The Impact of Scholarly Concentration Programs on Graduates' Career Choices and Interest in the Care of Older Patients.

BACKGROUND: More geriatricians are needed to care for the aging population. Geriatric scholarly concentration programs (GSCPs) may promote medical students' interest in this underserved field or careers working with older adults. Additionally, graduates of GSCPs may be more comfortable and competent in providing care for older adults. Surveys were administered to graduates of GSCPs to determine the role of these programs in shaping medical students' careers and views about caring for older adults.  Methods: The purpose of this study is to understand the impact of GSCPs on medical graduates' career choices and self-perceived skill and comfort in caring for older adults. A Qualtrics survey (Qualtrics International Inc., Seattle, Washington, United States) was developed and distributed to 83 graduates of four GSCPs in the United States. Data were analyzed using a significance level of p>0.05 for all tests. Descriptive statistics were calculated to summarize the data. Wilcoxon signed-rank tests were used to test for significant differences in interest in pursuing a career in geriatrics or working with older adults. Qualitative responses were coded and analyzed for themes.  Results: A total of 34 out of 83 surveyed graduates of GSCPs indicated a higher interest in geriatrics as a career as well as increased comfort and self-perceived skill in caring for older adults after completing the GSCP. The components of the GSCP that most strongly improved the participants' ability to care for older adults included the curriculum (n=31, 91%) and mentoring (n=28, 82%). An overwhelming majority of survey participants felt GSCPs should be offered as part of medical school programming (n=33, 97%).  Conclusion: This study suggests that GSCPs increase interest and competence in caring for older adults and increase interest in a career in geriatrics. GSCPs should be implemented across medical schools.

Use of Virtual Interactive Patient Encounters to Prepare First-Year Medical Students for Clinical Practice.

PROBLEM: With the dissolution of the Step 2 Clinical Skills exam, medical programs have a greater responsibility to teach and assess clinical skills in the preclerkship years. Clinical teaching this early has traditionally been avoided because of insufficient integration with biomedical sciences, curricular time constraints, and concerns about overwhelming novice learners with clinical learning objectives. To overcome these barriers, the authors created a clinical framework for the biomedical science curriculum by integrating a series of virtual interactive patient (VIP) videos. APPROACH: Matriculating first-year medical students were enrolled in a clinically integrated biomedical science course that used VIP videos to teach and assess clinical skills. The VIP videos were enhanced with interactive pop-in windows, and at the conclusion of each video, students performed a clinical documentation task and received immediate feedback. The authors implemented 7 VIP cases during fall 2021 in which first-year medical students wrote the patient care plan, problem representation statement, or clinical reasoning assessment. Student responses were independently evaluated by course faculty using a 4-level scoring scale. The authors calculated the pooled mean scores for each documentation task and examined student feedback. OUTCOMES: Seven VIP encounters were assigned to 124 students (mean response rate, 98.5%). Pooled mean scores on the clinical documentation tasks showed that most students were able to achieve levels 3 or 4 when writing the patient care plan (97 [82%] to 113 [94%]), addressing social determinants of health (80 [67%]), writing an accurate problem representation statement (113 [91%] to 117 [94%]), and performing clinical reasoning skills (48 [40%] to 95 [82%]). NEXT STEPS: VIP encounters were feasible to produce, effective at integrating course content, successful at assessing student clinical documentation skills, and well received. The authors will continue to produce, implement, and study the VIP as an integrating learning tool in undergraduate medical education.

Geriatrics Scholarly Concentration Programs Among U.S. Medical Schools.

OBJECTIVES: To identify and describe geriatric scholarly concentration programs (GSCPs) among U.S. medical schools. DESIGN: Survey and interview. SETTING: Allopathic and osteopathic medical schools in the United States. PARTICIPANTS AND METHODS: We used a systematic internet search, forum postings, and word of mouth to identify all U.S. allopathic and osteopathic medical schools with existing GSCPs. GSCP directors completed an online survey. We conducted interviews with key faculty of two representative programs. MEASUREMENTS: GSCP size, goals, duration of activity, requirements, funding sources, and student outcomes. RESULTS: Nine GSCPs were identified, and eight responded to the survey. The number of current medical student participants ranged from 0 to 28, with a mean cohort size of 23. All programs included the following components: formal mentoring, clinical experiences in geriatric medicine beyond the standard medical school curriculum, and research. Half required students to complete an independent research project. GSCPs reported challenges, including low student interest, lack of availability of faculty mentors, and budget constraints; however, student satisfaction was high. Among three programs that reported on the residency matches of their graduates, half matched into a residency with a geriatric subspecialty training option. CONCLUSIONS: Among U.S. medical schools, there are few GSCPs. The GSCP model may help compensate for limited exposure to geriatric competencies in the standard medical school curriculum for a subset of interested students and may increase interest in geriatrics subspecialty training.

Geriatric Resource Teams: Equipping Primary Care Practices to Meet the Complex Care Needs of Older Adults.

Primary care practices lack the time, expertise, and resources to perform traditional comprehensive geriatric assessment. In particular, they need methods to improve their capacity to identify and care for older adults with complex care needs, such as cognitive impairment. As the US population ages, discovering strategies to address these complex care needs within primary care are urgently needed. This article describes the development of an innovative, team-based model to improve the diagnosis and care of older adults with cognitive impairment in primary care practices. This model was developed through a mentoring process from a team with expertise in geriatrics and quality improvement. Refinement of the existing assessment process performed during routine care allowed patients with cognitive impairment to be identified. The practice team then used a collaborative workflow to connect patients with appropriate community resources. Utilization of these processes led to reduced referrals to the geriatrics specialty clinic, fewer patients presenting in a crisis to the social worker, and greater collaboration and self-efficacy for care of those with cognitive impairment within the practice. Although the model was initially developed to address cognitive impairment, the impact has been applied more broadly to improve the care of older adults with multimorbidity.

Resident learning across the full range of core competencies through a transitions of care curriculum.

The authors developed a Transitions of Care (TOC) curriculum to teach and measure learner competence in performing TOC tasks for older adults. Internal medicine interns at an academic residency program received the curriculum, which consisted of experiential learning, self-study, and small group discussion. Interns completed retrospective pre/post surveys rating their confidence in performing five TOC tasks, qualitative open-ended survey questions, and a self-reflection essay. A subset of interns also completed follow-up assessments. For all five TOC tasks, the interns' confidence improved following completion of the TOC curriculum. Self-confidence persisted for up to 3 months later for some but not all tasks. According to the qualitative responses, the TOC curriculum provided interns with learning experiences and skills integral to performing safe care transitions. The TOC curriculum and a mixed-method assessment approach effectively teaches and measures learner competency in TOC across all six Accreditation Council for Graduate Medical Education competency domains.

Advancing Geriatrics Education Through a Faculty Development Program for Geriatrics-Oriented Clinician Educators.

Geriatrician and nongeriatrician faculty need instruction as teachers to provide quality training for a broader community of physicians who can care for the expanding population of older adults. Educators at Duke University designed a program to equip geriatrician and nongeriatrician faculty to develop quality educational programs and teach medical learners about geriatrics. Eighty-three faculty representing 52 institutions from across the United States participated in mini-fellowship programs (2005-09) consisting of workshops and 1-year follow-up mentoring by Duke faculty. Participants attended 1-week on-campus sessions on curriculum development and teaching skills and designed and implemented a curriculum in their home institution. Participant specialties included general medicine (nearly 50%), family medicine, surgery, psychiatry, rehabilitation medicine, and emergency medicine. Pre- and postprogram self-efficacy surveys, program evaluation surveys, and 6- and 12-month progress reports on scholars' educational projects were used to assess the effect of the Duke mini-fellowship programs on participants' educational practices. Forty-four scholars (56%) completed the end-of-year self-efficacy survey and end-of-program evaluation. Self-efficacy results indicated significant gains (P < .001) in 12 items assessed at 1 week and 1 year. Scholars reported the largest average gains at 1 year in applying adult learning principles in the design of educational programs (1.72), writing measurable learning objectives (1.51), and identifying optimal instructional methods to deliver learning objectives (1.50). Participants described improved knowledge and skills in designing curricula, implemented new and revised geriatrics curricula, and demonstrated commitment to faculty development and improving learning experiences for medical learners. This faculty development program improved participants' self-efficacy in curriculum design and teaching and enhanced geriatrics education in their home institutions.

Implementing Culture Change in Nursing Homes: An Adaptive Leadership Framework.

PURPOSE OF THE STUDY: To describe key adaptive challenges and leadership behaviors to implement culture change for person-directed care. DESIGN AND METHODS: The study design was a qualitative, observational study of nursing home staff perceptions of the implementation of culture change in each of 3 nursing homes. We conducted 7 focus groups of licensed and unlicensed nursing staff, medical care providers, and administrators. Questions explored perceptions of facilitators and barriers to culture change. Using a template organizing style of analysis with immersion/crystallization, themes of barriers and facilitators were coded for adaptive challenges and leadership. RESULTS: Six key themes emerged, including relationships, standards and expectations, motivation and vision, workload, respect of personhood, and physical environment. Within each theme, participants identified barriers that were adaptive challenges and facilitators that were examples of adaptive leadership. Commonly identified challenges were how to provide person-directed care in the context of extant rules or policies or how to develop staff motivated to provide person-directed care. IMPLICATIONS: Implementing culture change requires the recognition of adaptive challenges for which there are no technical solutions, but which require reframing of norms and expectations, and the development of novel and flexible solutions. Managers and administrators seeking to implement person-directed care will need to consider the role of adaptive leadership to address these adaptive challenges.

Development and assessment of a web-based clinical quality improvement curriculum.

BACKGROUND: Understanding quality improvement (QI) is an important skill for physicians, yet educational interventions focused on teaching QI to residents are relatively rare. Web-based training may be an effective teaching tool in time-limited and expertise-limited settings. INTERVENTION: We developed a web-based curriculum in QI and evaluated its effectiveness. METHODS: During the 2011-2012 academic year, we enrolled 53 first-year internal medicine residents to complete the online training. Residents were provided an average of 6 hours of protected time during a 1-month geriatrics rotation to sequentially complete 8 online modules on QI. A pre-post design was used to measure changes in knowledge of the QI principles and self-assessed competence in the objectives of the course. RESULTS: Of the residents, 72% percent (37 of 51) completed all of the modules and pretests and posttests. Immediate pre-post knowledge improved from 6 to 8.5 for a total score of 15 (P < .001) and pre-post self-assessed competence in QI principles on paired t test analysis improved from 1.7 to 2.7 on a scale of 5 for residents who completed all of the components of the course. CONCLUSIONS: Web-based training of QI in this study was comparable to other existing non-web-based curricula in improving learner confidence and knowledge in QI principles. Web-based training can be an efficient and effective mode of content delivery.

Using the jigsaw cooperative learning method to teach medical students about long-term and postacute care.

Since many of the frailest and most vulnerable Americans reside in nursing homes, medical students need focused education and training pertaining to this setting. A unique cooperative learning experience utilizing the jigsaw method was developed to engage and expose students to the institutional long-term and postacute care (LTPAC) setting and the roles of personnel there. To accomplish these goals, small groups of medical students interviewed LTPAC personnel about their role, generally, and in relation to a specific patient case. These groups were then rearranged into new groups containing 1 student from each of the original groups plus a faculty facilitator. Each student in the new groups taught about the role of the LTPAC professional they interviewed. To assess the effectiveness of this learning experience, students and LTPAC personnel provided written feedback and rated the activity using a 5-point Likert scale (1 = worst; 5 = best). Students also took a knowledge test. The activity received ratings from students of 3.65 to 4.12 (mean = 3.91). The knowledge test results indicated that students understood the roles of the LTPAC personnel. In general, the jigsaw exercise was well-received by participants and provided an effective means of introducing medical students to the nursing home environment.

An advanced course in long term care for geriatric medicine fellows.

Long term care deserves focused attention within a geriatric medicine fellowship curriculum to ensure that graduates are prepared not only for clinical care but also for the leadership, administrative, educational, quality improvement, and health policy aspects of their future roles. This report describes the curriculum development and program evaluation of an advanced course in long term care for geriatric medicine fellows and other graduate/post-graduate health professionals at Duke University. Course evaluation had 4 goals: (1) to determine how well the learning objectives were met; (2) to evaluate individual components of the course to improve subsequent offerings; (3) to determine whether additional topics needed to be added; and (4) to evaluate the effectiveness of the discussion forum component of the course. Learner self-efficacy improved within all competency areas but especially those of practice-based learning and system-based practice. Evaluation results led to curriculum revision that has maintained course relevance and sustained it within the larger geriatrics fellowship curriculum. Components of this course can be easily adapted to other curricular settings for fellows and residents.

Ensuring vitamin D supplementation in nursing home patients--a quality improvement project.

Randomized controlled trials have shown that adequate vitamin D supplementation in nursing home (NH) residents reduces the rates of falls and fractures. In our NH, review of medication administration records of all patients (n = 101) revealed that only 34.6% of the patients were currently prescribed adequate doses of vitamin D, revealing a need for intervention. We designed a Quality Improvement (QI) project with the objective of improving the vitamin D prescription rate in our NH. We used the Plan-Do-Study-Act (PDSA) approach to implement this QI project. Patients not currently prescribed an adequate dose of vitamin D were identified and started on a daily dose of 800 IU of vitamin D. Additionally, patients who were experiencing falls while on an adequate dose of vitamin D for 3 months were examined for the possibility of vitamin D deficiency and were started on 50,000 IU of vitamin D per week for 12 weeks if they were found to be vitamin D-deficient based on blood levels of 25-hydroxy-vitamin D below 30 ng/mL. We found that with several PDSA cycles over a period of 5 months, the prescription rate for vitamin D was increased to 86%, surpassing our initial goal of 80%. In conclusion, we found that a multidisciplinary QI program utilizing multiple PDSA cycles was effective in reaching target prescription rates for vitamin D supplementation in a population of NH patients.

Prioritizing culture change in nursing homes: perspectives of residents, staff, and family members.

OBJECTIVES: To explore the perspectives and priorities of nursing home residents, family members, and frontline nursing staff concerning a broad range of items representing common targets of culture change initiatives. DESIGN: Qualitative study. SETTING: A Veterans Affairs Community Living Center and two community nursing homes in North Carolina. PARTICIPANTS: Residents (n = 21), family members (n = 21), and direct-care nursing staff (n = 21) were recruited, with equal numbers in each group from each site. MEASUREMENTS: Participants rated the importance of 62 items from the Centers for Medicare and Medicaid Services Artifacts of Culture Change instrument. Participants sorted cards reflecting each culture change artifact in two phases, identifying and ranking those of more and less importance to them to derive one distribution of preferences for each respondent. Q-sort analysis identified groups of respondents who prioritized similar items; qualitative analysis sought themes or explanations for the responses. RESULTS: Wide variation in respondent preferences was observed. Some respondents viewed several items that others valued highly as unimportant or undesirable. Some items were not high priorities for any respondents. Four groups of respondents with similar preferences were identified: practical and independence-focused respondents, who prioritized ease of use of the physical environment; staff-focused respondents, who prioritized nursing staff retention and development; consistency and choice-focused respondents, who prioritized stable nurse staff-resident relationships and resident choice; and activity and community-focused respondents, who prioritized community gathering spaces and activities. CONCLUSION: Resident, family, and staff priorities for culture change vary, and diverse priorities of stakeholders should be considered to inform culture change efforts on a local and national level.

Urinary Tract Infections in Older Adults Residing in Long-Term Care Facilities.

Urinary tract infections (UTIs) are commonly suspected in residents of long-term care (LTC) facilities, and it has been common practice to prescribe antibiotics to these patients, even when they are asymptomatic. This approach, however, often does more harm than good, leading to increased rates of adverse drug effects and more recurrent infections with drug-resistant bacteria. It also does not improve genitourinary symptoms (eg, polyuria or malodorous urine) or lead to improved mortality rates; thus, distinguishing UTIs from asymptomatic bacteriuria is imperative in the LTC setting. This article provides a comprehensive overview of UTI in the LTC setting, outlining the epidemiology, risk factors and pathophysiology, microbiology, diagnosis, laboratory assessment, and management of symptomatic UTI.

Update on teaching in the long-term care setting.

Since the advent of the teaching nursing home, made formal in the 1980s, long-term care has been used to teach geriatric medicine. Despite this, national surveys have indicated a need for more training during residency to facilitate the appropriate care for the frail long-term care patient population. In addition to medical knowledge, the long-term care site is appropriate for teaching the Accreditation Council of Graduate Medical Education's core competencies of "practice-based learning and improvement," "interpersonal and communication skills," and "systems-based practice." Program planners should emphasize opportunities for students to demonstrate their skill in one of these competencies.

Urinary tract infections in long-term care residents.

Urinary tract infection (UTI) is common in long-term care (LTC) residents; however, most infections are asymptomatic and do not require treatment. Differentiating asymptomatic from symptomatic UTI is challenging, because LTC residents typically have chronic genitourinary complaints, multiple comorbid illnesses, and communication barriers. Although consensus guidelines have been proposed to improve the accuracy of identifying symptomatic UTIs and minimize treatment of asymptomatic UTIs, diagnostic accuracy is not yet optimized. Strategies for prevention of UTI are unsatisfactory and require further study; nevertheless, there is some evidence for the efficacy of cranberry products and vaginal estrogen to prevent recurrent UTI in women.

Nutritional supplements for older adults: review and recommendations--Part II.

The use of nutritional supplements (NS) with the intention of improving health and delaying age-related chronic disease is a common practice among older adults; however, randomized controlled trials have yielded mixed results regarding the likelihood that these NS provide true health benefits. We reviewed the findings of these studies regarding the effects of NS of folic acid, vitamin B(12), vitamin B(6), and omega-3 fatty acids on health outcomes in older adults. Our conclusions include the following: Supplements of the B vitamins folate, B(12) and B(6) have been studied with regards to primary and secondary prevention of a number of major age-related chronic diseases, including cardiovascular disease (CVD), stroke, cognitive decline, and cancer. While there are some encouraging findings with regards to stroke, depression, and macular degeneration (although in only one study in the latter case), there is little evidence of benefit of B vitamin NS for delaying CVD or age-related cognitive changes. In the few cancer-related studies, the evidence of benefit is coupled with concerns about enhancing the growth of existing undiagnosed cancers. In contrast, clear health benefits have been shown with modest increases in consumption of fatty fish or fish oil supplements, including a reduction in the risk of sudden cardiac death. In addition, there is evidence that high dose fish oil supplements may lower serum triglyceride levels.

Mentoring: a key strategy to prepare the next generation of physicians to care for an aging America.

Mentoring is an important instructional strategy that should be maximally used to develop the next generation of physicians who will care for a growing population of frail older adults. Mentoring can fulfill three specific purposes: (1) help learners choose an area of specialty, (2) help fellows and new faculty navigate advancement in the academic environment, and (3) help new physicians enter a local medical community and develop a high-quality, professionally rewarding, financially viable practice that meets the needs of older adults. The components and process of mentoring are reviewed. Current and potential mechanisms to promote mentoring for the specific purpose of increasing the quality and quantity of physicians available to care for the older adult population are discussed.

Nutritional supplements for older adults: review and recommendations-part I.

The majority of older adults take nutritional supplements (NS) to prevent deficiencies and/or because they are interested in the potential health promoting effects of these nutrients. This review explores the evidence of benefit for supplements of multivitamin/minerals (MVM), antioxidant nutrients, and vitamin D/calcium. Major conclusions include the following: While recommendations that older adults take a daily MVM are common, there is limited scientific support for the health-related efficacy of these supplements. In contrast, a number of antioxidant nutrients have been extensively studied. The evidence does not support a recommendation for vitamins A, C, E, or antioxidant combinations in the prevention of CVD or cancer. Based on encouraging preliminary findings, more study is recommended on the benefit of antioxidant supplements for age-related macular degeneration and of selenium for cancer prevention. In contrast to the state of the art for antioxidant supplements, there is strong and compelling support for the health benefits of supplements of Vitamin D and calcium when intake/status of these nutrients is not optimal. Thus, specific recommendations for these supplements in older adults are warranted.

Body mass trajectory, energy balance, and weight loss as determinants of health and mortality in older adults.

The relationship between body mass (usually measured as BMI in kg/m(2)) and healthy longevity is a major focus of study in the nutrition and aging field. Over-nutrition now rivals frailty as the major nutritional concern; the number of older adults who are obese has increased dramatically in the past 3 decades. While obesity exacerbates a host of life-threatening, age-related chronic diseases, a somewhat paradoxical finding is that being somewhat overweight in old age appears to be a benefit with regard to longevity. In our recently completed systematic review of randomized controlled weight reduction trials, we found that weight loss interventions in overweight/obese older subjects led to significant benefits for those with osteoarthritis, coronary heart disease, and type 2 diabetes mellitus, while having slightly negative effects on bone mineral density and lean body mass. In contrast to this finding, the preponderance of epidemiological evidence indicates that higher BMIs are associated with increased survival after age 65 years. Because of this contradictory state of the science, there is a critical need for further study of the relationship of weight and weight loss/gain to health in the later years of life.