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By Rosanne M. Leipzig MD, PhD Hopefully, as a geriatrics fellow, you're finding yourself learning all sorts of new things about how to better care for your older patients - which medications to avoid and which to prescribe, how to evaluate patients' cognition and gait, and how to manage agitated, demented or delirious patients without physical or chemical restraints. In my experience, it's not uncommon for fellows to be wondering why they didn't learn some of these lessons during residency or even medical school, since they certainly were exposed to and responsible for the care of older patients in these settings. Well, it's a good question and one that received an initial answer this past year. In July 2007, the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation (JAHF) hosted a National Consensus Conference on Geriatric Education. The charge was to attain consensus on a minimum set of graduating medical student competencies (learning outcomes) to assure competent care to older patients by new interns. Medical school is the one time that we have access to everybody who is going to be a physician in this country, so it is a unique opportunity to instill the basics of good care for older adults in order to help ensure that when these students are practicing physicians, they will have the correct reflexes for providing care for older adults. It's not that there isn't a list of what medical students should be taught in geriatrics - in fact, there are several lists. The problem is that the lists are overly comprehensive - so much so that medical school curriculum committees, deans of education, or geriatrics educators feel totally overwhelmed by the extensive lists of topics, amount of curricular time and faculty needed, and lack of clarity over the level of proficiency expected of the student. The AAMC/Hartford initiative began with the following goal: to develop a consensus on competencies expected for a limited number of clinical skills in specific geriatric content areas that could guide educators by establishing minimum standards for the most basic knowledge, skills and attitudes graduates of medical schools can be expected to demonstrate. The idea was that, at the start of their internships, these graduates would be able to provide adequate care to older adults. The focus would be on issues that matter to health outcomes for older adults, or as Dr. Lisa Granville, Professor of Geriatrics at Florida State University and Chair of the AGS Education Committee, puts it, a "Don't kill granny" curriculum. The process for developing the competencies began by determining a small number of domains on which to concentrate. Thirty-nine leaders in geriatric medical education voted on 52 domains that had been culled from the previously existing geriatric curriculum lists, decreasing the number by half. Geriatrically interested individuals (members of the Association of Directors of Geriatric Academic Programs (ADGAP), the principal investigators of Reynolds grants and of Centers of Excellence, and the geriatric interest groups of the Society of General Internal Medicine, Society of Teachers of Family Medicine, and Association of Program Directors in Internal Medicine) then completed an on-line survey identifying their top eight content domains. Based on 117 responses, the terminology for each domain underwent discussion. The resulting domains are: Cognitive and behavioral disorders Medication management Self-care capacity Falls, balance, gait disorders Atypical presentation of disease Palliative care Hospital care for elders Healthcare planning and promotion The steering committee identified 3-5 learning outcomes for each content domain, drawing from those developed by Mount Sinai School of Medicine, the Florida Consortium for Geriatric Education, and Florida State University. These learning outcomes were posted on a 'wiki' and the steering committee went through several iterations of each competency to arrive at 35 learning outcomes. These were then evaluated by educators in each of the following disciplines: Geriatrics (respondents = 81); Family Medicine (respondents =67); Internal Medicine (respondents =77); Deans of Medical Education and Curriculum (respondents = 24); Program Directors in Neurology (respondents = 20) and General Surgery (respondents = 43). These respondents completed an online survey asking whether a resident "Must", "Should" or "Does not need" to be competent, at the start of internship, in each of the 35 learning outcomes. Results were analyzed in aggregate and by discipline. Eleven of the competencies received more than 25% "Does not need" ratings overall. Interestingly, there was considerable consistency across disciplines, often including those geriatricians who had not participated in the steering committee. Discussion ensued as to the reasons for rejection, in particular: (a) whether the outcome was too advanced for a medical student, (b) whether it was poorly worded, or (c) whether there was some other reason for rejection. The discussion also considered whether, despite the survey results, the committee members still felt this was a critical outcome for medical students. Results of this process were presented as a "trial balloon" document for discussion at the JAHF-AAMC conference. During the conference, small groups worked for two days on the competencies for specific domains, resulting in 26 final competencies. After the conference, steering committee members reframed the competency statements so that each: Uses cognitive learning verbs such as "explain," "identify," "document," "define and distinguish," "perform," "assess," "compare and contrast," etc. States the competencies as behaviors that occur during patient care and can be measured (less listing, more doing and interpreting); and Is written as a completion of this sentence: "The graduating medical student, in the context of a specific older adult patient scenario (real or simulated), must be able to:" The final document was sent to all conference participants and steering committee members for approval. It will be available on the Portal of Geriatrics Online Education (www.POGOe.org) in November. Remember- it's a floor, not a ceiling. These are competencies that every medical school in the country should be able to get its students to achieve. If they're able to do more- how great! Next stops: Competencies for residents (then fellows, practicing physicians, etc…). |
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