Aging is not an Illness: Exploring Geriatricians' Resistance to Serious Illness Conversations.

CONTEXT: Serious illness conversations help clinicians align medical decisions with patients' goals, values, and priorities and are considered an essential component of shared decision-making. Yet geriatricians at our institution have expressed reluctance about the serious illness care program. OBJECTIVES: We sought to explore geriatricians' perspectives on serious illness conversations. METHODS: We conducted focus groups with interprofessional stakeholders in geriatrics. RESULTS: Three key themes emerged that help explain the reluctance of clinicians caring for older patients to have or document serious illness conversations: 1) aging in itself is not a serious illness; 2) geriatricians often focus on positive adaptation and social determinants of health and in this context, the label of "serious illness conversations" is perceived as limiting; and 3) because aging is not synonymous with illness, important goals-of-care conversations are not necessarily documented as serious illness conversations until an acute illness presents itself. CONCLUSION: As institutions work to create system-wide processes for documenting conversations about patients' goals and values, the unique communication preferences of older patients and geriatricians should be specifically considered.

Toward a 21st-century health care system: recommendations for health care reform.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

Teaching geriatric assessment: use of a hybrid method in a family medicine clerkship.

BACKGROUND AND OBJECTIVES: We addressed a lack of geriatric content in our third-year family medicine clerkship. Adding this content posed a challenge in that students are dispersed to clinical sites across New England. Our goal was to promote student skill in functional assessment of elderly patients. METHODS: We used multiple formats: a workshop, a small-group case discussion, an online video, and an online discussion of a new geriatric case. Students were directed to use five assessment tools on actual patients in the office and on a home visit. RESULTS: A total of 155 students participated in the new curriculum. Students completed a required home visit on an older patient and evaluated geriatric patients in an office setting. They performed the Mini-Mental State Exam (MMSE), Activities of Daily Living Scale (ADL), Instrumental Activities of Daily Living Scale (IADL), Geriatric Depression Scale (GDS), and Get-Up-and-Go tests in patients in both settings. There was significant improvement from before to after the clerkship in identification of the appropriate geriatric assessment tool to use (MMSE 86% to 96%; ADL/IADL 32% to 94%; GDS 71% to 94%, and Get-Up-and-Go 4% to 58%). Students evaluated the curriculum positively. CONCLUSIONS: We were able to successfully increase the correct selection of and document high rates of use of geriatric functional assessment tools in our third-year family medicine clerkship using a mixture of teaching methods.

Development and implementation of an objective structured clinical examination to provide formative feedback on communication and interpersonal skills in geriatric training.

Teaching and assessment of communication and interpersonal skills, one of the American Council for Graduate Medical Education-designated core competencies, is an important but difficult task in the training of physicians. Assessment of trainees offers an opportunity to provide explicit feedback on their skills and encourages learning. This article describes a pilot study in which clinician-educators affiliated with the geriatrics training programs at Beth Israel Deaconess Medical Center and Boston University Medical Center designed and piloted a novel Objective Structured Clinical Examination (OSCE) to assess the communication and interpersonal skills of medical, dental, and geriatric psychiatry fellows. The OSCE consisted of three stations where geriatricians and standardized patients evaluated candidates using specifically designed checklists and an abbreviated version of the Master Interview Rating Scale. Communication skills were assessed through performance of specific "real life" clinical tasks, such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills were assessed through the effect of the communication between doctor and standardized patient on fostering trust, relieving anxiety, and establishing a therapeutic relationship. This pilot study demonstrated that the OSCE format of assessment provides a valid means of evaluating the communication and interpersonal skills of interdisciplinary geriatric trainees and provides a valuable forum for formative assessment and feedback. Given that geriatricians and non geriatricians involved in elder care both need communication and interpersonal skills, this novel OSCE can be used for assessment of these skills in trainees in diverse healthcare subspecialties.