Enhancing Physician Enhancing Physician Education Education

in Geriatric Medicinein Geriatric Medicine

Lisa Granville, M.D.Lisa Granville, M.D.

““SHIFT”SHIFT”What Is What Is TaughtTaught What Is Learned

Developing a Competency-Developing a Competency-Based Geriatrics Based Geriatrics

CurriculumCurriculum

Right Time for “Shift”Right Time for “Shift”

• Growing education opportunitiesGrowing education opportunitiesExpectations for geriatrics: Expectations for geriatrics: - UME ….AAMC / Hartford / DWRUME ….AAMC / Hartford / DWR- GME ….RRC RequirementsGME ….RRC Requirements- CME ….Baby boomersCME ….Baby boomers

• Models of competency Models of competency - ACGME ACGME - USMLE Clinical Skills examUSMLE Clinical Skills exam

The Florida Consortium for The Florida Consortium for Geriatric Medical EducationGeriatric Medical Education

A statewide collaboration on physician A statewide collaboration on physician education in geriatricseducation in geriatrics

FCGME Participating Institutions: FCGME Participating Institutions: Florida State UniversityFlorida State University

Nova Southeastern UniversityNova Southeastern UniversityUniversity of FloridaUniversity of FloridaUniversity of MiamiUniversity of Miami

University of South FloridaUniversity of South Florida

Founded May 31, 2001

Initial Focus: Competency Initial Focus: Competency Identification and PromotionIdentification and Promotion

Criteria for content selection:Criteria for content selection:Multifactorial etiology, overlooked or mistaken as normal aging, Multifactorial etiology, overlooked or mistaken as normal aging, benefiting from interventions and/or amenable to biopsychosocial benefiting from interventions and/or amenable to biopsychosocial approachapproach

Reviewed published core curriculum from the American Geriatrics Reviewed published core curriculum from the American Geriatrics SocietySociety– Knowledge (Related to Clinical Practice)Knowledge (Related to Clinical Practice)

Geriatric Syndromes and Conditions. Geriatric Syndromes and Conditions. – A basic understanding of risk factors, causes, signs, symptoms, A basic understanding of risk factors, causes, signs, symptoms,

differential diagnosis, initial diagnostic evaluation, and preventive differential diagnosis, initial diagnostic evaluation, and preventive strategies. strategies.

Adopted AGS geriatric syndromes: Adopted AGS geriatric syndromes: – Chronic pain, delirium, dementia, depression, falls, medications, Chronic pain, delirium, dementia, depression, falls, medications,

osteoporosis, pressure ulcers, sensory impairment, and urinary osteoporosis, pressure ulcers, sensory impairment, and urinary incontinenceincontinence

Content Area: Medical Student Basic Competencies for IncontinenceThe medical student will:

EpidemiologyEpidemiology (incidence, prevalence, risk (incidence, prevalence, risk factors, causes)factors, causes)

1. Express awareness that UI is not a normal consequence of aging2. Identify UI as an under reported condition3. 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 Diagnosis && EvaluationEvaluation (definition, classification, (definition, classification, signs, symptoms, differential signs, symptoms, differential diagnosis, initial diagnostic diagnosis, initial diagnostic evaluation, evaluation tools)evaluation, evaluation tools)

5. Know the World Health Organization definition of UI6. Show consideration for patient comfort and demonstrate interviewing techniques to improve reporting of UI7. Apply the AHCPR guide for initial evaluation of UI8. Demonstrate the application and interpretation of UI evaluation tools (PVR, voiding diary)9. Distinguish between transient and established UI10. Define, describe symptoms and identify common causes of the four types of established UI (urge, stress, overflow, functional)

ComplicationsComplications (morbidity, mortality, (morbidity, mortality, function, QOL)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 & ManagementRx & Management (including preventive (including preventive strategies)strategies)

13. List 3 general approaches to UI management (behavioral, medical, surgical)14. Provide 2 examples for each general approach to UI management15. Associate appropriate interventions with each type of UI16. Relate incontinence management products (e.g., pads, catheters) to individual patient needs

ResourcesResources17. 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 management19. Identify professional referrals for UI management: (e.g., urology, ob gyn, geriatrics, enterostomal nursing, physical therapy) )

““SHIFT”SHIFT”What Is What Is LearnedLearned What Is Done

Improving Older Adults’ Care:Improving Older Adults’ Care:

Changing Physician BehaviorChanging Physician Behavior

Urinary IncontinenceUrinary Incontinence

Guidelines:Guidelines:• Given limited educational time for geriatrics Given limited educational time for geriatrics • Using existing “geriatrics faculty” (sometimes = Using existing “geriatrics faculty” (sometimes =

no geriatricians)no geriatricians)• What can each school accomplish?What can each school accomplish?

19 learning objectives19 learning objectivesWhat are the priorities?What are the priorities?

– Recognize syndromesRecognize syndromes• Realize Syndromes are not normal agingRealize Syndromes are not normal aging

– Initiate screening / evaluation Initiate screening / evaluation – Understand treatment approachesUnderstand treatment approaches– Know where to refer Know where to refer

Urinary IncontinenceUrinary Incontinence

1. Apply the AHCPR guide for initial evaluation of UI2. Demonstrate the application and interpretation of UI

evaluation tools (PVR, voiding diary)3. Distinguish between transient and established UI4. Associate appropriate interventions with each type of UI5. 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 IncontinenceUrinary Incontinence

Can we use these learning objectives for residents, Can we use these learning objectives for residents, fellows, practicing physicians?fellows, practicing physicians?

• LO: Associate appropriate interventions with each type LO: Associate appropriate interventions with each type of UIof UI

• Medication for URGE UIMedication for URGE UI– UME: anticholinergic agentsUME: anticholinergic agents– GME: specific medications with dose and potential ADEsGME: specific medications with dose and potential ADEs– Geriatrics Fellow: off-label medications and their useGeriatrics Fellow: off-label medications and their use

Developing National Developing National Consensus on Geriatric Consensus on Geriatric

Milestones for PhysiciansMilestones for Physicians

AAMC Minimum Geriatrics AAMC Minimum Geriatrics Competencies for Medical Competencies for Medical

StudentsStudents

Ground rulesGround rules• Must focus on issues that matter to health Must focus on issues that matter to health

outcomesoutcomes• Important to patient care likely to occur at Important to patient care likely to occur at

start of internship… “don’t kill granny” start of internship… “don’t kill granny” • Similar to quality indicators, “floor” Similar to quality indicators, “floor”

behaviors could be taught and evaluated behaviors could be taught and evaluated at any medical schoolat any medical school

AAMC Minimum Geriatrics AAMC Minimum Geriatrics Competencies for Medical Competencies for Medical

StudentsStudents26 competencies nested in 8 domains26 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 BehaviorsDeveloping Stealth Behaviors

FSUCOM MissionFSUCOM Mission

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

Distributed Campus ModelDistributed Campus Model

Proposed UME: M1, M2 TrainingProposed UME: M1, M2 Training Geriatricize Clinical Skills TrainingGeriatricize Clinical Skills Training

– Stealth approach, across the lifespanStealth approach, across the lifespan

– Creation of good practice habits over 2 years Creation of good practice habits over 2 years

– 4 domains of desired behaviors4 domains of desired behaviors• Communication skillsCommunication skills: collaborative care, avoidance of : collaborative care, avoidance of

medical jargon, routine patient education medical jargon, routine patient education

• Functional assessmentFunctional assessment: routine assessment of ADLs, : routine assessment of ADLs, IADLs; anticipatory planning for limitationsIADLs; anticipatory planning for limitations

• Social settingSocial setting: living arrangements, social support: living arrangements, social support

• Therapeutic reviewTherapeutic review: consider non-drug management, : consider non-drug management, collaboratively develop care planscollaboratively develop care plans

Senior Mentors / Developmentally Senior Mentors / Developmentally Delayed ProgramDelayed Program

– Explore biases regarding function and ageExplore biases regarding function and age

– Explore value of applying geriatric care Explore value of applying geriatric care principles across the lifespanprinciples across the lifespan

Clinical Learning CenterClinical Learning Center

Focused History and Physical Exam Interview techniques Introduces self and observer. Explains student role Washes hands before touching patient; rewashes as appropriate Demonstrates SOFTEN behaviors Uses PEARLS statements Gathers information in logical/organized order; proceeds from general to specific Uses understandable language; avoids/explains jargon Uses summarization Provides opportunity for questions Assesses need for patient education; if appropriate provides needed patient education Concludes the session by telling patient what will happen next before student leaves room If dyad/couple present, appropriately addresses both individuals If dyad/couple present, offer/arrange to interview/examine patient in private Medical History Elicits chief complaint (CC). Stated in words of patient Identifies other agenda items early in interview Performs thorough HPI:

Quality/character Quantity/severity Location/radiation Context/setting Onset/duration/frequency/progression Modifying factors Associated symptoms/symptom-specific ROS

Elicits previous similar episodes Elicits patient’s ideas re: causation of symptoms Elicits patient’s worry/concerns about symptoms Elicits impact on daily life ( self care, work, relationships) Elicits baseline functional ability Elicits medical diseases/conditions Elicits all prescribed medications used Elicits all OTC medications, herbal therapies used Elicits all non-medication approaches used Elicits household members and environment Elicits support system Elicits appropriate items from:

Past medical history (allergies, meds, adult diseases, hospitalizations, surgeries, etc.) Social/personal history (tobacco, alcohol, drugs, diet, living situation, finances, etc.) Family history Occupational/environmental history

Physical Exam Perform appropriate systems exams

Required Clerkship

Family Medicine

Internal Medicine

Obstetrics/ Gynecology

Pediatrics Psychiatry Surgery

Principles: Communication skills

X X X X

Functional assessment

X X X

Social setting X X X X X Therapeutic review

X X X X

Syndromes: Delirium X X X Dementia X X X Depression X X Falls X X Nutritional compromise

X X

Polypharmacy X X Urinary incontinence

X X

Stealth PartnershipsStealth Partnerships

What SHOULD the geriatric What SHOULD the geriatric milestones be for:milestones be for:

• All graduating medical studentsAll graduating medical students– AAMC geriatrics competenciesAAMC geriatrics competencies

• All primary care residentsAll primary care residents– SGIM-AGS-SHM Education Consortium SGIM-AGS-SHM Education Consortium – IM-FM RRC revisions projectIM-FM RRC revisions project

• Practicing physiciansPracticing physicians– AMA Aging InitiativeAMA Aging Initiative

What can we do together…What can we do together…