Practicing physician education in geriatrics: lessons learned from a train-the-trainer model

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture-style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small-group, learner-centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community-based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self-reported knowledge, attitudes, and office-based practices on the target topics at the time of training and at the 6-month follow-up (P<.001) and two-thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off-the-shelf review (mean rating+/-standard deviation 4.1+/-0.71, with 1 = not at all and 5 = significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on-line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer-led, community-based sessions using principles of knowledge translation and evidence-based tool kits with materials for providers and patients.     

A new after-care model in geriatrics

78 geriatric patients predominantly suffering from cardiocerebrovascular diseases (stroke, heart insufficiency) and lesions respectively operations of the locomotion system (fractures, arthroses) were admitted in 1987 from acute hospitals for after-treatment (short-term care). 35 (= 45%) of them (average age 80 (61-92) could be discharged after 63.5 days on average, 11 died from intercurrent complications, 9 remained for long-term care as inrehabilitable. Besides other concomiting troubles mainly cardiac and circulation affections were present in the majority of patients. Their identification (a. o. by means of ultrasonic methods) and therapy also means a secondary prevention of cerebral as well as of fall and injuries inducing risk factors. The results confirm the principal rehabilitation chance of multimorbid geriatric patients by use of the diagnostic and therapeutic special potential of geriatrics.     

以问题为导向的教学模式在老年医学教学中应用初探

随着人口老龄化的加速,老年疾病防治成为我国现阶段卫生保健工作的重点之一。因此我们对老年医学的教学工作提出了更高的要求。如何通过教学调动学生对老年疾病的重视及学习的积极性,进而使老年医学教学进程稳定发展,是我们有待思考和解决的问题。以问题为导向的教学方法（PBL）与以往的教学模式相比,在培养医学生综合能力、创新精神和团队精神等方面起到了推进作用,现正逐步应用于老年医学的教学领域。     

Patient safety in geriatrics: a call for action

Patient safety has become a major public health concern following the publication of the landmark report, To Err Is Human, by the Institute of Medicine in 1999. This report, along with a subsequent report, Crossing the Quality Chasm, recommended the design of a safer health care system by integrating well-established safety methods to avert medical errors. However, neither patient safety report specifically addressed the implications of safety for elderly patients. This article examines those implications by describing the association between aging and medical errors, identifying geriatric syndromes as medical errors, and focusing on six recommendations that will improve the safety of geriatric care. These six recommendations include the detection and reporting of geriatric syndromes, identifying system failures when geriatric syndromes occur, establishing dedicated geriatric units, improving the continuity of care, reducing adverse drug events, and improving geriatric training programs.     

Hospital medicine fellowships: works in progress

The field of hospital medicine continues to grow rapidly, and with this growth has come the realization that residency alone may not provide the full complement of skills required of a successful hospitalist. As a result, several institutions have started hospitalist fellowships, new programs with the specific goal of training clinicians to improve hospital care. These fellowships offer diverse approaches to preparation for a hospitalist career, with opportunities for advanced training in clinical care, teaching, research, and quality improvement. This article provides an overview of the programs, explores the choices for trainees in selecting a fellowship, and the challenges for institutions in developing a new fellowship. Although hospitalist fellowships are still in evolution, they will play an important role in the development of hospital medicine.     

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 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.     

Teaching interdisciplinary geriatrics ambulatory care: a case study

Interdisciplinary health care training is advocated by numerous government and philanthropic organizations. Educators in the health professions are increasingly offering training in interdisciplinary health care in a variety of contexts, including ambulatory settings. This paper describes a three-year program to teach skills in interdisciplinary care to learners from internal medicine, social work, pharmacy, and nursing in a geriatrics clinic at a major academic institution in the United States. Framed in a critical review of existing evidence for the effectiveness of interdisciplinary training and health care and expert recommendations, specific recommendations are made to educators interested in interdisciplinary training in ambulatory settings.     

Problems of the health-impaired elderly: a foundation's experience in geriatrics

Elderly people, particularly those over age 75, are subject to problems of access to needed health services, of the appropriateness of these services in relation to their needs, and of increasing infirmity, disability and dependency, with loss of their natural support systems. The proportion of health expenditures deployed to deal with the institutionalization and long-term requirements of elderly people is increasing in a national climate characterized by tightening constraints on public expenditures for health care under Medicare and Medicaid. The Robert Wood Johnson Foundation has accepted objectives and roles to find better ways to use what we already know to improve elderly people's access to health care, to improve their functional effectiveness, and to make their health care more affordable. The results of some of the programs it has supported represent innovative approaches and demonstrate ways in which we may accomplish these objectives.     

Future history: medical informatics in geriatrics

With deference to Isaac Asimov's The Foundation, which is the inspiration for this series, we briefly describe the "present history" of medical informatics (the application of information technology in medicine) in geriatrics, and then project a "future history" of this same endeavor. The older patient often has multiple acute and chronic problems that require management by a variety of medical professionals in a variety of settings. Proper care necessitates efficient gathering, integration, and management of information by each professional in each setting. As medical informatics evolves, we project that barriers to information exchange (both between providers and between providers and patients) will continue to decrease while the quality and relevance of exchanged information will continue to increase. The nexus of care will be the electronic medical record (EMR), which will shed its current paper chart metaphor and adopt an industrial process metaphor based on tasks and tolerances or goals. The multidisciplinary management of geriatric patients will strike a new balance: doctors, nurses, allied health professionals, family, and patients will all participate in the management of the patient's care. The EMR will coordinate data from a variety of novel sources, including wearable sensors monitoring physiologic parameters, falls, diet, ambulation, and medication compliance. The highly organized data in the EMR will allow explicit decision support for computer-facilitated, evidence-based care; will empower midlevel providers and patients with an increased role in the care plan; and will promote the realignment of care from hospitals/clinics to the patient's home.     

Hypodermoclysis: benefits and indications in geriatrics

PURPOSE: Older people are at high risk of dehydration. Oral intakes are often inadequate routinely. Intravenous infusion may be difficult in these patients and harmful. Subcutaneous infusion or hypodermoclysis is a useful technique for the cure of a moderate dehydration in elderly patients and especially for its prevention. Moreover, this technique is of great interest in end-life patients. CURRENT KNOWLEDGE AND KEY POINTS: When it is used correctly and when its contraindications are respected (emergency situations), hypodermoclysis is a simple, safe, sure, effective and comfortable technique. It does not need trained supervision and can be used both in an institution and at home, thus avoiding hospitalization of older subjects and reducing health costs. This technique has considerable benefits both psychologically and financially. FUTURE PROSPECTS AND PROJECTS: The numerous advantages of hypodermoclysis should encourage its wider use in older patients at home as well as in institutions. Moreover, new indications need to be evaluated. In this way, subcutaneous infusion of therapeutics or prevention of protein-energy malnutrition by hypodermoclysis of amino acids need further investigations.