1. Experience in Implementing New Expanded Curriculum in Geriatrics for a Family Medicine Residency Program O Pishchalenko, MD, PhD, N Palafox, MD, MPH, P Blanchette, MD, MPH Departments of Geriatric Medicine and Family Medicine, JABSOM, UH

2. Abstract PURPOSE: rapidly growing elderly population of the 'baby boomers' necessitates expanding and improving baseline education in geriatric care among Family Medicine/ Primary Care resident trainees. Excellence in delivering quality geriatric care and improving performance in geriatrics on ABFM certifying exams were the goals of our redesigned 3-year geriatrics curriculum for an FM residency. METHODS: For the last 2.5 years we successfully implemented and conducted new redesigned and expanded curriculum for Geriatrics, consisting of longitudinal experiences and increased didactics in all 3 years. We were able to increase by 33% teaching time in the currently 1-month block rotation for 3rd year residents. Residents were trained in expanded variety of inpatient, outpatient, SNF/Rehab Center, and home visits settings. The longitudinal curriculum incorporated caring for increasing panel of SNF patients for 24-48 months and integrating relevant geriatrics topics into existing rotations. Faculty geriatrician conducted such experiences as: didactics seminars; interdisciplinary team (IDT) meetings; home visits; elements of in-patient geriatric consult services and out-patient geriatric family counseling. Evaluation of the block rotation was done by all residents being completed anonymous form using a 1 to 5 Likert scale (5 being most favorable) plus comments. RESULTS: We received very consistent support for our new curriculum by residents giving overall rating for rotation 4.35; content relevance to future practice 4.29 and that curriculum should continue and expand 4.61.The strongest points of the curriculum were considered: one-on-one tutoring and the rotation learning to service ratio; detailed discussions on specifics of geriatric care of patients seen; topics (comprehensive geriatric assessment dementia, doing MMSE, medications/polypharmacy in elderly; delirium, home care). The most frequent suggestions for improvement were: more home visits; increased number of complex patients; increased topics in behavioral health, end-of-life and ethics; fewer IDT meetings. Absence of yet fully functional independent geriatric clinic (currently in organizational development) is consistently perceived as the weakest point of the program. As a temporary alternative solution we attempting to conduct geriatric assessments of elderly patients from residents own 'primary panel'. As more residents were exposed to parts of our new curriculum from their first year more of them started favoring idea of conducting rotation during R2 year (3.95). The short one-month rotation plus clinic scheduling conflicts could explain the perception of high quality but excessive reading assignments. CONCLUSION: Residents strongly agreed on relevance and importance of learning quality geriatric care to their future practices, their improved confidence and skills and unanimously supported idea to increase the curriculum time. Our other goal is to expand cross-cultural component of the geriatric training as our residents caring for significant number of Pacific minorities' population.

3. Purpose:  Develop a strong Geriatric Medicine curriculum & Cross-cultural Geriatrics of the Pacific  Attain the highest standards of excellence in delivering quality geriatric care  Develop FM physicians with a strong interest in expanding the geriatrics part of their practice  Improve performance in geriatrics on ABFM certifying examinations

4. Development: A new curriculum was designed based on:  National experts experience by literature review  Interviews with key faculty and residents  Needs assessment based on previous experience, resident performance, problems, and potential solutions  New curriculum was designed to enhance previous longitudinal geriatric clinical and didactic experiences.

5. Curriculum Design:  Longitudinal - residents caring for panel of SNF patients for 24-36 months in 100-bed SNF and home visits.  Integrated - relevant geriatric issues and cases discussed during existing rotations:  clinic and in-hospital geriatric case discussions  problem-solving conferences  discharge planning rounds  meetings with community agencies staff.

6. Curriculum Design : Clinical experiences conducted by the Faculty geriatrician:  Block rotation  Home visits  Consultations  Skilled Nursing Facility  Family Counseling  Compassionate care-giving

7. Curriculum Design :  Block rotation:  concentrated efforts to master the basics of Geriatric Medicine  acquired knowledge and skills to be utilized throughout the rest of the training program.  Home visits:  assess and provide high quality home care  facilitate keeping elderly patients at home

8. Curriculum Design :  Consultations: comprehensive geriatric medical and preoperative assessments.  Skilled Nursing Facility longitudinal experience:  special challenges and differences of SNF care  role of the medical staff  understanding complex SNF regulations  importance of multi-disciplinary team work  in- training sessions to the nursing staff.

9. Curriculum Design :  Family Counseling:  consideration of elders history and legacy & multi-cultural issues of the Pacific  inter-generational issues, family & social network, spiritual context  permanent placement in institutional care, advance directives, DPOA, sibling rivalries.  Compassionate caregiving:  addresses emotional and spiritual needs while providing quality medical care.

10. Results  Teaching time increased by 33%  Developed from three to four-week block rotation for the 3rd year residents  Evaluation was performed through anonymous 1 to 5 Likert scale (5 being most favorable) plus comments.

11. Results  Overall rotation rating: 4.35 /5  Content relevance to future practice: 4.29 /5  Curriculum should continue & expand: 4.61 /5  Usefulness of clinical experience: 4.57 /5  Residents especially appreciated:  one-on-one tutoring & feedback  detailed discussions of patients seen  discussions on specific geriatric topics  teaching to service ratio.

12. Results

13.  Suggestions for restructuring were:  more home visits  see and discuss more complex patients  expand topics on behavioral issues, psychotropic medications, and end-of-life & ethics  more active role in multi-disciplinary team meetings

14. Results  The short four-week rotation plus busy FM clinic schedule could explain the perception of high quality but excessive reading assignments  As more residents were exposed to parts of new curriculum from their first year opinions started favoring (3.95) rotation to be geared for the R1/R2 levels (instead of R3)

15. Discussion:  Residents unanimously agreed that:  new curriculum improved their confidence and skills in taking care for elderly  rotation should continue & expand

16. References:  Blanchette P, Flynn B. Geriatric Medicine: An Approaching Crisis. Generations, Spring 2001, Vol XXV, No. 1: 80-84  Counsels SR. Curriculum Recommendations for Resident Training in Geriatrics Interdisciplinary Team Care. JAGS 1999; 47:1145-1148.  Gold G. Education in Geriatrics: A Required Curriculum for Med. Students. The Mount Sinai JoM, 1993; Vol.60, No.6.  Reuben DB, at al. The Critical Shortage of Geriatrics Faculty. JAGS 1993; 4:560-569.  Sullivan GM. Curriculum Recommendations for Resident Training in Home Care. JAGS;1998; 46:910-912.