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Why Residents Should Attend the AGS' Annual Scientific Meeting, April 30- May 3 2008 By Maura Brennan, MD, & Sandra Bellantonio, MD, Co-chairs of the Education Committee's Subcommittee on Resident Recruitment
Learn Something Different:
The content at AGS' Annual Scientific Meeting differs from that at any other conference. Faculty come from many medical and surgical specialties and include pharmacists, nurses and therapists. The annual meeting is a great chance for residents to review current evidence about best evaluation and management of common office and hospital problems, including delirium, health care maintenance for elders, and falls. In addition, many sessions cover surgical challenges such as wound management or discuss the unique needs of elders in subspecialties such as geriatric oncology. There are multiple offerings; residents can tailor the program to their own interests. There is something for everyone and countless opportunities to learn something new.
Network:
Thousands of people come from across the country to attend these sessions. Seek out those who work in a field that interests you. If you are considering a fellowship in a given institution go to some lectures or workshops given by faculty from that program, approach them after the sessions and introduce yourself. If there is a particular research area that fascinates you, study the advance program and do the same thing. You will be amazed at how welcoming the geriatricians are. (Think about it for a minute-have you ever met a geriatrician who was unkind or didn't want to talk to a trainee?) When you sit down at a lunch meeting choose a table with people that you don't know and then get to know them!
Stretch Your Academic Wings:
AGS runs a very open and warm conference. There are many ways that residents can work on professional development at the meeting. Check out some of the posters (especially the Residents Poster Session the evening of May 2nd). See what other house officers have done and note how they present their research, teaching projects and case reports. Check out the closing plenary session on the evening of Saturday May 3rd. Teams of house officers will be competing to answer questions based on recent articles in the geriatric literature. It will be fun and you could consider applying to be on one of the quiz teams next year.
Develop Organizational Skills and Experience:
A successful medical career requires skill in working through systems; these include hospital bureaucracies, outpatient practices, political entities like CMS, and professional medical societies. AGS welcomes resident participation. For example, residents have been appointed to working groups of the residency recruitment subcommittee. You could do this as well. This provides great experience for future work both in AGS and in other organizations.
Become A Better Teacher:
As Dr. Cader states in her accompanying article in this issue, residents need to teach older patients and their families. I would add that they also need to convey basic geriatric knowledge to interns, nurses and medical students. Try teaching about falls risk in the community and learn how to screen for gait impairment while at AGS. On Friday May 2nd staff and faculty will be at Union Station in Washington, D.C. supervising trainees (residents, fellows, medical, nursing and PT students) who will assess passers-by for gait impairment, hand out brochures and provide basic counseling. This is likely to get significant local publicity. To prepare you for this task, there's a clinical skills workshop on Thursday the 1st of May. Volunteers for the Union Station program can review falls screening strategies there. (Other learning possibilities at that one workshop include breaking bad news, avoiding the hazards of hospitalization, joint injections, minimizing drug errors in elders, writing exercise prescriptions, identifying elder abuse, the problem driver, low back pain and quick cognitive screening tools). You might also consider attending some sessions on teaching geriatrics. This will all help you do a really special morning report or unusual noon conference after your return to your home program.
Find out About Career Opportunities:
Surveys suggest that geriatricians are among the happiest and best-satisfied physicians in medicine today. Find out more about the different opportunities that exist. Geriatricians work as hospitalists, primary care physicians, administrators, academics, community health leaders, home care doctors, palliative care experts, nursing home medical directors and inpatient and outpatient consultants. In addition, many physicians specialize in other fields but incorporate geriatrics into their academic and clinical work. For example, there are growing subspecializations in geriatric cardiology, oncology, nephrology, palliative care and infectious diseases. AGS wants residents to come to the conference and enhance their ability to care for older adults even if they don't intend to seek fellowship training in geriatrics. Talk to as many people as you can and come to the meeting of the Resident's Section for lunch on Saturday and learn more. We understand that most of the care provided to elders will not be at the hands of geriatricians. The Society is committed to improving the geriatric skills and knowledge of internists, surgeons, primary care practitioners and subspecialists alike.
How to Have a Blast (And Learn the Most you Can) at AGS' Annual Scientific Meeting
Mix It Up:
Choose different types of content and formats. If you go to lectures only, it'll get boring no matter how good the speakers are. By all means choose some big group lectures-for example, the IOM report on upcoming challenges in caring for an aging population. What's discussed there will be important for all physicians in the years ahead. The session on frailty may help you to see your patients and their problems in a different way. Also make time for reviewing posters and attending interactive workshops like the one concerning teaching physical diagnosis in older adults, and try out "meet the expert sessions" such as the one on using the PDA version of "Geriatrics at Your Fingertips". I would also recommend that you attend at least one special interest group (ethnogeriatrics, acute care, health care systems, etc.) and check out some of the paper sessions where the newest research is presented. When you choose the content area for your daily schedule, select some sessions close to your clinical and academic heart but stretch yourself; attend at least one program daily that covers an area you have never thought about or discussed.
Attend As Many of the Sessions Targeting Residents as Possible:
At a minimum these include the Multidisciplinary Clinical Skills Program on Thursday, the Union Station Falls Screening Program and Resident Poster Session on Friday, and the Residents' Section meeting and "That Was the Year That Was" Quiz Contest with resident teams on Saturday, May 3rd.
Do Some Homework:
Study the program beforehand and pay attention to the faculty presenting the various topics. Plan your days at the conference wisely. Check if anyone is coming from your own area or institution. See who is working on clinical topics or research of interest. Learn who is attending and speaking from places where you may wish to work, do research or pursue a fellowship in the future.
Take an Active Role:
Even if you feel shy-speak up. Ask questions in meetings and talk to speakers or other participants afterwards. Look at people's nametags and where they are from and introduce yourself freely. (You may want to bring a few CVs and business cards just to be on the safe side.) Sign up for the mentoring program and spend some time with an established and accomplished person who is interested in trying to advance your career goals! Volunteer for the Union Station program and talk to people in the residency recruitment subcommittee about how to help with ongoing projects after you return to your home programs.
Come to AGS-learn, get involved, have fun and grow!
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What Residents Should Know About Caring for Older Patients By Rukshana Cader, MD, Chair of the AGS Residents Section
I am a third-year resident in internal medicine at Baystate Medical Center in Springfield, Massachusetts. I have been active in my program's geriatric medicine track and am the vice-president of our AGS residency chapter. This year I am also serving as president of the AGS resident section. Our goals for this year are to encourage resident members to establish their own AGS chapters, help with outreach programs for elders in their communities, and participate more actively in research activities and academic projects. I have thought a great deal about what house officers should know about the care of geriatric patients and I was delighted when AGS staff asked me to record a few thoughts on the topic for this trainee newsletter. Over the last few years I have learned several important lessons about the care of the elderly.
1. Things are not always what they seem: Atypical presentations in the elderly are "typical"
Many medical conditions present atypically in the older population. Cardiovascular disease may present classically with shortness of breath and lower extremity edema, but it may also declare itself primarily through fatigue, weight loss, increased confusion or general decline. Infections like pneumonia or UTIs often manifest themselves by altered mental status, hypothermia, and leukopenia in the elderly while younger patients would usually present with fever, SOB or dysuria. Atypical symptoms present a diagnostic challenge and contribute to unnecessary testing and procedures. This can delay appropriate treatment and result in increased morbidity, mortality and hospital length of stay.
2. For geriatric patients Ockham's Razor often is not helpful
Ockham's Razor is the principle proposed by William of Ockham in the 14th century: "Pluralitas non est ponenda sine neccesitate" which translates as, "entities should not be multiplied unnecessarily". This has come to be a major tenet informing the thought processes of both medical and surgical physicians. We seek to find the single unifying diagnosis that best explains the full constellation of the patient's findings. This works well for younger patients. However, older adults often have multiple sources of pathology and a plethora of contributing factors contributing to a given decompensation. A systematic approach and an open mind is vitally important in this situation to allow for appropriate management and to avoid premature closure.
3. What appears to be simple may in reality be more complex
For example, the elderly patient who presents with a fall illustrates this point. It would be easy to say that the patient simply tripped and sustained no injury. A careful history and exam may reveal ataxia due to a cerebellar stroke, poor eyesight that impaired safe ambulation, incontinence from a UTI, or confusion from a medication change. These are just several of the multiple factors that may result in the "geriatric syndrome' of falls. In addition to medical problems the diagnostic and management approach must be broader-based and also consider housing conditions, family support, furniture placement, ADLs, medication compliance, etc.
4. Residents must serve as educators for the elderly and their families
Residents care for many older patients in all sites of care. Explaining drug regimens, treatment choices and the natural history of their diseases are some of our responsibilities. For example, house officers are often the first doctors to discuss goals of care with geriatric patients. These may be healthy elders in our outpatient clinics or critically ill patients on acute care services. It is our duty to talk to our older patients and clarify their end-of-life wishes, goals of care, code status, and expected quality of life. Many times we leave these discussions until the last possible moment; this is an error. Advance planning with the patient and family members provides better care and more informed decision making.
5. Geriatrics is a specialty with its own body of expertise, but regardless of the fields residents pursue, geriatrics will be part of their professional lives.
Hospitalists will struggle to care for the agitated dementia patient. The internist in the office will worry about the old lady who falls. The surgeon will be uncertain whether the confused patient can give consent for the procedure. The elderly gastroenterology patient with diarrhea will develop skin breakdown or "failure to thrive." The renal patient with diabetes will suffer functional decline. None of us will be able to care well for patients in our various areas of specialization without an understanding of geriatric syndromes and appropriate drug selection and dosing for elders. This is simply the minimum that is required of a modern physician who wishes to provide good overall care.
Training in geriatrics allows trainees to develop a better understanding of medicine today and what lies ahead as we ourselves age. It is important to approach the elderly the way we would like to be treated -- with an individualized plan of care and respect and dignity. This is equally important for the senior marathoner and the patient who is imminently dying. I hope that AGS in general and the new Residents Section can work to make this a reality.
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An Educational Experience in Transitions of Care
By Gina Luciano, MD
Two weeks of my second year in residency were not spent writing notes or searching through medical literature researching various diagnoses. I spent those two weeks following hospitalized patients after discharge to extended care facilities. My goal was to learn about transitions of care by shadowing patients' health care providers. My initial experience was with an 88-year-old woman admitted with rhabdomyolysis and an upper respiratory infection. She had spent four days in the hospital and was being transferred to a local skilled nursing facility. I arrived at the nursing home a few minutes after her to find the RN at the SNF already sorting through a bulky pile of papers that had come with the patient. After the nurse and I spent an hour analyzing the records, I began to realize the countless ways in which transitions of care can endanger patients. There had been no direct oral communication from the hospital providers to the accepting facility, which exacerbated the potential for medication errors. The nurse struggled valiantly to put the pieces of the patient's short but intricate hospital stay together.
This two-week transitions rotation is part of an inpatient medicine month recently devised by Dr. Lauren Meade, Associate Program Director of the Internal Medicine Residency Program, at Baystate Medical Center in Springfield, Massachusetts. The goal is to identify problems in transitions of care by following patients beyond their hospital stays into extended care facilities. Patients are identified by hospital case managers orchestrating the transfers. It is modeled after JCAHO's tracer methodology, which seeks to improve quality and probe the health care system for inconsistencies in standards of care by following randomly selected patients.1
I had never spent time at a skilled nursing facility, and did not realize the extent of the paperwork that accompanies a new patient. At a minimum this included discharge summaries by the physician and the nurse (both of which had separate medication lists), a copy of the medication administration record (MAR), and the last few days of progress notes. What was most impressive was how difficult it often was for the SNF nursing staff accepting the patient to reconcile the patient's medications, to understand the events during the hospitalization and to determine what further workup or appointments were needed in the face of such a large amount of information conveyed from multiple people.
Medication reconciliation is the most complex issue. For the patient described earlier, the nurse I shadowed and interviewed spent an hour painstakingly working through the three different medication records delivered by the hospital. She explained that, more often than not, the MAR does not correspond to the medications in the discharge summaries. While it seemed obvious to me that drugs could have simply been discontinued prior to discharge, this discrepancy became a source of confusion and frustration to the nursing staff since they lacked information about why recent changes were made. The inherent danger is amplified when patients are transferred late in the day. A SNF night nurse may be caring for up to twenty patients at a time and patients are unlikely to see a doctor until at least the next day.
I have always spent much time scripting my discharge summaries. I check and recheck the hospital course narrative, medication lists and follow-up plans; however, this rotation forced me to visualize the broader picture. Without an appreciation for the challenges facing care providers in the receiving facilities I did not really know how to maximize patients' safety. An understanding of the realities at the accepting facility is critical to avoiding problems. Communication is imperative to ensuring that patients continue to receive quality care upon discharge. Guaranteeing good care at transitions requires: effective communication between the discharge doctor and nurse, coordination between the discharging and accepting physicians and nurses, a thorough and complete discharge summary including reconciled medications, health problems, functional and cognitive status and follow-up plans, and, finally, communication among all providers and the patient and his or her loved ones.
This rotation was not specifically part of the geriatric curriculum but I believe it is relevant to the geriatric education of residents in a variety of ways. I have a special interest in the care of elders and have taken geriatric electives and continue to participate in a geriatric medicine track at my hospital. The majority of hospital days are spent by older patients and more of them require post-acute care than younger patients. Geriatric patients are also the most vulnerable because of their diminished organ reserves, the complexity of their medical problems, and frequent problems with communication. It is well-known that they are more likely to suffer adverse drug events than younger patients. This tracer experience taught me other things about caring for older adults. It brought home to me the importance of communication, the role of the team and the challenges facing nurses. I feel a heightened sense of camaraderie with nursing staff and have increased respect for those who strive to provide post-acute care.
I do not know where my medical career will take me, but this experience was fundamental to advancing and improving my abilities as a physician. It is easy to fall into the trap of seeing residency only as a time to broaden medical "book" knowledge and to disregard care that occurs outside the microcosm of the hospital. This rotation forced me to step out of my usual role and to scrutinize the health care system from a different vantage point. This is the system that I, my patients, and my aging relatives must navigate. This rotation made me a better doctor and more sensitive to the challenges of caring for an aging population. I recommend that other residency programs consider incorporating similar opportunities for their trainees.
1"Tracer methodology: how it can help you improve quality: quality pros see opportunity to identify system, process problems". HealthCare Benchmarks and Quality Improvement. FindArticles.com. 31 Mar. 2008. http://findarticles.com/p/articles/mi_m0NUZ/is_6_11/ai_n6183790
1Coleman EA. Falling Through the Cracks: Challenges and Opportunities for Improving Transitional Care for Persons with Continuous Complex Care Needs. Journal of the American Geriatrics Society. 2003;51(4):549-555.
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Residents: Establish an AGS Resident Chapter at your Institution.
The purpose of the resident chapter network is to interest physicians-in-training in the field of geriatrics, to enhance the visibility of geriatric medicine at the resident level, and to provide educational programs on geriatric medicine. To learn more about establishing a chapter at your institution, please visit our homepage.
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Students
Students: Establish an AGS Student Chapter at your School
The purpose of the AGS student chapter network is to interest physicians-in-training in the field of geriatrics, to enhance the visibility of geriatric medicine at the medical school level, and to provide educational programs concerning geriatric medicine. Forty-five schools across the country currently have AGS student chapters. To learn more about establishing a chapter at your school, please visit the AGS Student Chapters home page.
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All Trainees
Sessions of Interest to Trainees at the AGS Annual Meeting in Washington, DC
The following sessions may be of particular interest to AGS Fellows, Residents, Students, and other AGS Trainees.
Thursday, May 1
7:00 - 9:00 AM
Fellows-in-Training Breakfast - The annual Fellows-in-Training Breakfast will feature Sharon A. Levine, MD, who will give a talk entitled "A Career in Geriatrics: A World of Possibilities". The traditional roundtables will follow, giving attendees an opportunity to meet with leaders in geriatrics on a variety of topics, such as job selection and balancing your personal and professional lives.
12:30 - 2:00 PM
Multidisciplinary Clinical Skills Workshop - Developed by the Nurses and Fellows-in-Training Sections, the Residents Special Interest Group and the Education Committee. This workshop will be an interactive, hands-on program featuring ten skills stations to develop clinical skills relevant to the care of older adults.
3:00 - 4:30 PM
Developing Your Career in Academic Geriatrics: From Fellowship to Independence - Developed by the Junior Faculty Research Career Development and the Mentoring Special Interest Groups, the Teachers Networking Session and the Education Committee. This symposium will present practical skills important to navigating the early career process; perspectives on navigating through post-fellowship junior faculty years; strategies to prioritize career development opportunities; and examples of early career conflicts and how to manage them.
4:45 - 6:15 PM
Release of the IOM Study on the Future Healthcare Workforce for Older Americans -The Institute of Medicine (IOM) released its long-awaited report concerning the readiness of the nation's healthcare workforce to meet the needs of an aging society in mid-April. The report concludes that the future workforce will be too small and will lack sufficient training to care for a population of elderly Americans that will double by 2030 "if current patterns of care and of the training of providers continue." The report calls for a wide range of sweeping initiatives to increase recruitment into geriatrics and ensure that all healthcare providers who care for older adults are adequately trained to do so. John W. Rowe, M.D., who chaired the IOM committee that authored the report, will present an overview, and a panel including Dr. Rowe and other committee members will discuss the implications of various findings and recommendations in the report. All will answer questions from the audience. The IOM committee includes several AGS members.
Friday, May 2
7:00 - 8:30 PM
Residents Poster Session - The second annual Residents Poster Session enables residents who are presenting research at the AGS annual meeting to discuss their research findings with their peers and with leaders in geriatrics. Residents at the poster session will also have the opportunity to "visit" with geriatrics fellowship programs at the fellowship fair being held as part of the session. Pizza and refreshments will be served.
10:00 AM - 2:00 PM
AGS/AFAR/John A. Hartford Foundation Student Poster Session & Luncheon - Supported by the AGS Foundation for Health in Aging Student Researcher Fund. The Student Poster Session enables students who participated in the Hartford/AFAR Student Geriatric Scholars Program and other students from all health professional disciplines who are presenting research at the AGS annual meeting to discuss their research findings with their peers and with leaders in geriatrics and aging research.
Saturday, May 3
12:45 - 2:45 PM
Residents Luncheon & SIG Meeting - All residents are encouraged to attend this new special interest group meeting and luncheon. Come and meet other residents and discuss your own ideas about the field and ways to get more involved in AGS.
Junior Faculty Research Career Development SIG & Workshop: A Round-Table Discussion Between Senior Leaders and Young Talent in Geriatrics - This session will provide the opportunity for junior faculty, fellows, and students to informally meet over lunch with senior faculty and leaders in aging. Participants are encouraged to discuss research interests, academic career development, career choices, job opportunities, and other topics pertinent to junior faculty development.
3:00 - 4:30 PM
Health Professional Students SIG Meeting - All health professional students are encouraged to attend this special interest group meeting. Come and meet other students, discuss your own ideas about the field and future career opportunities.
4:45 - 6:15 PM
That Was The Year That Was: Join residents and faculty in taking the Geriatrics Knowledge Challenge - Four teams of house officers will compete in a ''Jeopardy''-like quiz show which will provide a thorough review of current articles in the geriatric literature to identify those areas where new strong evidence has emerged that should affect your practice. Categories to be covered include: medications, palliative medicine, dementia/delirium/depression, function and falls, prevention/screening and general/miscellaneous.
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