Building psychosocial programming in geriatrics fellowships: a consortium model.

Geriatric psychosocial problems are prevalent and significantly affect the physical health and overall well-being of older adults. Geriatrics fellows require psychosocial education, and yet to date, geriatrics fellowship programs have not developed a comprehensive geriatric psychosocial curriculum. Fellowship programs in the New York tristate area collaboratively created the New York Metropolitan Area Consortium to Strengthen Psychosocial Programming in Geriatrics Fellowships in 2007 to address this shortfall. The goal of the Consortium is to develop model educational programs for geriatrics fellows that highlight psychosocial issues affecting elder care, share interinstitutional resources, and energize fellowship program directors and faculty. In 2008, 2009, and 2010, Consortium faculty collaboratively designed and implemented a psychosocial educational conference for geriatrics fellows. Cumulative participation at the conferences included 146 geriatrics fellows from 20 academic institutions taught by interdisciplinary Consortium faculty. Formal evaluations from the participants indicated that the conference: a) positively affected fellows' knowledge of, interest in, and comfort with psychosocial issues; b) would have a positive impact on the quality of care provided to older patients; and c) encouraged valuable interactions with fellows and faculty from other institutions. The Consortium, as an educational model for psychosocial learning, has a positive impact on geriatrics fellowship training and may be replicable in other localities.

A conceptual framework for understanding iatrophobia.

OBJECTIVE: Iatrophobia - fear of doctors, medical care, or the medical care system - is common among patients and can negatively impact their health-seeking behaviors and relationships with health care professionals. Despite this, academic literature on iatrophobia often fails to explore its nuanced causes. METHODS: We establish a conceptual framework of iatrophobia, categorizing sources of fear that may create barriers to accessing medical care, and recommend a research agenda to address this phenomenon and understand its role in medical care. RESULTS: The framework includes three categories of determinants of iatrophobia: patient fear of illness and the medical exam, patient fear of physician reaction, and patient fear related to barriers to care. These categories represent influences from individual to more system-related factors associated with the physician-patient relationship. Research examining iatrophobia should focus on understanding its prevalence, how patients cope with their fear, discussing iatrophobia in the physician-patient encounter, the sociopolitical contribution to iatrophobia, and how iatrophobia can be reduced. CONCLUSIONS: Iatrophobia can be categorized into three primary domains, but it remains poorly understood. PRACTICE IMPLICATIONS: A more thorough understanding of iatrophobia will help to contextualize its role amid other barriers to care and patient health outcomes.

Communication involving special populations: older adults with cancer.

PURPOSE OF REVIEW: Cancer has a high incidence and death rate among older adults. The objective of this article is to summarize current literature about communication between older adults and medical professionals in cancer care. Our article addresses four categories related to communication: first, ageism; second, screening; third, treatment; and fourth, end of life (EoL) care. RECENT FINDINGS: Current literature suggests that cancer treatment for older patients may be influenced by ageist biases. Older patients prefer that clinicians incorporate health status to individualize screening decisions although some patients don't consider life expectancy to be an important factor in screening. Patients often agree with the oncologists' treatment recommendations but want to be involved in the decision-making process. Lastly, work is being conducted to associate quality communication of EoL issues with hospital performance measures. SUMMARY: Patients are at risk of age-based disparities in cancer screening, treatment, and EoL care. Older adults are not a homogenous group and all elderly cancer patients need to have an individualized approach to care. Medical professionals must understand patients' goals and values and involve them in shared decision-making and preparation for EoL.

Introduction to the older patient: a "first exposure" to geriatrics for medical students.

In 2003, Weill Cornell Medical College developed a 4-hour module to introduce the geriatric patient within the required first-year doctoring course. The educational intervention highlights the importance of communication between older patients and physicians, the utility of an enhanced social history and functional assessment, and the pitfalls of ageism in the medical setting. The module incorporates film, the performing arts, and small-group exposure to a community-residing older person. To evaluate the module's effect, four successive classes of first-year medical students (2003-2006) responded to a 14-item questionnaire and three opened-ended questions at the end of the 4-hour curriculum. Quantitative and qualitative analysis reveal consistently strong positive student feedback to this module. Almost all students agreed that the learning objectives were clear (99%) and had been met (99%). Several curricular interventions received high endorsement from the respondents in their questionnaire and narrative comments. Most (94%) were in strong agreement that meeting the older patient in the small group was a worthwhile experience. Also, students appreciated observing an example of a substandard interview (76% in strong agreement) and then a demonstration of effective communication (83% in strong agreement) through dramatic enactments. The majority of students (97%) commented that exposure to these presentations enabled them to see ageist behavior firsthand and to observe how ageist attitudes interfere with appropriate diagnosis and medical care. This approach to introducing the older patient may be of use at other medical schools. Future studies will need to evaluate the long-term effect of this educational intervention.

Contracts, covenants and advance care planning: an empirical study of the moral obligations of patient and proxy.

Previously we had speculated that the patient-proxy relationship existed on a contractual to covenantal continuum. In order to assess this hypothesis, and to better understand the moral obligations of the patient-proxy relationship, we surveyed 50 patient-proxy pairs as well as 52 individuals who had acted as proxies for someone who had died. Using structured vignettes representative of three distinct disease trajectories (cancer, acute stroke, and congestive heart failure), we assessed whether respondents believed that proxies should follow explicit instructions regarding life-sustaining therapy and act contractually or whether more discretionary or covenantal judgments were ethically permissible. Additional variables included the valence of initial patient instructions--for example, "to do nothing" or "to do everything"--as well as the quality of information available to the proxy. Responses were graded on a contractual to covenantal continuum using a modified Likert scale employing a prospectively scored survey instrument. Our data indicate that the patient-proxy relationship exists on a contractual to covenantal continuum and that variables such as disease trajectory, the clarity of prognosis, instructional valence, and the quality of patient instructions result in statistically significant differences in response. The use of interpretative or covenantal judgment was desired by patients and proxies when the prognosis was grim, even if initial instructions were to pursue more aggressive care. Nonetheless, there was a valence effect: patients and proxies intended that negative instructions to be left alone be heeded. These data suggest that the delegation of patient self-determination is morally complex. Advance care planning should take into account both the exercise of autonomy and the interpretative burdens assumed by the proxy. Patients and proxies think inductively and contextually. Neither group viewed deviation from patient instructions as a violation of the principal's autonomy. Instead of adhering to narrow notions of patient self-determination, respondents made nuanced and contextually informed moral judgments. These findings have implications for patient education as well as the legal norms that guide advance care planning.

Physician-older patient communication about cancer.

Cancer is frequently a disease of older individuals. Communication between physicians and older patients about cancer prevention, screening, diagnosis, treatment and care is complicated by a variety of factors including patients' beliefs, perceptions, and knowledge about cancer. In addition, other older patient factors such as possible sensory deficits, cognitive impairment, functional limitations and accompaniment by significant others to the medical encounter influence communication. Physicians' attitudes about aging may also affect recommendations for cancer screening, treatment regiments and care of older cancer patients. To understand communication as a complex, multidimensional human enterprise requires knowledge of older patients' lived experience of cancer and their need for honest and compassionate care. Research findings on physician-older patient communication about cancer need to be translated into medical education, training and practice to improve the care of the older cancer patient.

Discussions about cognitive impairment in first medical visits: older patients' perceptions and preferences.

Primary care physicians are the first medical contact for most patients with early-stage dementia. However, little is known about older patients' desire for discussions about cognitive problems or the frequency of discussions about cognitive status during primary care visits. To investigate this question, older patients and accompanying individuals were interviewed separately following the first visit with a primary care physician in an outpatient geriatric medical practice. Patients indicated that memory was discussed in 62 percent of visits. When memory was not discussed, almost one-third of patients stated that they would have wanted to discuss it. Physicians were more likely than patients to initiate discussions about memory. Patient factors, including age, gender, the presence of an accompanying individual, number of diagnoses, and the patient's statement that cognitive function was a main goal of the visit, were examined as predictors of the likelihood of discussion of memory during the first visit. Patients who identified discussing cognitive function as a goal of the visit were more likely to have a discussion about memory than those who did not.

Older patient-physician discussions about exercise.

This cross-sectional observational study examined the frequency of older patient-physician discussions about exercise, who initiates discussions, and the quality of questioning, informing, and support about exercise. The study used a convenience sample of 396 follow-up visits at 3 community-based practice sites, with 376 community-dwelling older patients and 43 primary-care physicians. Audiotapes were analyzed using the Multi-Dimensional Interaction Analysis coding system. Results demonstrate that exercise was discussed in 13% of visits and the subject was raised equally by patients and physicians. Exercise was significantly more likely to be discussed in dyadic visits (14.7%) than in triadic visits (4.1%). Patient level of education, patient overall physical health, and the physician's being female were significant predictors of the occurrence of exercise discussion. Given the importance of exercise for maintaining health and independence in older adults, more clinical and research attention is needed to address barriers to effective discussions in this area.

Feasibility of a patient-driven approach to recruiting older adults, caregivers, and clinicians for provider-patient communication research.

PURPOSE: This report describes the implementation of a novel, patient-driven approach to recruitment for a study of interpersonal communication in a primary care setting involving persons with Alzheimer's disease (AD), their family caregivers, and their primary care providers (PCPs). DATA SOURCES: Patients and caregivers were centrally recruited from a university-based memory clinic, followed by the recruitment of patient's individual PCPs. Recruitment tracking, naturalistic observation, and survey methods were used to evaluate recruitment success. CONCLUSIONS: About half of the patients and caregivers (n = 54; 51%) and most of the PCPs (n = 31; 76%) who we approached agreed to an audiorecording of the patient's next PCP visit. Characteristics of patient, caregiver, and PCP participants were compared to those of nonparticipants. Patient characteristics did not differ by participation status. Caregivers who volunteered for the study were more likely to be female and married than were those who declined to participate. Compared to nonparticipants, PCPs who agreed to the study were appraised slightly more favorably by patients' caregivers on a measure of satisfaction with care on the day of the visit. The vast majority of participating PCPs (95%) reported that the study had little or no impact on the flow of routine clinical operations. IMPLICATIONS FOR RESEARCH: Findings support the feasibility of a patient-driven approach to recruitment for studies involving multiple linked participants. Our discussion highlights possible advantages of such an approach, including the potential to empower patient participants while achieving maximum variability within the pool of clinician participants.

Discussion of depression in follow-up medical visits with older patients.

OBJECTIVES: To determine the frequency of discussion about depression in follow-up medical visits of older patients, who initiates these discussions, the quality of responsiveness of physicians and patients in these discussions, and patient and physician characteristics that influence these discussions. DESIGN: Convenience sample of 482 audiotaped follow-up visits. SETTING: Three community-based practice sites. PARTICIPANTS: Three hundred seventy-six community-dwelling older patients without dementia and 43 primary care physicians. MEASUREMENTS: Audiotapes were analyzed using the Multi-Dimensional Interaction Analysis system to determine the content and process of medical conversations; patients completed Medical Outcomes Study 36-item Short Form Survey questionnaires immediately after the visit. RESULTS: Depression was discussed in 7.3% of medical visits; physicians raised this topic in 41% of visits, patients raised it in 48% of visits, and accompanying persons raised it in 10% of visits. Visits were longer when the topic of depression was discussed. Depression was raised almost exclusively in the first 2.5 years of the patient-physician relationship. Physicians with some geriatric training were more likely to discuss depression, and these visits were shorter than visits to physicians without geriatric training. CONCLUSION: Depression was raised infrequently in follow-up visits. The high prevalence of depression in older people and the associated mortality merit discussion of depression early and later in the patient-physician relationship. Although visits were longer when depression was discussed, physicians with some geriatric training were more likely to raise depression, and more time-efficient when they did so, than physicians without geriatric training.