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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 Program Accreditation.
Rosanne M. Leipzig, MD, PhD
Brookdale Department of Geriatrics
and Palliative Medicine
Mount Sinai School of Medicine
Residents + Fellows
Make it easier to teach
Make it easier to assess
Geriatrics in High Stakes Examinations
Geriatrics requirements for accreditation
Leveraging Geriatrics Medical Education
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.
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
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.
Social WorkPartnership for Health in Aging (PHA) Competencies
“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
Mostly Knows, Knows How, Shows
Policy for securing and releasing assessment materials
Some materials not directly accessible on POGOe
released upon request and
verification of requester’s faculty status
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.
Provide appropriate preventive care and teach patient regarding self-care
Approximate timeframe by which this should be achieved
General Evaluation Strategies
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
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.
ABIM interested in having residency programs pilot this as competency-based learning
Speak with Anne Fabiny or Brent Williams if interested in reviewing
Assessment tools with the new rating instrument
Funded by AMA
involves one of the 26 geriatrics competencies, and/or
involves one of ABIM’s 16 geriatric syndromesand/or
involves a “geriatric” disease/condition:
not covered by a competency,
predominantly affects 65+,
testing what is typically seen in an older adult,
if the examinee gets it wrong – could hurt an older adult
Eg, differential diagnosis of abdominal pain in an older adult
Constipation and fecal incontinence
Dizziness / lightheadedness
Falls and gait disorders
Failure to thrive
Examples of others being considered
Medicine Sub Internship
N = 8
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.
3 forms for each Step; all >65 yo
MCQ Knowledge Gaps
Geriatric content in Clinical Skills exam
Ways to provide feedback to schools
Geriatrics shelf exam
Geriatrics subscores on 2 exams given at most schools (IM, surg, psych?)
Composite geriatric subscore from questions on several shelf exams
REFUSED request to add geriatrics to this list!LCME Revised Standard ED-15Commentary
2001-2009: specific geriatrics questions
2010: Geriatrics questions eliminated
Currently lobbying for reinstatement in 2011
Faculty with credentials appropriate to the care setting must supervise all clinical experiences. These experiences must include:
Judicious Resource Use
(Basic geriatric instruction)
$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
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
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.
Continue work as a Geriatrics Learning Community
MCQ question writers
Clinical Skills exam
New blueprint for certification exam
So older patients will get safer, better care
Don’t Kill Granny!
NEEDED: Consensus on markers for direct observation
What tool to use?
Gait and balance assessment
Get Up and Go?
Checklist of critical behaviors
Faculty Development to use checklists to get consistent ratings of competency (inter-rater reliability)
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