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.     

Strength in Numbers: A National Monthly Case Conference Series for Fellows

Small fellowship programs face challenges in providing learners with sufficiently diverse experiences and patient populations. The Fellows Most Difficult Case Conference is designed to broaden geriatric medicine fellows' exposure to cases and to faculty and fellows from around the country through a monthly telephone conference. We describe this innovative approach to a national monthly complex case conference that fellows from almost one‐third of geriatrics fellowship programs attend, including its value to geriatric fellows and faculty and administrative costs. Once per month, a fellow presents a case, a moderator leads the discussion, and 2 faculty members provide teaching points during the 60‐minute session. Participants rated the conference's value using an 11‐item on‐line survey followed by a debriefing held during a regularly scheduled 2017 monthly conference. Thirty‐six percent of eligible participants responded to the survey (67/186), with 75% of respondents reporting that they applied knowledge gained from the conferences to their patient care at least 1 or 2 times per month and 41% that they applied it at least once per week. Participants appreciated the inclusion of multiple programs, the duration of the conference, and the interactive approach. Our administration time was less than 5 hours per month, plus a few additional hours annually to create the academic year schedule. We believe that this national case conference, the first of its kind in the country, involving almost one‐third of geriatrics fellowship programs, is an innovative and valuable way for fellows to explore complex cases and variations in regional perspectives and to connect with additional colleagues.     

Addressing sexual health in geriatrics education

ABSTRACT

Adults remain sexually active well into later life, but few report discussing sexual health with a physician after age 50. The authors explored how geriatrics education might better address sexual health in the context of a psychosocial conference for geriatrics fellows, program directors, and faculty comprising an informational plenary, which included a skills-building presentation on taking sexual histories, and a program director/faculty roundtable. Although informed about older adult sexual health, knowledge scores of geriatrics fellows increased following the plenary. Fellows reported inconsistent sexual history taking with older adults and noted patient differences in age and gender as barriers. The roundtable discussion highlighted several barriers to inclusion of sexual health content in geriatrics curricula including competing competencies, lack of educational materials, and discomfort with this topic on the part of faculty. Implications of these findings for geriatrics training and education programs and suggestions for improving this domain of geriatrics education are discussed.     

Geriatrics training in general internal medicine fellowship programs: current practice, barriers, and strategies for improvement

To ensure its growth and prosperity, general internal medicine will need to embrace care of the elderly, research on aging, and geriatrics education as components of its core mission. Experts agree that general internal medicine fellows could benefit from increased opportunities in research on aging and geriatrics education; however, important barriers will hamper efforts to integrate geriatrics training into general internal medicine fellowship programs. This article reviews the barriers to integration and proposes solutions for overcoming those barriers. As a result of interviews and meetings with a broad representation of general internists, geriatricians, funding agencies, and policymakers, we propose 2 interventions: 1) the development of institutional program grants to foster collaboration between general internal medicine and geriatrics faculty in the training of general internal medicine fellows and 2) the creation of a 3-year fellowship program combining general internal medicine and geriatrics. This article discusses the importance of evaluating these and other programs intended to increase the geriatrics experience of general internal medicine fellows, and it describes the potential implications of these changes for a broad array of stakeholder institutions.     

Development and validation of a geriatrics knowledge test for primary care residents

This study reports the development and preliminary validation of an instrument to measure geriatrics knowledge of primary care residents. A 23-item test was developed using questions selected from the American Geriatrics Society's Geriatrics Review Syllabus. Ninety-six internal medicine and family practice residents, 14 geriatrics fellows, and 11 geriatrics faculty members participated in the study. Findings support the reliability (Cronbach's a 5 0.66) and validity (content and "known groups") of this short test. Predictive validity and sensitivity of the test to changes in knowledge will have to be further explored as residents progress through their training.
KEY WORDS: geriatrics knowledge assessment; evaluation of residency programs; geriatrics education.     

Building academic geriatric capacity: an evaluation of the John A. Hartford Foundation Centers of Excellence initiative

Almost 15 years ago, the John A. Hartford Foundation began its Centers of Excellence (CoE) program. In summer 2002, a quantitative and qualitative evaluation of the CoE program was conducted. The evaluation used previously collected quantitative data from surveys of program directors and graduates of fellowship programs, as well as interviews and surveys of currently funded CoEs. Since its inception, the CoE program has supported 163 geriatrics fellows, of whom 63% entered academic geriatrics. Almost half of these graduating fellows have gone to new academic institutions. CoEs have also supported 222 faculty, including some who were in disciplines other than geriatrics. The vast majority (82%) have remained in academics, and nearly two-thirds are currently in geriatrics. As the priorities and needs of the institutions and geriatrics programs changed, most centers shifted their CoE priorities. These changes predominantly took two forms: a refocus from one activity to another or an expansion of outreach or levels of support. Based upon this formal evaluation, the Hartford-supported CoE program has been successful in strengthening academic geriatrics, particularly in attracting, developing, and retaining geriatrics faculty.     

The Training of Geriatricians in the United States: Three Decades of Progress

During the past 3 decades, significant progress has been made in preparing U.S. physicians to care for the growing elderly population. This paper reviews progress in training and certifying internists and family physicians in geriatric medicine. The establishment of the National Institute on Aging, a series of Institute of Medicine reports, Veterans Health Administration initiatives, and leadership and investment by the public sector and private foundations have supported the development of geriatric medicine training programs. In 1988, the Accreditation Council for Graduate Medical Education initially accredited 62 internal medicine (IM) and 16 family practice (FP) geriatric medicine fellowship programs. By academic year 2001–2002, 120 geriatric medicine fellowships were training 338 fellows. A recent survey of U.S. medical schools found a total of 869 full-time equivalent (FTE) geriatrics faculty members. Their geriatrics programs had a median of 5.0 FTE physician faculty members, with a range of 0 to 42. Recent surveys of IM and FP residency programs found 803 geriatrician faculty members teaching in IM residency programs (53% response rate) and 453 teaching in FP residency programs (75% response rate). From 1988 through 2002, 10,207 Certificates of Added Qualifications in Geriatrics were awarded. The distribution of these practicing geriatricians varied considerably by state, with the national average being 5.5 per 10,000 persons aged 75 and older. Individual state rates ranged from 2.2 to 15.9. Although geriatric medicine training has grown remarkably over the past 3 decades, this growth is still not producing the number of geriatricians needed to care for the growing elderly population. Thus, expanded investment in the training of geriatricians as faculty and practitioners is needed.     

National survey of geriatric medicine fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs Geriatrics Workforce Policy Studies Center

This article documents the development of geriatric medicine fellowship training in the United States through 2009. Results from a national cross-sectional survey of all geriatric medicine fellowship training programs conducted in 2007 is compared with results from a similar survey in 2002. Secondary data sources were used to supplement the survey results. The 2007 survey response rate was 71%. Sixty-seven percent of responding programs directors have completed formal geriatric medicine fellowship training and are board certified in geriatrics, and 29% are board certified through the practice pathway. The number of Accreditation Council for Graduate Medical Education-accredited fellowship programs has slowly increased, from 120 (23 family medicine (FM) and 97 internal medicine (IM)) in 2001/02 to 145 in 2008/09 (40 FM and 105 IM), resulting in a 21% increase in fellowship programs and a 13% increase in the number of first-year fellows (259 to 293). In 2008/09, the growth in programs and first-year slots, combined with the weak demand for geriatrics training, resulted in more than one-third of first-year fellow positions being unfilled. The number of advanced fellows decreased slightly from 72 in 2001/00 to 65 in 2006/07. In 2006/07, 55% of the advanced fellows were enrolled at four training programs. In 2008/09, 66% of fellows were international medical school graduates. The small numbers of graduating geriatric medicine fellows are insufficient to care for the expanding population of older frail patients, train other disciples in the care of complex older adults, conduct research in aging, and be leaders in the field.     

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.     

The use of the internet in geriatrics education: results of a national survey of medical geriatrics academic programs

In order to characterize use of the Internet in medical geriatrics education programs, 130 medical education programs in the U.S. that train medical students, interns, residents, fellows and practicing physicians were asked to complete a survey developed by the Consortium of E-Learning in Geriatrics Instruction (CELGI). Sixty-eight programs (52.3%) returned surveys. Fifty-four (79%) of those responding reported using the Internet specifically for geriatric medical education, and 38 (56%) reported they are developing Internet materials. Twentythree undergraduate, 31 graduate, and 26 continuing medical education programs reported at least 25% of their curriculum was Internet-based. Users and developers of medical geriatric Internet materials had more full-time faculty and nonclinical faculty. The results of our survey indicate that the Internet is being widely used in medical geriatric education.     

Education in Geriatric Medicine:

The Texas Consortium of Geriatric Education Centers was establisged in 1985. The primary goal of the Consortium is the continued professional development of health professions faculty in gerontology and geriatrics. This article describes a multi-level program of institutional development which has been initiated to accomplish this goal. The components of the program include a strategic planning document (Institutional Action Plan), and a professional development program for faculty (Personal Action Plan). Since October 1985 a total of 63 health professions faculty from 9 academic institutions have enrolled in the two-year program. As designated trainees, these individuals are expected to complete a seven-unit Learning Module in Geriatrics, attend two content-intensive multidisciplinary institutes, and prepare a structured plan for the introduction of aging content within educational experiences provided students in health-related disciplines. The design of the instructional program provided faculty trainees is also described.     

Professional development in geriatrics for community-based generalist faculty

Generalist physicians provide most primary care for older people. Increasingly, undergraduate clinical education occurs in community sites. Hence, community-based generalist faculty members need continuing education in geriatrics to support clinical practice and teaching. The Geriatrics Scholars Program provided continuing medical education (CME) in geriatrics over a 3-year period to 88 participants. Sixty physicians completed 30 or more hours of education and were designated Geriatrics Scholars. On an anonymous exit survey, Scholars reported being better equipped to care for elderly patients and to teach geriatrics and improved patient care in specific aspects of geriatrics, including medication use, cognition, and functional assessment. In summary, community-based generalist faculty who participated in a substantial, 3-year program of geriatrics CME reported that their care of older people and their teaching of geriatrics were enhanced.     

The geriatrics excellence in teaching series: an integrated educational skills curriculum for faculty and fellows development

Geriatricians need to acquire skills in teaching and curriculum development to educate physicians caring for the growing population of adults aged 65 and older. To meet this challenge, educators in the Duke University Center for the Study of Aging and Human Development introduced a monthly seminar series to promote the development of geriatrics faculty and fellows as clinician educators. Ten educational skills development seminars were incorporated into geriatrics grand rounds in the first year of the program. These sessions were implemented using a variety of active learning strategies to expose participants to innovative adult learning-centered approaches for enhancing learning and instruction in medical education. Participants assessed all sessions using a feedback form and were surveyed at the end of the series to measure their overall satisfaction with the program and ascertain its effect on their roles as educators. Participants rated individual sessions highly, and respondents to the survey at the end of the course agreed that the Geriatrics Excellence in Teaching Series provided them with resources for use in their teaching practices and attested to having already applied knowledge and skills learned in the series in their teaching practices. Key elements for the program's success included an upfront needs assessment to prioritize topics, interactive sessions promoting skill development through actual practice of various strategies, open discussions to identify challenges and solutions, and a convenient and customary time slot. This format can be replicated with other geriatrics programs, providing a needed opportunity for faculty and fellows to learn about education principles.     

What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End‐of‐Training Entrustable Professional Activities for Geriatric Medicine

Entrustable professional activities (EPAs) describe the core work that constitutes a discipline's specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end‐of‐training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatrician's fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.     

Improving Care Using a Bidirectional Geriatric Cardiology Consultative Conference

More than 13 million persons in the United States aged 65 and older have cardiovascular disease (CVD), and this population is expected to increase exponentially over the next several decades. In the absence of clinical studies that would inform how best to manage this population, there is an urgent need for collaborative, thoughtful approaches to their care. Although cardiologists are traditionally regarded as leaders in the care of older adults with CVD, these individuals have multiple comorbidities, physiological differences, and distinct goals of care than younger patients that require a specialized geriatric lens. Thus, collaboration is needed between geriatricians, cardiologists, and other specialists to address the unique needs of this growing population. Accordingly, clinicians at New York University Langone Health and School of Medicine established a monthly Geriatric Cardiology Conference to foster an integrative approach to the care of older adults with CVD by uniting specialists across disciplines to collaborate on treatment strategies. At each conference, an active case is discussed and analyzed in detail, and a consensus is reached among participants regarding optimal treatment strategies. The conference attracts faculty and trainees at multiple levels from geriatrics, cardiology, and cardiothoracic surgery. The model may serve as a paradigm for other institutions moving towards geriatric‐informed care of older adults with CVD.     

A Collaborative National Model to Assess Competencies for Medical Students,Residents, and Other Healthcare Practitioners in Gait and Falls Risk Evaluation

To ensure that the healthcare workforce is adequately prepared to care for the growing population of older adults, minimum competencies in geriatrics have been published for medical students and primary care residents. Approaches to teaching and assessing these competencies are needed to guide medical schools, residencies, and continuing medical education programs. With sponsorship by the Education Committee and Teachers Section of the American Geriatrics Society (AGS), geriatrics educators from multiple institutions collaborated to develop a model to teach and assess a major domain of student and resident competency: Gait and Falls Risk Evaluation. The model was introduced as a workshop at annual meetings of the AGS and the American College of Physicians in 2011 and 2012. Participants included medical students, residents, geriatrics fellows, practicing physicians, and midlevel practitioners. At both national meetings, participants rated the experience highly and reported statistically significant gains in overall competence in gait and falls risk evaluation. The largest gains were observed for medical students, residents, and practicing physicians (P < .001 for all); geriatrics fellows reported a higher level of baseline competence and therefore had a lower magnitude of improvement, albeit still significant (P = .02). Finally, the majority of participants reported intent to disseminate the model in their institutions. This article describes the design, implementation, and evaluation of this collaborative national model. A number of institutions have used the model, and the goal of this article is to aid in further dissemination of this successful approach to teaching and assessing geriatrics competencies.     

The development of academic geriatric medicine in the United States 2005 to 2010: an essential resource for improving the medical care of older adults

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full‐time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.     

Faculty development in geriatrics for clinician educators: a unique model for skills acquisition and academic achievement

As the size of the aged American population increases, so too does the shortage of trained providers in geriatrics. Educational strategies to train physicians at all levels of experience within adult medical and surgical disciplines are needed to complement fellowship training, given the small size of most academic faculties in geriatrics. This article describes a unique faculty development program that creates geriatrically oriented faculty in multiple disciplines. The Boston University Center of Excellence in Geriatrics (COE), funded by the John A. Hartford Foundation, has trained 25 faculty members. Four to six scholars enter the program each year and participate in the COE 1 day per week. Nine months are spent in four content modules-Geriatrics Content, Clinical Teaching, Evidence-based Medicine, and Health Care Systems; 3 months are spent in supervised scholarly activities and clinical settings. A self-report questionnaire and a structured interview were used to evaluate the outcomes of participation in the COE. The results from the first 4 years of the program are reported. The response rate was 83% for the self-report questionnaire and 75% for the structured interview. The results indicate that the COE is effective in improving scholars' assessment and management of older patients. The structured interview revealed that the COE program promotes the integration of geriatrics into clinical teaching at the medical student and resident level. Participants also completed scholarly projects in geriatrics. This program effectively trains faculty scholars to better care for older adults and to teach others to do likewise.     

The Impact of Health Care Reform on Gastroenterology Fellows: Are Training Programs Preparing Them for the Future?

Objective : Health care reform is dramatically changing the practice and delivery of medical care. The goal of this investigation was to examine gastroenterology trainees' outlook on the impact of health care reform on training programs. Methods : A 24-question survey was mailed in February 1996 to 780 GI fellows obtained from the comprehensive American College of Gastroenterology (ACG) database. Results : A total of 362 fellows responded (46%): 85% were male, 57% Caucasian, 75% married, and 86% were university-based. Ninety-six percent of fellows believed that health care reform is adversely affecting the quality of health care and 94.1% felt that it was adversely affecting fellowship training. Eighty-eight percent expressed concern over the impact of health care reform on practice opportunities. Only 9% of fellows reported that their training program had established a specific educational program addressing health care reform. where 83% of fellows felt that their program should do so. Conclusion : Gastroenterology fellows are concerned about the impact of health care reform on the quality of care and the quality of their fellowship training. Trainees believe that programs are not providing sufficient education to help them respond to the changes in health care.