Enhancing Physician Education in Geriatric Medicine Lisa Granville, M.D.

“SHIFT” What Is Taught What Is Learned Developing a Competency- Based Geriatrics Curriculum

Right Time for “Shift” Growing education opportunitiesGrowing education opportunities Expectations for geriatrics: -UME ….AAMC / Hartford / DWR -GME ….RRC Requirements -CME ….Baby boomers Models of competencyModels of competency -ACGME -USMLE Clinical Skills exam

The Florida Consortium for Geriatric Medical Education A statewide collaboration on physician education in geriatrics FCGME Participating Institutions: Florida State University Nova Southeastern University University of Florida University of Miami University of South Florida Founded May 31, 2001

Initial Focus: Competency Identification and Promotion Criteria for content selection: Multifactorial etiology, overlooked or mistaken as normal aging, benefiting from interventions and/or amenable to biopsychosocial approach Reviewed published core curriculum from the American Geriatrics Society –Knowledge (Related to Clinical Practice) Geriatric Syndromes and Conditions. –A basic understanding of risk factors, causes, signs, symptoms, differential diagnosis, initial diagnostic evaluation, and preventive strategies. Adopted AGS geriatric syndromes: –Chronic pain, delirium, dementia, depression, falls, medications, osteoporosis, pressure ulcers, sensory impairment, and urinary incontinence

Content Area : Medical Student Basic Competencies for Incontinence The medical student will: Epidemiology (incidence, prevalence, risk factors, causes) 1. Express awareness that UI is not a normal consequence of aging 2. Identify UI as an under reported condition 3. Know the prevalence of established UI and its association with physical dependence or frailty (e.g., community 15%; hospital 35%, nursing home 50%) 4. Determine the presence of contributors (e.g., DRIP DRIP or DIAPPERS) to a transient etiology of UI Diagnosis & Evaluation (definition, classification, signs, symptoms, differential diagnosis, initial diagnostic evaluation, evaluation tools) 5. Know the World Health Organization definition of UI 6. Show consideration for patient comfort and demonstrate interviewing techniques to improve reporting of UI 7. Apply the AHCPR guide for initial evaluation of UI 8. Demonstrate the application and interpretation of UI evaluation tools (PVR, voiding diary) 9. Distinguish between transient and established UI 10. Define, describe symptoms and identify common causes of the four types of established UI (urge, stress, overflow, functional) Complications (morbidity, mortality, function, QOL) 11. Identify UI morbidity in the biopsychosocial domains: physical (infections, skin breakdown), emotional (social isolation, anxiety), reduced QOL12. Demonstrate the ability to identify UI morbidity in a patient interview/ physical examination Rx & Management (including preventive strategies) 13. List 3 general approaches to UI management (behavioral, medical, surgical) 14. Provide 2 examples for each general approach to UI management 15. Associate appropriate interventions with each type of UI 16. Relate incontinence management products (e.g., pads, catheters) to individual patient needs Resources 17. Be aware of “national” organizations relevant to UI (e.g., International Continence Society) 18. Appreciate the advantages of an interdisciplinary approach to UI evaluation and management 19. Identify professional referrals for UI management: (e.g., urology, ob gyn, geriatrics, enterostomal nursing, physical therapy) )

“SHIFT” What Is Learned What Is Done Improving Older Adults’ Care: Changing Physician Behavior

Urinary Incontinence Guidelines: Given limited educational time for geriatricsGiven limited educational time for geriatrics Using existing “geriatrics faculty” (sometimes = no geriatricians)Using existing “geriatrics faculty” (sometimes = no geriatricians) What can each school accomplish?What can each school accomplish? 19 learning objectives What are the priorities? –Recognize syndromes Realize Syndromes are not normal agingRealize Syndromes are not normal aging –Initiate screening / evaluation –Understand treatment approaches –Know where to refer

Urinary Incontinence 1. Apply the AHCPR guide for initial evaluation of UI 2. Demonstrate the application and interpretation of UI evaluation tools (PVR, voiding diary) 3. Distinguish between transient and established UI 4. Associate appropriate interventions with each type of UI 5. Relate incontinence management products (e.g., pads, catheters) to individual patient needs 6. Identify professional referrals for UI management: (e.g., urology, ob gyn, geriatrics, enterostomal nursing, physical therapy) )

Urinary Incontinence Can we use these learning objectives for residents, fellows, practicing physicians? LO: Associate appropriate interventions with each type of UILO: Associate appropriate interventions with each type of UI Medication for URGE UIMedication for URGE UI –UME: anticholinergic agents –GME: specific medications with dose and potential ADEs –Geriatrics Fellow: off-label medications and their use

Developing National Consensus on Geriatric Milestones for Physicians

AAMC Minimum Geriatrics Competencies for Medical Students Ground rules Must focus on issues that matter to health outcomesMust focus on issues that matter to health outcomes Important to patient care likely to occur at start of internship… “don’t kill granny”Important to patient care likely to occur at start of internship… “don’t kill granny” Similar to quality indicators, “floor” behaviors could be taught and evaluated at any medical schoolSimilar to quality indicators, “floor” behaviors could be taught and evaluated at any medical school

AAMC Minimum Geriatrics Competencies for Medical Students 26 competencies nested in 8 domains Medication managementMedication management Self-care capacitySelf-care capacity Falls, balance, gait disordersFalls, balance, gait disorders Hospital care for eldersHospital care for elders Cognitive and behavioral disordersCognitive and behavioral disorders Atypical presentation of diseaseAtypical presentation of disease Health care planning and promotionHealth care planning and promotion Palliative carePalliative care

Developing Stealth Behaviors

FSUCOM Mission The mission of FSUCOM is to educate and develop exemplary physicians who practice patient-centered health care, discover and advance knowledge, and are responsive to community needs, especially through service to elderly, rural, minority and underserved populations.

Distributed Campus Model

Proposed UME: M1, M2 Training Geriatricize Clinical Skills Training –Stealth approach, across the lifespan –Creation of good practice habits over 2 years –4 domains of desired behaviors Communication skills: collaborative care, avoidance of medical jargon, routine patient educationCommunication skills: collaborative care, avoidance of medical jargon, routine patient education Functional assessment: routine assessment of ADLs, IADLs; anticipatory planning for limitationsFunctional assessment: routine assessment of ADLs, IADLs; anticipatory planning for limitations Social setting: living arrangements, social supportSocial setting: living arrangements, social support Therapeutic review: consider non-drug management, collaboratively develop care plansTherapeutic review: consider non-drug management, collaboratively develop care plans

Senior Mentors / Developmentally Delayed Program Senior Mentors / Developmentally Delayed Program –Explore biases regarding function and age –Explore value of applying geriatric care principles across the lifespan

Clinical Learning Center

Stealth Partnerships

What SHOULD the geriatric milestones be for: All graduating medical studentsAll graduating medical students –AAMC geriatrics competencies All primary care residentsAll primary care residents –SGIM-AGS-SHM Education Consortium –IM-FM RRC revisions project Practicing physiciansPracticing physicians –AMA Aging Initiative

What can we do together…