Herding Cats:
Leverage Points for Geriatric
Medical Education in 2011
Rosanne M. Leipzig, MD, PhD
Brookdale Department of Geriatrics
and Palliative Medicine
Mount Sinai School of Medicine
Table of Organization
Medical Education Table of Disorganization
School
Program
Accreditation
Professional
Certification
Professional
Licensing
NBME
Medical
Students
LCME
Residents +
Fellows
ACGME
ABMS
FSMB
ACCME
ABMS
FSMB
Practicing
Physicians
Getting Change in Medical
Education is Like Herding Cats
Medical
Education
Geriatricizing Medical
Education
• Leverage Points
– Make it easier to teach
– Make it easier to assess
– Faculty development
– Geriatrics in High Stakes Examinations
– Geriatrics requirements for
accreditation
– Advocacy
That Was the Year That Was
2010
Leveraging Geriatrics Medical
Education
Leverage Point
Making it Easier to Teach
Surgical Anesth
Specialty ENT
Residents Ob-Gyn
Geriatric Competencies
by Learner
Geriatric
Fellows
Residents
Sub-Specialty
Fellows
Medical
Students
Emergency Medicine
Internal Medicine
Family Medicine
Surgery
Practicing MDs
Falls Competencies
Med Student:
Ask about falls, watch the patient rise from a chair and walk, record
and interpret
In a faller, construct a differential diagnosis and evaluation plan to
address the multiple etiologies identified.
IM/FM Resident:
Yearly screen all ambulatory elders for falls or fear of falling. If
positive, assess gait and balance, evaluate for potentially
precipitating causes, and implement interventions
In hospitalized medical and surgical patients, evaluate at admission
and regularly for fall risk……and institute appropriate
corrective measures
Falls competencies
Geriatric Fellow:
• Recognize abnormal gaits associated with specific
conditions, and perform and interpret common gait
and balance assessments.
• Conduct an appropriate evaluation of patients who
fall, implement strategies to reduce future falls, fear
of falling, injuries, and fractures, and followup on
referrals.
• Implement strategies to reduce falls in patients in all
health care settings.
Partnership for Health in Aging
(PHA) Competencies
•
•
•
•
•
Dentistry
Medicine
Nursing
Nutrition
Occupational
Therapy
• Pharmacy
• Physical Therapy
• Physician
Assistants
• Psychology
• Social Work
Still Need to Get
Teaching Materials
Genetics/Genomics
NO TIME!!
End-of-Life Care
ACGME Competencies
Geriatrics
QI projects
EBM
Cultural Competency
Blended Learning
• LEARNERS: acquire knowledge prior
to face time with faculty
• FACULTY: with student on
knowledge application
– Direct observation and modeling
– Formative feedback on performance
– Iterative performance till competency
achieved
The Portal of Geriatric Online Education
www.POGOe.org
“One-Stop Shopping” for
Geriatric Education Materials
Sponsored by the Association of Directors of Geriatric Academic Programs through a grant from
the Donald W. Reynolds Foundation, managed by the Mount Sinai School of Medicine
POGOe Products
597 POGOe Products
545
Instructional
products
52
Assessment
Products
POGOe Collaborations
• Hartford Geriatrics Nursing Initiative (HGNI)
– formalized 2010
– 11 products posted, more to come (113 potential)
• Geriatrics-for-Specialists Initiative (GSI)
– began 2003
– 7 posted products thus far
G-Wiz (Geriatric Wizard)
• Identifies the best POGOe products
for each medical student
competency
G-Wiz (Geriatrics Teaching Wizard)
POGOe Product Reviews
• JAGS e-learning section
– Examples:
• New Mexico's Health Care Decision Making
• Harvard’s Web-Based Module to Train and
Assess Competency in Systems-Based
Practice
• Arizona’s Elder Care Provider Fact Sheets
• Editor’s Choice on POGOe and in
monthly newsletter
Video Library
ReCAP
POGOe Works in Progress
Virtual Clerkship
•
•
Medical student curriculum that students
can use independently
Clerkship Directors will be able to:
• Customize or use as pre-packaged curriculum (plug
and play)
• Track student usage
• View statistics page capturing student activity
•
Pilot funded to develop 1 domain
Updated Search
At This Meeting
• Town Halls
– Geriatric Fellows Competencies
– POGOe Users Group
• Feedback on POGOe: help make it suit your
needs
• Input on virtual clerkship and other features
• POGOe booth: (Beta) Test drive new
search engine and get a chocolate
treat!
Leverage Point:
Making it Easier to Assess
•
•
•
•
•
•
The Reynolds TransInstitutional Evaluation
Group (R-TIEG)
Anne Fabiny (Harvard)
Jim Powell (Vanderbilt)
Donna Rosenstiel (Vanderbilt)
Renee Porier (Vanderbilt)
Gail Sullivan (U Conn)
Brent Williams (Michigan)
R-TIEG: ‘Best’ ways to assess
each student competency
• Spearheaded by U Cal consortium
– Knowledge: shelf-like exam.
– Performance in practice
• Direct observation: mini-clinical exam (Cex)
checklists.
– Clinical skills
• Objective Structured Clinical Exams
(OSCEs), standardized patients,
simulations, etc.
TIREG: Assessment Tool
Rating
• Developed an assessment rating
instrument
• Beta tested the instrument
• Now- Using the instrument to evaluate
existing assessment tools (Looking for
volunteers)
• Next steps: Map tools to competencies
• Will be available (and searchable) on
POGOe (estimated date: AGS 2011)
POGOe Assessment Tools
• Mostly Knows, Knows How, Shows
• Policy for securing and releasing
assessment materials
•
•
Some materials not directly accessible
on POGOe
“Human Firewall”
• released upon request and
• verification of requester’s faculty status
Learner Assessments
ACGME Milestones
• ACGME mandate
• Develop milestones of competency
– Help to interpret the ACGME core
competencies for each specialty
– Assist with the assessment of competency
– Provide specific feedback to learners
regarding progression towards
competence.
IM Milestones
• ACGME Competency
– Patient Management
• Developmental milestone
– Provide appropriate preventive care and
teach patient regarding self-care
• Approximate timeframe by which this
should be achieved
– 6 months
• General Evaluation Strategies
– Chart review
IM/FM Competencies /
Milestones Relationship
Brent Williams work
• 11 competencies are specific instances of one or
more Milestones
• 11 competencies not directly addressed
– identify unrecognized problems that are NOT a
complaint or presenting problem, in individual
encounters with patients at high risk.
– case-finding and targeted risk assessment for
syndromes are rarely addressed in the
milestones
IM/FM Competency /
Milestones Relationship
4 competencies are not reflected in Milestones.
– Advance care planning.
– Determining decision-making capacity.
– Actively identifying and addressing patientspecific barriers to communication.
– Identifying with the patient, family and care
team when goals of care and management
should transition to primarily comfort care.
How does the milestone crosswalk
make it easier to teach and assess
geriatrics?
ABIM interested in having
residency programs pilot this as
competency-based learning
Internship OSCEs:
Geriatric Stations
• University of Michigan
• 15- minute encounter of a patient about to
be discharged from the hospital focusing
on two dimensions:
• Geriatric Assessment (ADLs, IADLs, Minicog, depression screen, continence, falls)
AND
• Communication skills (separate rating,
verbal and non-verbal communication skills,
getting glasses on, etc.)
At This Meeting
• Evaluator’s Toolbox
working group
• Assessment Fair
• NBME workshops
• Clinical Skills sessions
• Learner Assessments 101
• 360 assessments
• DDx of Delirium: training
to competence
Speak with Anne Fabiny or Brent Williams if interested in reviewing
Assessment tools with the new rating instrument
Leverage Point
Faculty Development
GACAs 2010
• 105 eligible applications received
– 80 new; 25 renewals
• 68 funded
– 66 MDs, 1 psychology, 1 physical therapy.
– 56 new; 12 renewals
• Assuming level funding, the next round
of GACAs will be in 2015.
Faculty Development
Possibility
• Adapting ABIM Faculty Development
course in assessment to geriatric
competencies
Leverage Point
Geriatrics in
High-Stakes Examinations
Changes to ABIM Internal
Medicine Examination
• Blueprint changed
– Previously 10% cross content
geriatrics, 0% primary geriatrics
• Now geriatrics is a primary content
area.
– 4% of the test
• Will test geriatric syndromes and the care of
geriatric patients, rather than just diseases
in older adults.
– 8% of the test will be cross content
2010 Exams Reviewed
• NBME subject (shelf) exams
• USMLE
– Step 1
– Step 2 Clinical Knowledge
– Step 2 Clinical Skills
– Step 3
– Computer-based simulation cases
• ABIM
– ‘Geriatric’ pool (cross-content items)
2010: Exam Reviewers
•
•
•
•
•
•
Christine Arenson
Lynn Bickley
Jan Busby-Whitehead
Danelle Cayea
Anne Fabiny
Lisa Granville
Funded by AMA
•
•
•
•
•
•
•
Bree Johnston
Reena Karani
Rosanne Leipzig
Sharon Levine
Joanne Schwartzberg
Amit Shah
Gail Sullivan
A Geriatric Question
1. involves one of the 26 geriatrics competencies,
and/or
2. involves one of ABIM’s 16 geriatric syndromes
and/or
3. involves a “geriatric” disease/condition:
(a)
(b)
(c)
(d)
not covered by a competency,
predominantly affects 65+,
testing what is typically seen in an older adult,
if the examinee gets it wrong – could hurt an older
adult
(a) Eg, differential diagnosis of abdominal pain in an older adult
ABIM Geriatric Syndromes
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Constipation and fecal incontinence
Delirium
Dementia
Depression
Dizziness / lightheadedness
Falls and gait disorders
Frailty
Hearing loss
Immobility
Malnutrition
Pain
Pressure ulcers
Sleep disorders
Urinary incontinence
Vision impairment
Failure to thrive
•From ABIM Geriatric Medicine Maintenance of Certification Examination Blueprint, http://www.abim.org/pdf/blueprint/geri_moc.pdf accessed
8/10/2010, with modifications to include content from the Blueprint Geriatric Psychiatry and Functional Assessment and Rehab categories
Geriatric Diseases
•
•
•
•
PMR/TA
Osteoporosis (OP)
BPH
Examples of others being considered
– Mesenteric ischemia
– AAA
– Volvulus
– Myasthenia Gravis
– Multiple Myeloma
NBME Subject Exams Reviewed
•
•
•
•
•
•
•
•
Family Medicine
Psychiatry
Internal Medicine
ObGyn
Surgery
Clinical Neurology
Medicine Sub Internship
Ambulatory
N=8
NBME Subject Exams
•
•
•
•
•
100 questions per exam
800 questions reviewed
147 (18.4%) involved people 65 or older
48 (32.7%) of these were ‘true geriatric.’
Numbers of ‘true geriatric’ per exam:
– Median 6.5, range of 1-12.
– Far lower than representation of this
population either in the discipline workload
or in the national adult population.
Preliminary
USMLE Exam Results
350
300
250
# Questions
200
# Geriatric Qs
150
# non-disease
Geriatric Q
100
50
0
Step 1
Step 2CK
3 forms for each Step; all >65 yo
Step 3
ABIM Review Results
160
140
120
# Questions
100
80
60
40
20
0
# Geriatric Qs
Non-disease
Geriatric Qs
Needs Identified from
Exam Reviews
• MCQ Knowledge Gaps
• Geriatric content in Clinical Skills exam
• Ways to provide feedback to schools
– NBME
• Geriatrics shelf exam
• Geriatrics subscores on 2 exams given at most
schools (IM, surg, psych?)
• Composite geriatric subscore from questions on
several shelf exams
– USMLE
• Geriatric subscore
At This Meeting
• NBME question writing sessions to
begin to fill in gaps
• Anne Jobe session on geriatrifying
Step 2 clinical skills
– Need for observational anchors in order
to be able to include geriatric
assessments as part of clinical skills
Leverage Point
Geriatrics Requirements in
Accreditation
LCME Revised Standard ED-15
The curriculum of a medical
education program must prepare
students to enter any field of
graduate medical education and
include content and clinical
experiences related to each phase
of the human life cycle
LCME Revised Standard ED-15
Commentary
It is expected that the curriculum will be guided
by the contemporary content from and the
clinical experiences associated with, among
others, the disciplines and related
subspecialties that have traditionally been
titled family medicine, internal medicine,
obstetrics and gynecology, pediatrics,
preventive medicine, psychiatry, and
surgery.
REFUSED request to add geriatrics to this
list!
AAMC Graduation
Questionnaire (GQ)
• 2001-2009: specific geriatrics
questions
• 2010: Geriatrics questions eliminated
• Currently lobbying for reinstatement
in 2011
Residency Review
Committees
• Dr. George Drach has appeared
before the RRC Chairs committee
and discussed the need for geriatric
competency.
• Each RRC is reviewing their geriatric
requirements
• Next steps unclear
Internal Medicine RRC
• Removed requirement for 1 month
geriatric rotation
• New language
Faculty with credentials appropriate to the care
setting must supervise all clinical experiences.
These experiences must include:
– exposure to each of the internal medicine
subspecialties and neurology;
– an assignment in geriatric medicine
Why the Change to Fewer
Requirements
• Medical education moving to outcomes,
getting away from process
• Carnegie Pillar 1:
– Standardization of learning outcomes
– Individualization of the learning process
• No longer telling schools/programs HOW
to teach.
• Increases influence of the Certification
and Licensing bodies
Encouraging Signs
MedPAC 2009 concerns
•
•
•
•
•
•
•
Communication
Care Coordination
Multidisciplinary Teamwork
Patient Safety
Judicious Resource Use
Nonhospital Experiences
(Basic geriatric instruction)
Congress and $$$
• $9 billion to GME from CMS
• June, 2009 MedPAC report to
Congress
– Concern that our health professionals
are not learning certain skills necessary
to work optimally in delivery systems
that focus on care coordination, quality,
or judicious resource use
June 2010 MedPAC Report to
Congress
Gaps in medical education, including physician
prep to care for older adults, be addressed by:
(1) Making a significant portion of Medicare’s
GME payments contingent on reaching desired
educational outcomes and standards, and
(2) Making information about Medicare’s
payments & teaching costs available to the
public - also fosters greater accountability for
educational activities within the GME
community
June 2010 MedPAC Report to
Congress
An educational goal that is particularly pertinent to Medicare is
the growing need for basic geriatric competency among
almost all our physicians, as called for by many experts,
clinicians, and researchers (Boult et al. 2010, Institute of
Medicine 2008, Leipzig et al. 2009).
While many specialties require some form of geriatric
instruction for ACGME accreditation, and several
organizations have collaborated to develop a set of geriatric
competencies for all medical students and residents,
Medicare’s GME financing does not place any
requirements on geriatric skills and experience.
Encouraging basic knowledge in geriatric care among
graduating residents would have important benefits for
elderly Medicare beneficiaries.
AMA: House of Delegates Resolution
sponsored by AGS
• Co-sponsored by:
–
–
–
–
–
–
–
–
American Academy of Child and Adolescent Psychiatry
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Physical Medicine and
Rehabilitation
American Academy of Psychiatry and the Law
American College of Physicians
American Medical Directors Association
American Psychiatric Association
Ensuring Physician Competence
in the Care of Older Adults
• RESOLVED, That Our AMA recognize the critical
need to ensure that all physicians who care for
older adults, across all specialties, are competent
in geriatric care, and encourage all appropriate
specialty societies to identify and implement the
most expedient and effective means to ensure
adequate education in geriatrics at the medical
school, graduate, and continuing medical
education levels for all relevant specialties
• Directive to Take Action.
Other Encouraging Actions
• JAMA series on geriatric care
• Elder Workforce Alliance (EWA): Health
reform
– Geriatrics recognized as Primary Care
• Our field’s strengths are the new ‘buzz’
words for health care
– Systems of care
– Transitions
– Interprofessional care….
2011: What’s Next?
Geriatricizing Medical
Education
• Consensus on what to teach and how to
assess
• Develop and rate assessment tools
• Faculty development
• Geriatrics in High Stakes Examinations
• Geriatrics requirements for accreditation
• Public Policy
Continue work as a Geriatrics Learning
Community
Opportunities
• NBME
– Geriatrics subscore?
• USMLE
– MCQ question writers
– Geriatrics subscore?
– Clinical Skills exam
• ABIM
– New blueprint for certification exam
Advocate for:
• Increasing numbers of GACAs and decreasing time
interval between RFAs
• Geriatrics to be seen as primary care by the PCMH & HRSA
• Hospital recognition (systems, transitions, medical errors)
• Continued collaboration with EWA to increase and raise
the bar for the workforce involved in geriatric care
• CMS dollars for nursing homes to cover residents and
attending’s time
• CMS requiring geriatric competence for GME payments.
• Developing a matrix for Medicare Physician Quality
Reporting Initiative (PQRI)
Why do we doing this?
• So older patients will
get safer, better care
• Remember—
– Don’t Kill Granny!
Clinical Skills Session
Assessment Gaps:
• NEEDED: Consensus on markers for direct
observation
– What tool to use?
• Gait and balance assessment
– Get Up and Go?
– POMA?
– Tandem Stance?
– Checklist of critical behaviors
– Faculty Development to use checklists to
get consistent ratings of competency (interrater reliability)
Direct Observation:
Faculty Ratings: ABIM 1-9
Satisfactory
Superior
Unsatisfactory
1
2
3
4
5
6
7
8
9
Direct Observation:
Faculty Ratings: ABIM 1-9 scale
Satisfactory
4
5
Superior
6
7
8
9
Direct Observation:
Faculty Ratings: ABIM 1-9
Satisfactory
Superior
Unsatisfactory
1
2
3
4
5
6
7
8
9
Direct Observation:
Faculty Ratings: ABIM 1-9 scale
Satisfactory
4
5
Superior
6
7
8
9
TUAG Direct Observation:
Faculty Ratings: ABIM 1-9 scale
Satisfactory
4
5
Superior
6
7
8
9
Timed Up and Go:
Standards for Evaluation
Skill
Specific Features
Communication Introduce oneself.
Explain the reason for the test.
Provide explicit instructions:
 Rise without using arms of chair
 If using assistive device, use if for test.
 How far to walk; when to turn/return.
Performing the Task Use chair without arms or wheels.
Guard the patient if safety is a concern.
Accurately time the test.
Reporting and Describe observations (use of arms to rise, stance, balance,
Interpretation step length, path deviation, turning, arm movement).
Report ‘score’ (time elapsed) (Cut-offs: ?8, 11, 15)
Accurately interpret the score in light of the gait and
balance observed.
TUAG Direct Observation:
Faculty Ratings: ABIM 1-9 scale
4
5
How Do We Get There?