elders as well as the frail and
vulnerable older people. In caring for well elders, residents can focus on the principles of
preventive medicine and secondary prevention.
- the curriculum is already crowded, so when new geriatric medicine courses are added, some
existing coursework may be eliminated. For students, this is best done by the replacing excess
elective time in the fourth year, and by improving the current coursework in the existing
curriculum. (30) Somewhat encouraging facts are, that often, surgical and medical residents can
learn the principles of good geriatric care with only a modest addition of well structured
curricular to their already bulging residency training curriculum. (25)
- to help their programs be successful, chairpersons of Family Practice departments should do
the following: (a) Make a commitment; otherwise, nothing will happen. (b) Recruit a
charismatic, energetic, respected, committed program leader. (c) Give the leader the time and
resources to succeed. He or she needs adequate money and space, adequate faculty and staff, and
adequate time for a fair test (at least 5 years). (d) Provide counsel and support for the program
leader. Run interference when necessary.
Needs Assessment
A strong Geriatric Medicine curriculum is an important goal for our Family Practice residency
program. The mission of our residency reflects an interest in developing family practice
physicians for whom geriatrics will be constantly expanding part of their practice. In addition,
our Program seeks to improve resident performance on both the family practice In-Training
examination and the American Board of family practice physician’s examinations.
Currently, Geriatric Medicine rotation at Family Practice Residency, UH consisted of a one
month block of geriatrics for third-year residents at the different sites, such as the Mililani
Physician Clinic, Wahiawa General Hospital in-patient service, one hundred beds Skilled
Nursing Facility and Rehabilitation Center, home visits and community resources network. All
patients are seen initially by residents (this includes residents taking first call for all their patients
at the SNF) and all are presented to an attending physician assigned to supervise the trainees and
formulated management plans.
Before revising the Geriatric Medicine experience at the Family Practice Residency Program,
University of Hawaii, a curricular needs assessment was performed. Structured individual and
group interviews with key physicians including Faculty Members and resident physicians who
had completed Geriatric Medicine rotation last year. The following questions were asked of
each:
1) What is the current performance of our residents in Geriatric Medicine?
2) What level of performance/ skills do we want in Geriatric Medicine?
3) What are some of the problems contributing the discrepancy between current and ideal
resident performance?
4) What are some solutions to these problems?
5) Describe the previous Geriatric Medicine experience including the learning climate, the
presence and clarity of goals and objectives, the methods used for enhancing understanding
and retention, and evaluation and feedback.
Performance: The faculty felt that the patient care performance of the residents in the Geriatric
Medicine rotation was average to above average. Residents had average scores on such tests as
the General Medicine in-service and the American Board of Family Physicians Examinations.
Residents felt their ability to provide general geriatric assessment and care was above average
but their depth of knowledge and understanding about more complex problems of geriatric
patient care was not sufficient. They felt that it’s necessary to have more in-depth learning of
Geriatric Medicine in order to be able to provide truly competent geriatric patient care. Also,
residents expressed concerns regarding some weakness in the structure of the Geriatric rotation
with significant amount of time devoted to self-leaning or “passive” learning in rehabilitation
unit or community resource organizations. Both residents and faculty agreed though that there is
very good bases to provide all aspects of geriatric patient care, including busy outpatient clinic,
inpatient experience in Wahiawa General Hospital, one hundred bed Skilled Nursing Facility, as
well as a developed network of home care visits and different community resources.
Problems: Residents and faculty showed agreement when considering problems that contribute
to current performance, such as: a high volume clinic and inpatient care services which often
interfere with education, though an overlap between the two helped expand patient base; a lack
of clear expectations for the learner along with mechanisms to achieve those expectations other
than just basic geriatric patient care experience; a deficiency of feedback and evaluation. In
addition, both residents and faculty felt that methodology of the current curriculum did not
sufficiently promote understanding of many sensitive issues of geriatric care, especially
importance of complex functional, behavioral and social issues, ethics, and end-of-life care.
Faculty felt there might be a perception from resident standpoint that Geriatric Medicine is not as
challenging or important as other aspects of family practice medicine and this may affect resident
study behaviors. The faculty and residents did not feel the discrepancy between current and ideal
performance was due to poor residents, poor faculty, an unsupportive or intimidating learning
environment, or an inadequate number or variety of patients on our clinics.
Solutions: The faculty felt that geriatric care performance by residents could be improved by
strengthening different aspects of geriatric curriculum. This can include developing different
teaching models (computer based leaning programs, standardized patients), expanding teaching
by increasing number of lectures covering all major geriatric topics, providing more direct
personal tutoring, implementing journal clubs and current literature review. This will help
residents meet or exceeded community standards in Geriatric patient care, expand their
knowledge, improve performances above the national average on the Geriatric Medicine sections
of standardized exams. Both groups felt solutions could potentially include developing more
structured and comprehensive curriculum, more teaching provided on individual tutoring basis,
direct involvement of the geriatrician faculty in all aspects of clinical inpatient and outpatient
geriatric care.
Faculty felt that it’s necessary to provide clear expectations with residents for goals and
objectives of Geriatric Medicine rotation. Both groups felt that self-assessments including testing
should be done, but its purpose should be to monitor progress and identify weaknesses, and not
to determine successful completion of the Geriatric Medicine rotation. It was felt that this would
also allow for more meaningful evaluation and feedback which both groups thought was
important but not, occurring frequently enough. Residents also suggested more direct
comprehensive geriatric assessment and care, patient-centered conferences (especially covering
complicated ethical and end-of-life issues), structured reading assignments, and educational
computer programs as possible solutions. Significant findings of this needs assessment are the
lack of a defined comprehensive curriculum and a learning strategy.
Implications for the Development Process
It is clear from the needs assessment and literature review that Geriatric Medicine rotation requires
much more attention in FP residency program. This is dictated by the demographic imperative, the
constant and significant increase in the geriatric population. In addition, because of the constraints
of a busy clinic, additional learning strategies must be explored. Faculty and residents felt that
resident performance in the Geriatric Medicine is currently less than ideal. They cite a lack of
understanding of common or complex geriatric care. In response to this deficiency and the need for
methodologies do not interfere with the function of the clinic or over-extend faculty, a
comprehensive Geriatric Medicine curriculum will be created. Also, self-paced, self-directed
approach can provide one opportunity to learn the breadth and depth of knowledge residents seek
without disrupting the operations of a busy outpatient clinic or overextending our faculty, as more
scheduled lectures or conferences could. Other modalities, such as the lectures and conferences
currently in place, will be continued to help residents meet expectations of other learning
objectives, and adding more patient-centered conferences will also be considered. Patient-centered
conferences can create efficiencies by improving care and reducing time-consuming inadequate
care.
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Curricular Goals
1) FP Residents will learn all aspects of all major Geriatric syndromes
2) FP Residents will develop new attitude toward care of Geriatric patients with emphasis on
complexity, functional status and social issues assessments as part of comprehensive care for
such patients.
3) FP will develop skills of adequately addressing ethical issues like advance directives or endof-life issues.
4) FP Residents will perfect their skills in performing complete Geriatric assessment.
5) FP Residents will be confident providing care for any Geriatric patient.
6) FP Residents will be able to successfully pass on all questions in Geriatric Medicine during
their FP Board Exam.
7) FP Residents will be confident providing Family Counseling care of the elderly individual in
the context of their family and social network. FP Residents will be confident handling the
family dynamics of emotionally charged issues such as moving to an assisted-living facility,
moving in with relatives, permanent placement in institutional care, naming a designated
surrogate or power of attorney.
Curricular Content
1) Complete Geriatric assessment
2) Altered Mental Status: Dementia vs Delirium
3) Urinary incontinence
4) Normal vs. pathologic aging
5) Osteoporosis
6) Falls
7) Insomnia
8) Depression in elderly
9) Advance directives
10) Ethical issues in the geriatrics facility
11) Atypical presentation of common diseases in Geriatric patients
12) End-of-life care (pain management and palliation of symptoms)
13) Tube feeding
14) Medicare/Medicaid/financial issues
15) Functional assessment of Geriatric patients
16) Nutrition
17) Screening issues in Geriatric medicine
18) Managing behavioral issues in demented patients
19) Family Counseling issues
Curricular Objectives :
1) Given a patient in the FP clinic FP resident will be able to appropriately evaluate, state and
address such issues of Geriatric Patient Care as functional status and social issues as an
important part of Geriatric medicine according to textbook, lectures, medical articles.
2) Given a patient in the FP clinic FP Resident will be able to adequately address ethical issues
(like advance directives or end-of-life issues or tube feeding according to textbook, lectures
and medical articles.
3) Given a patent in the FP clinic FP Resident will be able to correctly perform complete
Geriatric assessment according to textbook, lectures and medical articles.
4) Given a patent in the FP clinic FP Resident will be able to correctly evaluate and manage
screening issues in elderly according to textbook, lectures and medical articles.
5) Given a patent in the FP clinic FP Resident will be able to correctly evaluate and manage
nutritional issues in elderly according to textbook, lectures and medical articles.
6) Given a patent in the FP clinic FP Resident will be confident in Medicare/Medicaid/financial
issues related to geriatric care according to textbook, lectures and medical articles.
7) Given a patent in the FP clinic FP Resident will be confident providing Family Counseling
care of the elderly individual in the context of their family and social network. FP Residents
will be confident handling the family dynamics of emotionally charged issues such as
moving to an assisted-living facility, moving in with relatives, permanent placement in
institutional care, naming a designated surrogate or power of attorney according to textbook,
lectures and medical articles.
Instructional Methods:
-
Actual patients in different clinical settings
Lectures
Personal tutoring/interactive discussions
Standardized patients
-
Reading (textbook, articles, etc.)
Role playing
Independent learning
Evaluations
Learner evaluations we will utilize:
- Written post test
- Observation of in-hospital/clinic performance
- Comparing scores of national in-service Exam
- Standardized patients
- Oral interviewing
1) We ask experts in the content area to review our curriculum to determine if the material is up
to date, accurate, and complete. This is done by asking two or three faculty members to complete
a specific evaluation form. A sample review form that can be modified is provided in appendix
one.
2) We ask experts in the area of curriculum design (education) to review the process
(curriculum) to determine if the objectives are measurable, the instructional methods make sense,
and whether or not the curriculum is consistent. A sample review form that you can use and
modify is provided in appendix two.
3) We will collect information from the participants on the educational experience. This would
include their perception of the value of the course, the amount of time devoted, homework, etc.
4) Outcomes
Content Review Form
People who could serve as content reviewers for your curriculum.
P. Blanchette
K. Masaki
N. Palafox
Questions to be ask content reviewers. Consider both specific and open-ended questions.
1) Is content of this curriculum adequately cover topics that FP needs to know about Geriatric
Medicine?
2) What are the strong points of this curriculum?
3) What are the weakest points of this curriculum?
4) What should FP Residents know from FP specialist standpoints?
5) Anything needs to be added?
6) Anything needs to be deleted?
Process Review Form
People who could serve as process reviewers for your curriculum.
P. Blanchette
K. Masaki
N. Palafox
Questions to be ask process reviewers. Consider both specific and open-ended questions.
1)
2)
3)
4)
Is this particular method of evaluation is appropriate?
Are objectives clear to learner?
Are objectives are achievable?
Are methods of teaching are appropriate?
Geriatrics Rotation FP R3 Participant Evaluation Form
Note to residents: The faculty take evaluations seriously. We appreciate your time to provide us
with thoughtful feedback. Please be assured that your evaluation for the rotation will not be
affected by critical feedback. The faculty will try to continuously improve the rotation, and there
is no better way to improve the course than for residents to help us make it better for those who
follow them into the program.
If you do not have enough room to write your suggestions, please attach another page.
1) Overall, did you like this course?
No, not at all
1
2
3
4
5
Yes, very much
Why?
2) How would you restructure or improve the course in any way? Please, give suggestions as
specific as possible.
3) Was the general content relevant to your current or future practice?
Not Important
1
2
3
4
5
Which topics or experiences were the most relevant?
Very important
Which topics or experiences were the least relevant?
4) As a whole, were the lectures or other didactic sessions useful for you?
Not Useful
1
2
3
4
5
Very useful
List the topics that you think were the most useful for you:
List the topics that were least useful for you:
Which topics would you add to the lecture/didactic curriculum: Why?
5) As a whole, were the clinical experiences useful for you?
Not Useful
1
2
3
4
5
Very useful
List the experiences that you think were the most useful for you: Why?
List the experiences that were least useful for you: Why?
6) Please evaluate the amount of “homework” (reading assignments, etc) that was required:
Too excessive 1
2
3
4
5
Just right
Comments:
7) Please evaluate the quality or usefulness of “homework” that was required:
Not at all useful 1
2
3
4
5
Very useful
Why?
7) Do you think the Geriatrics rotation should continue?
No, waste of time
1
2
3
4
5 Yes, very important
Why?
8) Should an introductory Geriatrics rotation, structured appropriately for the R1 level, be
added to the R1 year:
No, not needed
1
2
3
4
5
Yes, definitely
Why?
9) Should a mid-level Geriatrics rotation, structured appropriately for the R2 level, be added to
the R2 year:
No, not needed
1
2
3
4
5
Yes, definitely
Why?
10) How would you improve the was that residents are evaluated during the rotation?
11) How would you improve the way that residents evaluate the rotation?
Outcomes Review Form
1. I learned important aspects of all major Geriatric syndromes
Disagree
1
2
3
4
5
Agree
Comments:
2. I developed improved confidence in my ability to provide comprehensive care for geriatric
patients, especially with regard to managing complexity, and assessing functional status and
social issues:
Disagree
Comments:
1
2
3
4
5
Agree
3. I developed improved skills in adequately addressing medical-ethical issues, such as advance
directives, end-of-life, and elder abuse and neglect:
Disagree
1
2
3
4
5
Agree
Comments:
4. I perfected my skills in performing a comprehensive Geriatrics assessment:
Disagree
1
2
3
4
5
Agree
Comments:
5. I became confident in providing care for any Geriatric patient:
Disagree
1
2
3
4
5
Agree
Comments:
6. This rotation will help me to correctly answer questions in Geriatric Medicine during my
Family Practice board exam:
Disagree
Comments:
1
2
3
4
5
Agree