Factors Associated with a Label of Failure to Cope in Older Medical Inpatients: a Case-Control Study.

BACKGROUND: The term failure to cope (FTC) is often used to dismissively describe hospitalized older adults. The purpose of this study was to identify the factors associated with receiving a label of FTC. METHODS: Age-matched, case-control study with electronic and paper chart review identifying patient characteristics and admission details. RESULTS: One hundred eighty-five patients 70 years of age or older admitted to a general medicine team over two years: 99 patients with the label of FTC and 86 controls. No patients labelled with FTC came from long-term care. Characteristics associated with a label of FTC included living alone (aOR 3.8, 95% CI 1.9-7.8), falls (aOR 3.8, 95% CI 1.9-7.8), rehospitalization (aOR 3.6, 95% CI 1.7-8.0), and living in an independent dwelling (aOR 2.4, 95% CI 1.0-5.5). A higher number of chronic medications was associated with a lower likelihood of being labelled with FTC (aOR 0.9, 95% CI 0.8-1.0). CONCLUSIONS: The results suggest that FTC is a label based predominantly on social factors and has no role in a medical assessment. The patient's home setting was the key factor in being labelled with FTC, most medical factors did not play a significant role, and a pervasive language of blame was present.

'Oh my God, I can't handle this!': trainees' emotional responses to complex situations.

CONTEXT: Dealing with emotions is critical for medical trainees' professional development. Taking a sociocultural and narrative approach to understanding emotions, we studied complex clinical situations as a specific context in which emotions are evoked and influenced by the social environment. We sought to understand how medical trainees respond to emotions that arise in those situations. METHODS: In an international constructivist grounded theory study, 29 trainees drew two rich pictures of complex clinical situations, one exciting and one frustrating. Rich pictures are visual representations that capture participants' perceptions about the people, situations and factors that create clinical complexity. These pictures were used to guide semi-structured, individual interviews. We analysed visual materials and interviews in an integrated way, starting with looking at the drawings, doing a 'gallery walk', and using the interviews to inform the aesthetic analysis. RESULTS: Participants' drawings depicted a range of personal emotions in response to complexity, and disclosed unsettling feelings and behaviours that might be considered unprofessional. When trainees felt confident, they were actively participating, engaged in creative problem-solving strategies, and emphasised their personal involvement. When trainees felt the situation was beyond their control, they described how they were running away from the situation, hiding themselves behind others or distancing themselves from patients or families. CONCLUSIONS: A sense of control seems to be a key factor influencing trainees' emotional and behavioural responses to complexity. This is problematic, as complex situations are by their nature emergent and dynamic, which limits possibilities for control. Following a social performative approach to emotions, we should help students understand that feeling out of control is an inherent property of participating in complex clinical situations, and, by extension, that it is not something they will 'grow out of' with expertise.

'How would you call this in English?' : Being reflective about translations in international, cross-cultural qualitative research.

INTRODUCTION: Medical education researchers increasingly collaborate in international teams, collecting data in different languages and from different parts of the world, and then disseminating them in English-language journals. Although this requires an ever-present need to translate, it often occurs uncritically. With this paper we aim to enhance researchers' awareness and reflexivity regarding translations in qualitative research. METHODS: In an international study, we carried out interviews in both Dutch and English. To enable joint data analysis, we translated Dutch data into English, making choices regarding when and how to translate. In an iterative process, we contextualized our experiences, building on the social sciences and general health literature about cross-language/cross-cultural research. RESULTS: We identified three specific translation challenges: attending to grammar or syntax differences, grappling with metaphor, and capturing semantic or sociolinguistic nuances. Literature findings informed our decisions regarding the validity of translations, translating in different stages of the research process, coding in different languages, and providing 'ugly' translations in published research reports. DISCUSSION: The lessons learnt were threefold. First, most researchers, including ourselves, do not consciously attend to translations taking place in international qualitative research. Second, translation challenges arise not only from differences in language, but also from cultural or societal differences. Third, by being reflective about translations, we found meaningful differences, even between settings with many cultural and societal similarities. This conscious process of negotiating translations was enriching. We recommend researchers to be more conscious and transparent about their translation strategies, to enhance the trustworthiness and quality of their work.

Exploring the Realities of Curriculum-by-Random-Opportunity: The Case of Geriatrics on the Internal Medicine Clerkship Rotation.

BACKGROUND: While major clerkship blocks may have objectives related to specialized areas such as geriatrics, gay and lesbian bisexual transgender health, and palliative care, there is concern that teaching activities may not attend sufficiently to these objectives. Rather, these objectives are assumed to be met "by random opportunity".((1)) This study explored the case of geriatric learning opportunities on internal medicine clinical teaching units, to better understand the affordances and limitations of curriculum by random opportunity. METHODS: Using audio-recordings of morning case review discussions of 13 patients > 65 years old and the Canadian geriatric core competencies for medical students, we conducted a content analysis of each case for potential geriatric and non-geriatric learning opportunities. These learning opportunities were compared with attendings' case review teaching discussions. The 13 cases contained 40 geriatric-related and 110 non-geriatric-related issues. While many of the geriatric issues (e.g., delirium, falls) were directly relevant to the presenting illness, attendings' teaching discussions focused almost exclusively on non-geriatric medical issues, such as management of diabetes and anemia, many of which were less directly relevant to the reason for presenting to hospital. RESULTS: The authors found that the general medicine rotation provides opportunities to acquire geriatric competencies. However, the rare uptake of opportunities in this study suggests that, in curriculum-by-random-opportunity, presence of an opportunity does not justify the assumption that learning objectives will be met. CONCLUSIONS: More studies are required to investigate whether these findings are transferrable to other vulnerable populations about which undergraduate students are expected to learn through curriculum by random opportunity.

Influenza vaccinations: older adults' decision-making process.

The purpose of this study was to explore the self-perceived influences among older adults in deciding whether to take or not take the seasonal influenza vaccine. Thirty-one receivers and six non-receivers (aged 67-91) participated in six focus groups in London, Ontario. The focus group meetings lasted approximately 60 minutes, were digitally audio-recorded, and transcribed verbatim. Inductive content analysis was performed to analyse the transcripts. The major facilitators of taking the vaccine were recommendations by, and trust in, health professionals, and a belief in vaccine efficacy. The major barriers were a fear of adverse reactions and the belief in resilience of an older adult. The Canadian Public Health Agency and allied health professionals should educate older adults in accurate influenza symptoms, vaccine efficacy, and populations at risk for contracting influenza. Focus should be given on correcting misconceptions about adverse events.

The comprehensive geriatric assessment guide: an exploratory analysis of a medical trainee performance evaluation tool.

PURPOSE: Few opportunities exist for medical students and residents to receive feedback on specific geriatric skills because they are frequently unsupervised when assessing elderly patients. Patients and caregivers are currently an untapped source of clinical content feedback. The purpose of this study was to determine whether patients/caregivers could accurately complete a postassessment evaluation of trainees' clinical performance. METHOD: The authors developed the Comprehensive Geriatric Assessment Guide (CGAG) consisting of 36 yes/no/don't-remember questions that prompt the patient/caregiver to indicate what topics the trainee discussed during clinical assessment. In 2010, two raters independently listened to audio recordings of 10 trainee-administered clinical assessments, scoring them using the CGAG to determine interrater reliability. Next, 32 patients/caregivers completed a CGAG after a trainee-administered clinical assessment. Then, the authors compared the results with a "gold standard" CGAG of the encounter. RESULTS: Interrater reliability for the CGAG was high (90.4% agreement), indicating that the patients/caregivers were able to accurately complete the postassessment CGAG. Of 36 CGAG questions, 30 had patient/caregiver and gold standard agreement of over 80%; the remaining 6 had low agreement. CONCLUSIONS: Patients and caregivers were able to recall sufficient clinical assessment detail to potentially provide constructive feedback to medical trainees on their assessment skills via the CGAG. Six questions with low agreement will be reworded to improve clarity on future versions of the CGAG. Future investigations will help determine whether use of the CGAG during medical education may help trainees improve assessment performance and allow educators to track progress in geriatric competencies.

Old news: why the 90-year crisis in medical elder care?

North American and European demographic projections indicate that by 2030, persons aged 65 and older will outnumber those younger than 15 by a ratio of 2:1. Curiously, principles of geriatric care have not taken strong hold among nongeriatric specialties, even as we approach the time of greatest need. To explore historical precedents for the current crisis in elder care, this article revisits the prescriptions of G. Stanley Hall's Senescence: The Last Half of Life (1922), a text widely recognized as one of the founding texts in the medicalized study of aging. It presents in brief three of Hall's major concerns-paucity of knowledge of nongeriatric specialists, the need for individualized care of elderly adults, and the prevalence of attitudinal obstacles in medical professionals caring for older persons-to demonstrate how little the language and content of modern appraisals have evolved since 1922. This disconcerting sense of paralysis is presented as an opportunity to advance important questions aimed at stimulating a more-comprehensive research agenda for addressing the future of medical elder care.

Underrepresentation of individuals 80 years of age and older in chronic disease clinical practice guidelines.

OBJECTIVE: To determine whether Canadian clinical practice guidelines (CPGs), and the evidence used to create CPGs, include individuals 80 years of age and older. DESIGN: Descriptive analysis of 14 CPGs for 5 dominant chronic conditions (diabetes, hypertension, heart failure, osteoporosis, stroke) and descriptive analysis of all research-based references with human participants in the 14 guidelines. MAIN OUTCOME MEASURES: To identify recommendations for individuals 65 years of age and older or 80 years of age and older and for those with multiple chronic conditions. RESULTS: Although 12 of 14 guidelines provided specific recommendations for individuals 65 years of age and older, only 5 provided recommendations for frail older individuals (≥ 80 years). A total of 2559 studies were used as evidence to support the recommendations in the 14 CPGs; 2272 studies provided the mean age of participants, of which only 31 (1.4%) reported a mean age of 80 years of age and older. CONCLUSION: There is very low representation of individuals in advanced old age in CPGs and in the studies upon which these guidelines are based, calling into question the applicability of current chronic disease CPGs to older individuals. The variety of medical and functional issues occurring in the elderly raises the concern of whether or not evidence-based disease-specific CPGs are appropriate for such a diverse population.

"But I see old people everywhere": dispelling the myth that eldercare is learned in nongeriatric clerkships.

PURPOSE: To test the assumption that knowledge, attitudes, and skills (KAS) in geriatrics are learned via exposure to elderly patients in nongeriatric clerkships. In the developed world, the proportion of adults > or = 65 years old will soon surpass the proportion of children <14. However, clinical clerkships containing geriatric rotations are not mandated by the Liaison Committee for Medical Education. METHOD: The authors assessed differences in geriatrics-focused KAS between medical students who completed a rotation in eldercare and those who completed a traditional nongeriatric clerkship. Over two academic years, the authors randomly assigned 263 clinical clerks to a clerkship year that did (eldercare group) or did not contain a two-week rotation focused on geriatrics. All students completed questionnaires that assessed their knowledge of and attitudes toward geriatric patients before and after their clerkships. Before graduation, all students completed an objective structured clinical examination (OSCE) including a clinical station focused on geriatrics. RESULTS: Questionnaire and OSCE station response rates were 74.8% and 100%, respectively. The eldercare group had significantly higher knowledge scores (P = .004). Students' attitudes toward older adults worsened over the clerkship year in both groups, but slightly less in the eldercare group; that group had significantly higher OSCE geriatric station scores and overall pass rates (both: P < .001). CONCLUSIONS: Geriatrics is often regarded as a nonessential discipline. This study showed, however, that a clerkship year containing a specialized geriatric rotation is significantly more effective than a traditional clerkship year in preparing students to care for an aging population.

Tracking clerkship experience: just what do clinical clerks see on an Elder Care rotation?

The Schulich School of Medicine, University of Western Ontario, Canada, has created a mandatory clerkship in Elder Care that consists of small group seminars, clinical experiences, and an Elder Care manual. This article describes the use of a paper-based log to track students' clinical encounters to determine whether the Elder Care clerkship offers students the opportunity for a broad range of clinical experiences to address curriculum objectives. Using a paper-based log that was completed after each clinical encounter, students recorded information including the reason for assessment, tests completed, care recommendations, and personal reflections. Each of 70 students completed an average of 5.5 logs. Cognitive/psychiatric, medical, functional, and social problems were reported in more than 83% of the logs. Almost all students saw at least one patient with cognitive decline and one with depressive symptoms. Only six students reported seeing a patient with delirium. Students were able to think reflectively on their experiences. In matching the clerkship objectives to the learning modality(ies) in which they were addressed, it was found that knowledge-related objectives were supported primarily by seminars and manual content. Skills-related objectives were supported primarily by clinical experiences. The clinical experience logs used in this study provided evidence that, in the Elder Care clerkship, for the most part, students are seeing what we think they should be seeing. Study results have informed the revision of the logs, which will be an ongoing method of tracking objectives and students' reflections and ensuring continuous quality improvement.

White coats meet grey power: students and seniors respond to an "intergenerational gala".

Research suggests that nonclinical interactions with older people may enhance medical students' traditionally poor attitudes toward this patient group. Although extensive literature has reported on student attitudes, seniors' perspectives of their relationships with younger healthcare professionals (HCPs) are generally unknown. This study explores students' and seniors' perceptions of aging and the influence of these perceptions on medical practice before and after a recreational, intergenerational event. In March 2006, the Schulich Faculty of Medicine and Dentistry at the University of Western Ontario held its second annual "Intergenerational Gala." Approximately 150 seniors and students were invited to complete a brief pre- and postevent questionnaire exploring attitudes toward aging, care of older people, and HCP training. After the event, approximately 60% of students did not feel that their curriculum contained adequate geriatrics content, and more than one-third of seniors did not feel that today's HCPs are adequately trained to address the healthcare needs of older people. Content analysis indicated strongly positive postevent perceptions of the gala but also considerable divergences between students' and seniors' responses to "To me, growing older means. ..." Seniors also offered advice to young HCPs encouraging listening, patience, and not using "age" as a medical diagnosis. The second Intergenerational Gala explored similarities and differences between how seniors and students view aging. Although significant changes in attitudes were not observed, qualitative responses from both groups suggest that similar events hold promise as part of a concerted curricular strategy to encourage and improve intergenerational relations in the context of medical practice.

Improving recruitment into geriatric medicine in Canada: Findings and recommendations from the geriatric recruitment issues study.

As the number of Canadians aged 65 and older continues to increase, declining recruitment into geriatric medicine (GM) raises concerns about the future viability of this medical subspecialty. To develop effective strategies to attract more GM trainees into the field, it is necessary to understand how medical students, residents, GM trainees, and specialists make career choices. The Geriatric Recruitment Issues Study (GRIST) was designed to assess specific methods that could be used to improve recruitment into geriatrics in Canada. Between November 2002 and January 2003, 530 participants were invited to complete the GRIST survey (117 Canadian geriatricians, 12 GM trainees, 96 internal medicine residents, and 305 senior medical students). Two hundred fifty-three surveys (47.7%) were completed and returned (from 54 participating geriatricians, 9 GM trainees, 50 internal medicine residents, and 140 senior medical students). The survey asked respondents to rate factors influencing their choice of medical career, the attractiveness of GM, and the anticipated effectiveness of potential recruitment strategies. Although feedback varied across the four groups on these issues, consistencies were observed between medical students and residents and between GM trainees and geriatricians. All groups agreed that role modeling was effective and that summer student research programs were an ineffective recruitment strategy. Based on the GRIST findings, this article proposes six recommendations for improving recruitment into Canadian geriatric medicine training programs.

. . . But does it stick? Evaluating the durability of improved knowledge following an undergraduate experiential geriatrics learning session.

Canada's aging population, fewer medical students training in geriatric medicine, and inadequate geriatric curricula require that medical schools immediately address how future physicians will be able to care for older people effectively. The medical literature suggests that experiential learning strategies improve undergraduate medical students' knowledge of and interest in less-popular subjects, but the durability of improvements resulting from these resource-intensive learning approaches remains unclear. In October 2001, a convenience sample of all University of Western Ontario medical students attending the geriatric component of their first year was randomized to attend one 3-hour didactic lecture or 3-hour experiential learning session. Approximately 1 year later, students completed a follow-up knowledge and attitudes survey that was matched to their first-year surveys using date-of-birth data. Of 100 completed follow-up surveys, 42 were used in formal analysis. Although initially the experiential group demonstrated a better knowledge score, at 1-year follow-up, there was no significant difference in knowledge, attitudes toward older people, or interest in geriatric medicine between the didactic (n=17) and experiential (n=25) groups. Nevertheless, these students (n=42) demonstrated better attitude scores than those (n=22) who had not attended either educational intervention. This study challenges the belief that an experiential approach is a superior training method to a didactic approach. One year after an educational intervention, there was no difference in geriatric knowledge, attitude scores, or interest in geriatric medicine between students who underwent a didactic lecture or a participatory, experiential learning session.

Interest in geriatric medicine in Canada: how can we secure a next generation of geriatricians?

In Canada, there is minimal training of geriatrics for physicians, a shortage of geriatricians, and extremely low numbers of students entering geriatrics. This study explored student interest in and barriers and enticements to geriatric medicine as a career choice. Medical students attending a university in Ontario, Canada, were surveyed in their first year (N=121), after a geriatric education session, and again in their second year (N=118) about their interest in a career in geriatrics. In the first year, less than 20% of students were interested in geriatrics; in the second year this decreased to 16%. In both years, female students were more interested than male students. Those students interested in geriatrics had higher hopes that their practice would involve primarily adults and seniors. Students not interested in geriatrics rated performing procedures and technical skills, not wanting to work with chronically ill patients, and caring for younger patients as important practice characteristics. Although the importance of prestige was low for all students, it was significantly higher for those not interested in geriatrics. Although changes to prestige, income, lifestyle, and length of residency training were identified as potential enticements to geriatrics, they were not major deterrents to a career in geriatrics. The findings suggest strategies that may affect student interest in geriatrics, such as increased and early student exposure to geriatrics with emphasis on fostering and nurturing student interest, consideration of various enticements to this specialty, and the development of health system-specific solutions to this problem. Knowledge of student and practice characteristics that increase the likelihood of selecting geriatrics as a specialty may allow for early identification and support of future geriatricians.