What Can a Primary Care Physician Discuss With Older Patients to Improve Advance Directive Completion Rates? A Clin-IQ.

Advance directives (ADs) provide patients with the opportunity to indicate their preferences for medical care while they still maintain the capacity to express their wishes, thus retaining autonomy. ADs increase the likelihood that patients will receive the care they desire, as their family members and physicians will better understand the level of care desired. Despite this, the AD completion rate by elderly patients continues to be low, especially for patients not facing serious illnesses. Primary care physicians (PCPs) are uniquely positioned to engage patients in discussions about ADs before a health crisis arises yet often do not due to time constraints. Using assets associated with the PCP relationship to and longitudinal care for patients, findings reveal that PCPs who emphasize the importance of ADs and who normalize the discussion during office visits by asking questions to understand patients' health goals and holding short conversations over several visits can improve AD completion rates.

Geriatrics Education Team Model Results in Sustained Geriatrics Training in 15 Residency and Fellowship Programs and Scholarship.

Caring for the growing elderly population will require specialty and subspecialty physicians who have not completed geriatric medicine fellowship training to participate actively in patient care. To meet this workforce demand, a sustainable approach to integrating geriatrics into specialty and subspecialty graduate medical education training is needed. This article describes the use of a geriatrics education team (GET) model to develop, implement, and sustain specialty-specific geriatrics curricula using a systematic process of team formation and needs assessment through evaluation, with a unique focus on developing curricular interventions that are meaningful to each specialty and satisfy training, scholarship, and regulatory requirements. The GET model and associated results from 15 specialty residency and fellowship training programs over a 4-year period include 93% curriculum sustainability after initial implementation, more than half of the programs introducing additional geriatrics education, and more than 80% of specialty GETs fulfilling their scholarship requirements through their curriculum dissemination. Win-wins and barriers encountered in using the GET model, along with the model's efficacy in curriculum development, sustainability, and dissemination, are summarized.

Elderly surgical patients: are there gaps in residency education?

BACKGROUND: Geriatric education is essential to ensure the competency of residents caring for the aging population. This study assesses and correlates resident and faculty perceptions of resident geriatric-related competencies to clinical care. METHODS: A survey was sent to 40 general surgery residents and 57 faculty members. Five clinical care markers were identified for chart audit. A retrospective chart audit was performed of 22 injured elderly patients. RESULTS: Among the respondents, 30 of 40 (75%) residents and 22 of 57 (39%) faculty completed the survey. Residents rated their competency higher than faculty on all competency-related questions (p = 0.0002). The following 4 questions had a mean faculty rating below acceptable: screening guidelines, delirium management, contraindicated medications, and medication adjustments. On chart review: code status was documented in 7 of 22 (32%) patients and goals of care in 1 of 22 (5%) patients. Pain control included rib block or epidural in 14 of 22 (64%) patients. Contraindicated medications were prescribed in 13 of 22 (59%) patients. CONCLUSION: A competency-based needs assessment of geriatric training in a general surgery residency has identified educational "gaps." This needs assessment supports implementation of geriatric education initiatives in our general surgery program.

Positioning medical students for the geriatric imperative: using geriatrics to effectively teach medicine.

Medical schools must consider innovative ways to ensure that graduates are prepared to care for the aging population. One way is to offer a geriatrics clerkship as an option for the fulfillment of a medical school's internal medicine rotation requirement. The authors' purpose was to evaluate the geriatrics clerkship's impact on internal medicine knowledge and medical student attitudes toward older adults. Mean National Board of Medical Examiners (NBME) internal medicine subject exam scores from geriatrics and internal medicine students who matriculated from 2005 to 2011 were compared using student's t-tests. Academic performance was controlled for using the United States Medical Licensing Exam Step 1 exam scores. Focus groups were conducted to explore student attitudes. Geriatrics students performed just as well on the NBME exam as their internal medicine colleagues, but reported greater comfort with elder care. Geriatrics students also reported more positive attitudes toward older adults. Completing an internal medicine requirement using a geriatrics clerkship is an innovation for medical school curriculum structure.

One specialty at a time: achieving competency in geriatrics through an e-learning neurology clerkship module.

BACKGROUND: E-learning integrated into traditional clerkships may supplement gaps in medical student training, such as geriatrics competencies. METHOD: An e-module, "Neurology and Dementia: Psychosocial Aspects of Care," was offered during the M3 Neurology clerkship. OSCE scores were compared between students who did and did not complete the e-module with written examination scores as control. RESULTS: Students who completed the e-module had significantly higher scores on the standardized patient (SP) evaluation, written note, and attention to psychosocial aspects of care (P < .05 for all). Exam scores were unaffected (P = .24). Students delaying the OSCE by four weeks still showed retention of this learning. CONCLUSIONS: An e-module addressing geriatrics core competencies presented during a neurology rotation resulted in sustained learning of these vital concepts.

Objective Structured Video Examinations (OSVEs) for geriatrics education.

The Medical College of Wisconsin (MCW) and the Wisconsin Geriatric Education Center (WGEC) are committed to developing educational materials for primary care physicians in training. In response to the opportunity created by the Accreditation Council for Graduate Medical Education (ACGME) competency mandate, an MCW-led interdisciplinary working group has developed competency-linked video-based assessment tools for use in primary care residency training programs. Modeled after the Objective Structured Clinical Examinations (OSCE), used as part of the medical licensing examination process, we created geriatric-focused Objective Structured Video Examinations (OSVEs) as a strategy to infuse geriatrics into residency training. Each OSVE tool contains a 1-3 minute video trigger that is associated with a series of multiple choice and/or constructed response questions (e.g., fill in the blank). These questions assess residents' understanding of video-demonstrated ACGME competencies including professionalism, systems-based practice, communication, and practice-based learning. An instructor's guide and scoring key are provided for each tool. Response to the OSVEs has been overwhelmingly enthusiastic including greater than 90% commitment by statewide faculty to use the tools in residency training.

A challenging patient, an innovative solution.

This report of the management of a 28-year-old patient over 2 and a half years illustrates how interaction between psychosocial issues and physical symptoms complicates diagnosis and management. The case also highlights the challenges inherent in a large health care system with multiple health care professionals, clinics, and available resources. A "team model" approach is outlined as a useful strategy in such cases. Once problem areas are defined, a partnership agreement (contract) is recommended, which applies structure and limits to the physician-patient relationship. This contract calls for mutual trust, communication, and accountability while preventing excessive use of the health care system. Our patient and hospital system greatly benefited by this approach as evidenced by (1) a 60% decrease in medication costs, (2) markedly decreased ED visits and telephone calls, (3) successful treatment of depression and anxiety, and (4) a positive outcome on the patient's health.