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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.

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herding cats leverage points for geriatric medical education in 2011

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

medical education table of disorganization
Medical Education Table of Disorganization










Medical Students




Residents + Fellows



Practicing Physicians


geriatricizing 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


that was the year that was 2010

That Was the Year That Was2010

Leveraging Geriatrics Medical Education

geriatric competencies by learner
Geriatric Competencies by Learner










Sub-Specialty Fellows



Practicing MDs

Emergency Medicine

Internal Medicine

Family Medicine


falls competencies
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 competencies1
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




Occupational Therapy


Physical Therapy

Physician Assistants


Social Work

Partnership for Health in Aging (PHA) Competencies
still need to get teaching materials
Still Need to Get Teaching Materials




QI projects

End-of-Life Care


ACGME Competencies

Cultural Competency

blended learning
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


“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 collaborations
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
G-Wiz (Geriatric Wizard)
  • Identifies the best POGOe products for each medical student competency
pogoe product reviews
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
virtual clerkship
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
at this meeting
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!
the reynolds trans institutional evaluation group r tieg
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
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
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
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

acgme milestones
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
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
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
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

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
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 working group
  • Assessment Fair
  • NBME workshops
  • Clinical Skills sessions
  • Learner Assessments 101
  • 360 assessments
  • DDx of Delirium: training to competence

Speak with Anne Fabiny or Brent Williams if interested in reviewing

Assessment tools with the new rating instrument

faculty development

Faculty Development

Leverage Point

gacas 2010
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
Faculty Development Possibility
  • Adapting ABIM Faculty Development course in assessment to geriatric competencies
changes to abim internal medicine examination
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 geriatrics
2010 exams reviewed
2010 Exams Reviewed
  • NBME subject (shelf) exams
    • 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
2010: Exam Reviewers
  • Christine Arenson
  • Lynn Bickley
  • Jan Busby-Whitehead
  • DanelleCayea
  • Anne Fabiny
  • Lisa Granville
  • Bree Johnston
  • Reena Karani
  • Rosanne Leipzig
  • Sharon Levine
  • Joanne Schwartzberg
  • Amit Shah
  • Gail Sullivan

Funded by AMA

a geriatric question
A Geriatric Question

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

abim geriatric syndromes
ABIM Geriatric Syndromes

Constipation and fecal incontinence




Dizziness / lightheadedness

Falls and gait disorders


Hearing loss




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
Geriatric Diseases


Osteoporosis (OP)


Examples of others being considered

Mesenteric ischemia



Myasthenia Gravis

Multiple Myeloma

nbme subject exams reviewed
NBME Subject Exams Reviewed

Family Medicine


Internal Medicine



Clinical Neurology

Medicine Sub Internship


N = 8

nbme subject exams
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
Preliminary USMLE Exam Results

3 forms for each Step; all >65 yo

needs identified from exam reviews
Needs Identified from Exam Reviews

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


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
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 cycleLCME Revised Standard ED-15
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!

LCME Revised Standard ED-15Commentary
aamc graduation questionnaire gq
AAMC Graduation Questionnaire (GQ)

2001-2009: specific geriatrics questions

2010: Geriatrics questions eliminated

Currently lobbying for reinstatement in 2011

residency review committees
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
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
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
medpac 2009 concerns
MedPAC 2009 concerns


Care Coordination

Multidisciplinary Teamwork

Patient Safety

Judicious Resource Use

Nonhospital Experiences

(Basic geriatric instruction)

congress and
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
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 congress1
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
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
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
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….
geriatricizing medical education1
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



Geriatrics subscore?


MCQ question writers

Geriatrics subscore?

Clinical Skills exam


New blueprint for certification exam

advocate for
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
Why do we doing this?

So older patients will get safer, better care


Don’t Kill Granny!

assessment gaps
Assessment Gaps:

NEEDED: Consensus on markers for direct observation

What tool to use?

Gait and balance assessment

Get Up and Go?


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
Direct Observation: Faculty Ratings: ABIM 1-9




1 2 3 4 5 6 7 8 9

direct observation faculty ratings abim 1 91
Direct Observation: Faculty Ratings: ABIM 1-9




1 2 3 4 5 6 7 8 9