- Email: [email protected]
Geriatrics content in residency curricula
Geriatrics Content in Residency Curricula RICHARD W. BESDINE, M.D., Farmington, Connecticut
wo trends drive curricula for geriatric training development: the rapid growth of the very elderly population, with their disproportionate use of health care, and the ascendancy of primary care. This article will outline the nature of the geriatrics knowledge base, the relationship of geriatrics to primary care, the faculty development needed to teach geriatrics, and the curriculum needed to train residency graduates in the care of older people.
T
THE NATUREOF GERIATRICS Geriatrics is based on an understanding of the changes associated with human aging and their interactions with disease. Clinical practice is dominated by the 75-85% of elderly who have common diseases along with the irreversible changes of aging. However, age-driven changes can best be studied in the 15-25% of older people who have no physical or cognitive function deficits. Within this group are a small number who, by family history or lifestyle, have few identifiable risk factors for diseases or disabilities other than those related to aging alone. These few set the standard for successful aging. Understanding which changes are due to intrinsic aging and which are due to disease is crucial for the clinician. The interaction of age-driven change with disease and environment dictates the special characteristics of geriatrics. This data base must be transmitted to students, house staff, and practitioners.
GERIATRICSAND PRIMARYCARE The relationship of geriatrics to primary care is central to curriculum development. Geriatricians practice and teach primary care as they train new faculty and teach geriatrics in undergraduate and postgraduate medical education. They are needed as primary physicians for the 20% of the population who are the oldest, frailest, have the most severe medical problems, incur the highest costs of care,
From the TravelersCenter on Aging and Departmentof Medicine,Universityof Connecticut Health Center, Farmington,Connecticut. Requestsfor reprints should be addressedto RichardW. Besdine, M.D., Travelers Center on Aging, University of Connecticut Health Center, MC5215, Farmington, Connecticut 06030.
4A-lOS
and have the most adverse effects. The irony is that these patients need specialists (geriatricians) to provide their primary care. The remaining 80% of older people, whose care is less complex, are best managed by generalist primary care physicians who received adequate geriatrics training from academic geriatricians. Consultative assistance from geriatricians will occasionally be needed. Geriatrics fellowship programs, which are now in jeopardy, shoulder the responsibility to produce faculty who can provide this curriculum development and teaching.
FACULTYDEVELOPMENTTO TEACHGERIATRICS An acute and growing demand exists for welltrained investigators and teachers in geriatrics. It requires time and effort to train these faculty [1-5]; there are no "90-day wonders." Population forecasts and projected work force shortages require us to enhance output and effectiveness of existing faculty development programs; research-intensive and teaching-intensive faculty have a powerful multiplier effect on the investment in their training because of the large number of other trainees and practitioners they subsequently influence. The goal is for medical schools and 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. The more academic programs also must produce research data to illuminate further our understanding of aging and improve care. But current training programs are not producing enough academic geriatricians [6-8]. At present, 96 geriatrics fellowships have been accredited by the Internal Medicine and Family Medicine Residency Review Committees of the Accreditation Council on Graduate Medical Education (ACGME). Four times since 1988, the American Boards of Internal Medicine and of Family Practice have offered an examination certifying Added Qualifications in Geriatrics for their diplomates. Although pass rates for graduates of approved programs are extremely high, of the nearly 6,000 physicians certified through the 1992 exam, only 617 have been fellowship graduates. This suggests that well under 1,000 geriatrics fellows have graduated in the past decade--the life span of most programs. In the last 3
October17, 1994 The AmericanJournalof Medicine Volume97 (suppl 4A)
APM SYMPOSIUMON GERIATRICEDUCATION/BESDINE
years, 16 of the best programs, funded by Health Resources Services Administration training grants, have had >20% of grant-supported slots unfilled. Why are there such alarming vacancy rates in geriatrics fellowships? One reason is that internal medicine residents are the major source of candidates, and the percentage of medical school graduates choosing internal medicine has fallen over the last two decades from >50% to <20%. A second reason is that primary care, the orientation required for geriatrics, is also in recession in spite of initiatives currently underway. A third reason is that geriatrics faculty are not paid as highly as faculty in procedure-rich specialties and subspecialties, and today's residents often graduate with loan burdens in excess of $100,000. In spite of these drawbacks, students and residents exposed to effective education in geriatrics respond with career interest. Fellowships at schools with meaningful curricula in aging, especially in medicine and family medicine, have had success recruiting candidates. The challenge most programs face is finding enough qualified faculty to teach geriatrics at their medical schools, not just in their comparatively small fellowship programs. Faculty shortages are exacerbated by contemporary undergraduate curricula, which emphasize small-group learning instead of large-group lect u r e s - s t r a t e g i e s that demand more faculty time. In addition, getting content on aging into increasingly crowded curricula requires persistent efforts by experienced senior faculty. Even so, now is the time of opportunity. Curriculum revitalization and renovation are occurring in many schools, and others are watching these changes intently. Residency programs are under pressure to become more relevant to the practice world of the 1990s and the 21st century.
IMPLEMENTING GERIATRICS CURRICULA Our goal is to assist accredited residency programs, especially in primary care specialties, in developing and implementing adequate, mandatory didactic and training experiences in aging [9,10]. (The major topics of a sample curriculum is provided in Table I [11].) Some residency programs are already developing geriatrics curricula. However, funding for faculty time to plan and implement curricula and for development of nontraditional sites for clinical training is needed for both undergraduate and residency programs. Internal medicine requires the largest investment because internists provide the most care to older adults and the most faculty in geriatrics. Family medicine, although aware of and responsive to training needs in geriatrics, is a smaller contributor to clinical and
TABLE I Residency Curriculum Content in Aging BasicSciences:Examplesof content Aging as a "normal developmentalprocess"; description of overall changesin appearanceand function from birth to old age. Effects of age on organ system anatomyand physiology(normalaging, free of disease). Consequencesof aging on drug metabolism. - Pharmacokinetics - Pharmacodynamics - Pharmacoepidemiology Neuroscience - Age-relatedCNS changes - Degenerativephenomena:Alzheimer'sdisease, Parkinson'sdisease, prion-associated diseases - Specialsenses (hearing,balance,vision, taste, smell) Environmental(exogenous)factors in aging - Nutrition - Pollutantsand environmentaltoxins Social and behavioralaspects of aging: psychologicand cognitive changes, environmentalfactors (family,friends, pets, independence,gender roles) Ethical and legal issues Population-basedsciences Pathophysiologyof aging
ClinicalSciences Comprehensivegeriatric assessment Atypical presentationof disease Multiplepathologyand interactionsamong diseasesand therapies Nonreportingof symptoms Geriatric syndromes:falls, incontinence,delirium,dementia,pressure sores, syncope, failure to thrive, sensory impairment,malnutrition,sleep disorder, dizziness, constipation Diseasesinfluencedby age-relatedchangesin organs and tissues Health promotion/diseaseprevention - Primaryprevention - Secondaryand tertiary prevention Site experiences:nursing home, rehabilitation,exercise sites, ambulatoryprimary care
academic geriatrics. Psychiatry, neurology, and gynecology are also important; some of the training needs for these residencies could be met by using resources in programs established for internal medicine. Residencies with demonstrated enthusiasm and leadership that are able and willing to implement a mandatory curriculum on aging could serve as roodels for other programs. Senior administrative commitment (e.g., department chair, residency director) is necessary to initiate a curriculum and evaluation plan. Grant support for initiation would help ensure that programs prepare students for the medicine of the future. Resources needed for implementation will depend on the size and complexity of each residency program. Funds would be used for planning the curriculum, for upgrading the skills and knowledge base necessary for teaching the new components, and for initial precepting and supervising of rotations.
October 17, 1994
The American Journal of Medicine
Volume 97 (suppl 4A)
4&-11S
APM SYMPOSIUMON GERIATRICEDUCATION/ WARSHAW
REFERENCES 1. Institute of Medicine. Aging and Medical Education: Report of a Study. Washington, D.C.: National Academy of Sciences; 1978. (IOM publication no. 78-04). 2. Kane RL, Solomon DR, Beck JC, et al. Geriatrics in the United States: manpower projections and training considerations (R 2543-HJK). Santa Monica, CA: Rand Corporation, 1980. 3. Kane RL, Solomon DH, Beck JC, et al. The future need for geriatric manpower in the United States. N Engl J Med 1980; 302: 1327-32. 4. U.S. Department of Healthand HumanServices. Report on Educationand Training in Geriatrics and Gerontology. [Administrative document.] Bethesda, MD: National Institute on Aging, 1984. 5. U.S. Department of Health and Human Services. Personnelfor Health Needs of the Elderly through Year 2020. [Administrative document.] Bethesda, MD: National nstitute on Aging, 1987 S. Institute of Medicine Committee on Leadership for Academic Geriatric Medicine.
Report of the Institute of Medicine: Academic Geriatrics for the Year 2000. J Am Gefiatr Soc 1987; 35: 773-91. 7. MoloneyTW, Paul B. Buildingthe future of geriatrics. J Am Geriatr Soc. 1991; 39: 425-8. 8. Reuben DB, Bradley TB, Zwanziger J, et al. The critical shortage of geriatrics faculty. J Am Geriatr Soc 1993; 41: 560-9. 9. ReubenDB, ZwanzigerJ, BradleyTB, et al. How many physicianswill be neededto provide medical care for older persons? Physician manpower needs for the 21st century. J Am Geriatr Soc 1993; 41: 444-53. 10. American College of Physicians, Health and Public Policy Committee. Issues Paper: Geriatric training and the internal medicine residency. Philadelphia:American College of Physicians, 1989. 11. Besdine RW. Curricular Strategies in Geriatrics Faculty Development.In: House Select Committee on Aging (eds). Shortage of Health Care ProfessionalsCaring for the Elderly: Recommendationsfor Change. [Administrative Document] Washington, D.C.: U.S. Congress, 1993.
Geriatric Medicine Training in Family Practice Residency GREGG WARSHAW, M.D., Cincinnati. Ohio
ecause family physicians and general internists B provide most primary care for older adults, we
must implement effective curricula in these residency programs. This article reviews educational strategies for geriatric medicine teachers within primary care residency programs, with an emphasis on program organization and resource development. Fifteen years ago, the Residency Review Committee for Family Practice directed residency programs to develop formal curricula in geriatric medicine [1,2]. In 1984, curriculum guidelines were published [3]. In 1990, 80% of family practice residencies had geriatric curricula; in 92% of these programs, it was required [4].
EDUCATIONALSTRATEGIES Geriatrics is taught in different ways in different settings, depending on each program's resources. Some key strategies will be discussed here. Combining Geriatrics with.Existing Programs A 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 the use of restraints and Foley catheters. Unfortunately, this approach is often insufficient because of a lack of interested and qualified faculty. 4A-12S
Developing New Longitudinal Experiences Longitudinal programs may include a conference series and having residents follow patients in community or institutional settings for 6-24 months. Advantages of this approach are that trainees follow patients through the healthcare system, become familiar with different clinical sites, and get to see patients improve from conditions (such as stroke) that require time for treatment response to become apparent. The disadvantage is that these programs occur at the same time as other competing responsibilities for the residents. Their more urgent clinical care responsibilities compete with time required to r e a d geriatric material or visit nursing home patients. Block Rotations Block rotations provide shorter longitudinal experience but allow residents to concentrate exclusively on geriatrics for a required period of t i m e - usually 1-2 months. This permits trainees to master a significant amount of material and apply it throughout the rest of their training program. Educational Materials Books and journals must be available for residents by setting up geriatric medicine sections in libraries. These sections should include special literature files and audiovisual materials. Portable videotape equipment can be used to tape family
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)
wo trends drive curricula for geriatric training development: the rapid growth of the very elderly population, with their disproportionate use of health care, and the ascendancy of primary care. This article will outline the nature of the geriatrics knowledge base, the relationship of geriatrics to primary care, the faculty development needed to teach geriatrics, and the curriculum needed to train residency graduates in the care of older people.
T
THE NATUREOF GERIATRICS Geriatrics is based on an understanding of the changes associated with human aging and their interactions with disease. Clinical practice is dominated by the 75-85% of elderly who have common diseases along with the irreversible changes of aging. However, age-driven changes can best be studied in the 15-25% of older people who have no physical or cognitive function deficits. Within this group are a small number who, by family history or lifestyle, have few identifiable risk factors for diseases or disabilities other than those related to aging alone. These few set the standard for successful aging. Understanding which changes are due to intrinsic aging and which are due to disease is crucial for the clinician. The interaction of age-driven change with disease and environment dictates the special characteristics of geriatrics. This data base must be transmitted to students, house staff, and practitioners.
GERIATRICSAND PRIMARYCARE The relationship of geriatrics to primary care is central to curriculum development. Geriatricians practice and teach primary care as they train new faculty and teach geriatrics in undergraduate and postgraduate medical education. They are needed as primary physicians for the 20% of the population who are the oldest, frailest, have the most severe medical problems, incur the highest costs of care,
From the TravelersCenter on Aging and Departmentof Medicine,Universityof Connecticut Health Center, Farmington,Connecticut. Requestsfor reprints should be addressedto RichardW. Besdine, M.D., Travelers Center on Aging, University of Connecticut Health Center, MC5215, Farmington, Connecticut 06030.
4A-lOS
and have the most adverse effects. The irony is that these patients need specialists (geriatricians) to provide their primary care. The remaining 80% of older people, whose care is less complex, are best managed by generalist primary care physicians who received adequate geriatrics training from academic geriatricians. Consultative assistance from geriatricians will occasionally be needed. Geriatrics fellowship programs, which are now in jeopardy, shoulder the responsibility to produce faculty who can provide this curriculum development and teaching.
FACULTYDEVELOPMENTTO TEACHGERIATRICS An acute and growing demand exists for welltrained investigators and teachers in geriatrics. It requires time and effort to train these faculty [1-5]; there are no "90-day wonders." Population forecasts and projected work force shortages require us to enhance output and effectiveness of existing faculty development programs; research-intensive and teaching-intensive faculty have a powerful multiplier effect on the investment in their training because of the large number of other trainees and practitioners they subsequently influence. The goal is for medical schools and 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. The more academic programs also must produce research data to illuminate further our understanding of aging and improve care. But current training programs are not producing enough academic geriatricians [6-8]. At present, 96 geriatrics fellowships have been accredited by the Internal Medicine and Family Medicine Residency Review Committees of the Accreditation Council on Graduate Medical Education (ACGME). Four times since 1988, the American Boards of Internal Medicine and of Family Practice have offered an examination certifying Added Qualifications in Geriatrics for their diplomates. Although pass rates for graduates of approved programs are extremely high, of the nearly 6,000 physicians certified through the 1992 exam, only 617 have been fellowship graduates. This suggests that well under 1,000 geriatrics fellows have graduated in the past decade--the life span of most programs. In the last 3
October17, 1994 The AmericanJournalof Medicine Volume97 (suppl 4A)
APM SYMPOSIUMON GERIATRICEDUCATION/BESDINE
years, 16 of the best programs, funded by Health Resources Services Administration training grants, have had >20% of grant-supported slots unfilled. Why are there such alarming vacancy rates in geriatrics fellowships? One reason is that internal medicine residents are the major source of candidates, and the percentage of medical school graduates choosing internal medicine has fallen over the last two decades from >50% to <20%. A second reason is that primary care, the orientation required for geriatrics, is also in recession in spite of initiatives currently underway. A third reason is that geriatrics faculty are not paid as highly as faculty in procedure-rich specialties and subspecialties, and today's residents often graduate with loan burdens in excess of $100,000. In spite of these drawbacks, students and residents exposed to effective education in geriatrics respond with career interest. Fellowships at schools with meaningful curricula in aging, especially in medicine and family medicine, have had success recruiting candidates. The challenge most programs face is finding enough qualified faculty to teach geriatrics at their medical schools, not just in their comparatively small fellowship programs. Faculty shortages are exacerbated by contemporary undergraduate curricula, which emphasize small-group learning instead of large-group lect u r e s - s t r a t e g i e s that demand more faculty time. In addition, getting content on aging into increasingly crowded curricula requires persistent efforts by experienced senior faculty. Even so, now is the time of opportunity. Curriculum revitalization and renovation are occurring in many schools, and others are watching these changes intently. Residency programs are under pressure to become more relevant to the practice world of the 1990s and the 21st century.
IMPLEMENTING GERIATRICS CURRICULA Our goal is to assist accredited residency programs, especially in primary care specialties, in developing and implementing adequate, mandatory didactic and training experiences in aging [9,10]. (The major topics of a sample curriculum is provided in Table I [11].) Some residency programs are already developing geriatrics curricula. However, funding for faculty time to plan and implement curricula and for development of nontraditional sites for clinical training is needed for both undergraduate and residency programs. Internal medicine requires the largest investment because internists provide the most care to older adults and the most faculty in geriatrics. Family medicine, although aware of and responsive to training needs in geriatrics, is a smaller contributor to clinical and
TABLE I Residency Curriculum Content in Aging BasicSciences:Examplesof content Aging as a "normal developmentalprocess"; description of overall changesin appearanceand function from birth to old age. Effects of age on organ system anatomyand physiology(normalaging, free of disease). Consequencesof aging on drug metabolism. - Pharmacokinetics - Pharmacodynamics - Pharmacoepidemiology Neuroscience - Age-relatedCNS changes - Degenerativephenomena:Alzheimer'sdisease, Parkinson'sdisease, prion-associated diseases - Specialsenses (hearing,balance,vision, taste, smell) Environmental(exogenous)factors in aging - Nutrition - Pollutantsand environmentaltoxins Social and behavioralaspects of aging: psychologicand cognitive changes, environmentalfactors (family,friends, pets, independence,gender roles) Ethical and legal issues Population-basedsciences Pathophysiologyof aging
ClinicalSciences Comprehensivegeriatric assessment Atypical presentationof disease Multiplepathologyand interactionsamong diseasesand therapies Nonreportingof symptoms Geriatric syndromes:falls, incontinence,delirium,dementia,pressure sores, syncope, failure to thrive, sensory impairment,malnutrition,sleep disorder, dizziness, constipation Diseasesinfluencedby age-relatedchangesin organs and tissues Health promotion/diseaseprevention - Primaryprevention - Secondaryand tertiary prevention Site experiences:nursing home, rehabilitation,exercise sites, ambulatoryprimary care
academic geriatrics. Psychiatry, neurology, and gynecology are also important; some of the training needs for these residencies could be met by using resources in programs established for internal medicine. Residencies with demonstrated enthusiasm and leadership that are able and willing to implement a mandatory curriculum on aging could serve as roodels for other programs. Senior administrative commitment (e.g., department chair, residency director) is necessary to initiate a curriculum and evaluation plan. Grant support for initiation would help ensure that programs prepare students for the medicine of the future. Resources needed for implementation will depend on the size and complexity of each residency program. Funds would be used for planning the curriculum, for upgrading the skills and knowledge base necessary for teaching the new components, and for initial precepting and supervising of rotations.
October 17, 1994
The American Journal of Medicine
Volume 97 (suppl 4A)
4&-11S
APM SYMPOSIUMON GERIATRICEDUCATION/ WARSHAW
REFERENCES 1. Institute of Medicine. Aging and Medical Education: Report of a Study. Washington, D.C.: National Academy of Sciences; 1978. (IOM publication no. 78-04). 2. Kane RL, Solomon DR, Beck JC, et al. Geriatrics in the United States: manpower projections and training considerations (R 2543-HJK). Santa Monica, CA: Rand Corporation, 1980. 3. Kane RL, Solomon DH, Beck JC, et al. The future need for geriatric manpower in the United States. N Engl J Med 1980; 302: 1327-32. 4. U.S. Department of Healthand HumanServices. Report on Educationand Training in Geriatrics and Gerontology. [Administrative document.] Bethesda, MD: National Institute on Aging, 1984. 5. U.S. Department of Health and Human Services. Personnelfor Health Needs of the Elderly through Year 2020. [Administrative document.] Bethesda, MD: National nstitute on Aging, 1987 S. Institute of Medicine Committee on Leadership for Academic Geriatric Medicine.
Report of the Institute of Medicine: Academic Geriatrics for the Year 2000. J Am Gefiatr Soc 1987; 35: 773-91. 7. MoloneyTW, Paul B. Buildingthe future of geriatrics. J Am Geriatr Soc. 1991; 39: 425-8. 8. Reuben DB, Bradley TB, Zwanziger J, et al. The critical shortage of geriatrics faculty. J Am Geriatr Soc 1993; 41: 560-9. 9. ReubenDB, ZwanzigerJ, BradleyTB, et al. How many physicianswill be neededto provide medical care for older persons? Physician manpower needs for the 21st century. J Am Geriatr Soc 1993; 41: 444-53. 10. American College of Physicians, Health and Public Policy Committee. Issues Paper: Geriatric training and the internal medicine residency. Philadelphia:American College of Physicians, 1989. 11. Besdine RW. Curricular Strategies in Geriatrics Faculty Development.In: House Select Committee on Aging (eds). Shortage of Health Care ProfessionalsCaring for the Elderly: Recommendationsfor Change. [Administrative Document] Washington, D.C.: U.S. Congress, 1993.
Geriatric Medicine Training in Family Practice Residency GREGG WARSHAW, M.D., Cincinnati. Ohio
ecause family physicians and general internists B provide most primary care for older adults, we
must implement effective curricula in these residency programs. This article reviews educational strategies for geriatric medicine teachers within primary care residency programs, with an emphasis on program organization and resource development. Fifteen years ago, the Residency Review Committee for Family Practice directed residency programs to develop formal curricula in geriatric medicine [1,2]. In 1984, curriculum guidelines were published [3]. In 1990, 80% of family practice residencies had geriatric curricula; in 92% of these programs, it was required [4].
EDUCATIONALSTRATEGIES Geriatrics is taught in different ways in different settings, depending on each program's resources. Some key strategies will be discussed here. Combining Geriatrics with.Existing Programs A 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 the use of restraints and Foley catheters. Unfortunately, this approach is often insufficient because of a lack of interested and qualified faculty. 4A-12S
Developing New Longitudinal Experiences Longitudinal programs may include a conference series and having residents follow patients in community or institutional settings for 6-24 months. Advantages of this approach are that trainees follow patients through the healthcare system, become familiar with different clinical sites, and get to see patients improve from conditions (such as stroke) that require time for treatment response to become apparent. The disadvantage is that these programs occur at the same time as other competing responsibilities for the residents. Their more urgent clinical care responsibilities compete with time required to r e a d geriatric material or visit nursing home patients. Block Rotations Block rotations provide shorter longitudinal experience but allow residents to concentrate exclusively on geriatrics for a required period of t i m e - usually 1-2 months. This permits trainees to master a significant amount of material and apply it throughout the rest of their training program. Educational Materials Books and journals must be available for residents by setting up geriatric medicine sections in libraries. These sections should include special literature files and audiovisual materials. Portable videotape equipment can be used to tape family
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)