BACKGROUND UM mandatory UME curriculum in geriatrics pain

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					       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          Professional    Professional
                  Program          Certification    Licensing
                 Accreditation



                                     NBME
Medical            LCME
Students



Residents +       ACGME              ABMS           FSMB
Fellows



Practicing
Physicians        ACCME              ABMS           FSMB
      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
                   Geriatric Competencies
Surgical Anesth          by Learner
Specialty ENT
Residents Ob-Gyn
                                       Geriatric
                                       Fellows

           Residents
Medical                         Sub-Specialty
Students                          Fellows
           Emergency Medicine
           Internal Medicine         Practicing MDs
           Family Medicine
           Surgery
          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      • Pharmacy
•   Medicine       • Physical Therapy
•   Nursing        • Physician
•   Nutrition        Assistants
•   Occupational   • Psychology
    Therapy        • Social Work
       Still Need to Get
      Teaching Materials

   Genetics/Genomics     Geriatrics
NO TIME!!                      QI projects

   End-of-Life Care             EBM

    ACGME Competencies   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
    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 Trans-
     Institutional 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 patient-
    specific 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, Mini-
       cog, 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            • Learner Assessments 101
   working group                  • 360 assessments
 • Assessment Fair                • DDx of Delirium: training
 • NBME workshops                   to competence
 • Clinical Skills sessions


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         •   Bree Johnston
•   Lynn Bickley              •   Reena Karani
•   Jan Busby-Whitehead       •   Rosanne Leipzig
•   Danelle Cayea             •   Sharon Levine
•   Anne Fabiny               •   Joanne Schwartzberg
•   Lisa Granville            •   Amit Shah
                              •   Gail Sullivan



              Funded by AMA
               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)   not covered by a competency,
  (b)   predominantly affects 65+,
  (c)   testing what is typically seen in an older adult,
  (d)   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




3 forms for each Step; all >65 yo
ABIM Review Results
      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 (inter-
    rater reliability)
   Direct Observation:
Faculty Ratings: ABIM 1-9




                    Satisfactory
   Unsatisfactory                      Superior


   1   2     3      4    5    6    7      8       9
      Direct Observation:
Faculty Ratings: ABIM 1-9 scale




      Satisfactory       Superior

       4    5        6   7   8   9
   Direct Observation:
Faculty Ratings: ABIM 1-9




                    Satisfactory
   Unsatisfactory                      Superior


   1   2     3      4    5    6    7      8       9
      Direct Observation:
Faculty Ratings: ABIM 1-9 scale




      Satisfactory       Superior

       4    5        6   7   8   9
   TUAG Direct Observation:
Faculty Ratings: ABIM 1-9 scale




      Satisfactory       Superior

       4    5        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?

				
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