Creating a geriatric medicine fellowship program in 10 "easy" steps

The aging of the U.S. population poses one of the greatest future challenges for family medicine and internal medicine residency training. One important barrier to providing quality education and training in geriatric medicine to residents is a serious and growing shortage of practicing geriatricians and geriatrics faculty. The Accreditation Council for Graduate Medical Education currently accredits 45 family medicine-based and 107 internal medicine-based geriatric medicine fellowships in the United States. There are 13 American Osteopathic Association-certified geriatric medicine fellowship programs. In this article, the authors examine the rationale for the development of additional geriatric medicine fellowship programs and offer some practical suggestions and pointers for those interested in developing their own geriatric medicine fellowships. The authors write from the perspective of their own recent experiences with the development and accreditation of a family medicine residency-affiliated fellowship in geriatrics. Other residencies may find this article useful in determining the feasibility of developing a geriatric medicine fellowship for their programs and communities and will find practical guidance for beginning the process.     

Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3-year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full-time equivalents (FTEs) (range 0-50), compared with a mean of 2.2 FTE faculty in 2002 (P相似文献   

Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.     

Geriatric training in emergency medicine residency programs.

STUDY OBJECTIVES: The health care needs of the elderly population are significantly different from those of younger patients and require special knowledge and skills on the part of emergency physicians. The purpose of this study was to identify the nature and extent of geriatric training currently provided to emergency medicine residents. DESIGN: Self-administered survey distributed to residency directors of the 85 accredited emergency medicine residency programs in the United States. INTERVENTIONS: The survey consisted of 17 questions focusing on residency directors' views about teaching and research of geriatric emergency care. RESULTS: Survey information was obtained from 85 (100%) emergency medicine residency programs. Forty percent (34 of 85) of respondents believed the teaching of geriatric emergency care was inadequate; 44 programs (52%) plan to increase the number of didactic hours devoted to geriatrics (mean increase of 5.9 hours). The five geriatric topics most frequently taught included acute dementia, atypical presentation of illness, common complaints in the elderly, geriatric trauma, and ethical issues. Sixty-five percent believed ongoing national research efforts regarding geriatric emergency medicine were insufficient; 21 programs (25%) had faculty involved in geriatric studies. Most respondents reported that growing numbers of elderly will have a major impact on all areas of patient care in the near future. CONCLUSION: Although geriatric emergency care is becoming an integral part of the emergency medicine residency program, there may be a need for better focused and more intensive training.     

Geriatric medicine curriculum consultations for family practice residency programs: american academy of family physicians residency assistance program/hartford geriatrics initiative

Increasing the quality and quantity of geriatric medicine training for family practice residents is a particular challenge for community-based programs. These programs have an average of only seven full-time equivalent physician faculty. This report summarizes results of the Residency Assistance Program/Hartford Geriatric Initiative (RAP/HGI) geriatric medicine curriculum consultations for family practice (FP) residency programs conducted from 1996 to 2001. This project was developed as part of the RAP in family practice. Ten experienced FP educators were selected and trained as special consultants. Between 1996 and 2001, 39 FP residency programs participated in the 1- to 4-day RAP/HGI consultations. The programs were diverse in size and location. The consultations reached 308 family practice residency faculty members involved in training 807 residents. Program evaluations of the consultants were uniformly in the very good to excellent range, with a mean rating of 4.6 (5-point scale, with 5 indicating excellent). At the end of the initial consultation visit, the residency program faculty and the consultant developed short-term goals for geriatrics program development. Eighty-five percent (33/39) of the programs submitted their curriculum goals in writing. The mean number of goals per program was 4.8 (range = 3-11). Of the 33 programs with written goals, follow-up was documented for 29 programs. Seventy-nine percent of the programs' self-defined educational goals were met during the 6 to 12 months of follow-up (range 50-100%). Ten of the programs implemented all of their educational goals. The RAP/HGI project demonstrated that achievable geriatric medicine curriculum improvements could occur as part of an onsite consultation process.     

The development of academic geriatric medicine: progress toward preparing the nation's physicians to care for an aging population

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full-time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy-one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.     

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.     

Residency training in internal medicine: time for a change?

Internal medicine residencies risk becoming obsolete if they are not adjusted to changing patterns of medical practice. Declining length of hospital stay, increased intensity of hospital care, movement of critical management decisions to outpatient settings, increased proportions of admissions for specific diagnostic procedures, and increased needs for perioperative consultations all erode the foundation of traditional internal medicine training. Furthermore, demographic shifts, the move to prepaid care, and a projected oversupply of subspecialists warrant more exposure to generalism and geriatrics. To prepare internists for clinical practice, some training should shift from medical wards and intensive care units to outpatient settings and surgical consultation, additional process skills must be taught, and the epidemiologically important non-internal-medicine disciplines should be included in the curriculum. These shifts will require changes in methods to pay for residency training, accreditation procedures for residency programs, and the residency certifying process. Most importantly, the model and organization of internal medicine training need to be reconsidered.     

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.     

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.     

Knowledge and attitudes about geriatrics of medical students, internal medicine residents, and geriatric medicine fellows

OBJECTIVES: To evaluate the attitudes and knowledge of medical students (MS1-3), internal medicine residents (postgraduate years 1 to 3 (PGY1-3)), and geriatric medicine fellows about elderly patients before implementation of a new geriatrics curriculum. DESIGN: Cross-sectional study. SETTING: An academic medical center. PARTICIPANTS: Two hundred eleven people participated: 54 MS1, 52 MS2, 50 MS3, 20 PGY1, 12 PGY2, 12 PGY3, and 11 geriatric medicine fellows. MEASUREMENTS: Each participant completed a questionnaire, including a 16-item geriatrics attitude scale, and a 23-item knowledge test (both revised versions of the University of California at Los Angeles (UCLA) Geriatrics Survey). Pearson correlation coefficients and t tests were used for statistical analyses. RESULTS: Both surveys demonstrated high internal consistency (alpha=0.70 and 0.71, respectively). Knowledge test scores increased with advancing level of training. MS1 and MS2 scored significantly lower and fellows scored significantly higher than others. PGY3 scored significantly higher than PGY1 on the knowledge test. All groups demonstrated positive attitudes toward geriatric patients (score>3.5). MS1 and fellows had significantly more favorable attitudes scores than more advanced students and residents. CONCLUSION: The results suggest that the UCLA Attitudes Scale and Knowledge Test can be used reliably to assess attitudes and knowledge level across all levels of medical education and training. The information from this study will be used to implement a more structured and comprehensive geriatrics curriculum across all trainee levels to improve attitudes and knowledge in the care of the geriatric patient.     

The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990 to 1998

The rapid growth of the older population has focused national attention on the need for physicians trained in geriatric medicine. To gain insight into the evolving status of the field, with particular focus on career decision-making and academic career development of trainees, we conducted a survey of physicians recently completing geriatric fellowships. The 107 accredited extant geriatric fellowship programs in the United States and Puerto Rico were contacted to identify trainees from 1990 to 1998. A mailed survey addressed relevant career development and training issues. Four hundred ninety out of 787 (62%) physicians responded; 20% completed 1 year and 80% 2 or more years of training. Half made the decision to pursue a career in geriatrics during residency, 27% decided before/during medical school, and a mentor influenced 48%. Currently, 80% have a Certificate of Added Qualifications in geriatric medicine, 69% hold academic appointments, 78% teach, 39% participate in research, and 44% author publications. Most are doing predominantly clinical work in multiple settings. Further analysis of the 1996-to-1998 cohort revealed that those completing fellowships of 2 or more years are more likely to identify all geriatrics as their professional focus, conduct and author research, work with multidisciplinary teams, and participate in professional geriatric societies. This national survey documents career decision-making and the academic and clinical profiles of physicians completing geriatric fellowship training in the past decade. Longer fellowship training is associated with academic career development. Although there is a national need to train clinical geriatricians, the additional need to train and fund future geriatric academic leaders requires increased attention.     

The effect of geriatric and palliative medicine education on the knowledge and attitudes of internal medicine residents

A recent Institute of Medicine report on geriatric work force issues recommends training residents in settings with geriatric patients and increasing certification requirements to include competence in the care of older adults. Although the number of internal medicine programs with a geriatric curriculum has increased, the scope and effectiveness of these programs vary. The purpose of this study was to evaluate the effect of a new academic geriatric and palliative medicine curriculum on the knowledge and attitudes of third-year internal medicine and fourth-year medicine and pediatrics residents. The study was conducted at The University of Texas Medical School at Houston. A new Division of Geriatric and Palliative medicine was created that offered inpatient, consultation, ambulatory, and home visit experiences in addition to didactic lectures. The University of Michigan Geriatrics Clinical Decision Making Assessment and the University of California at Los Angeles Geriatric Attitude Test was used to evaluate pre- and post-rotation knowledge and attitudes. Residents' knowledge improved after completing the rotation, as shown by a 6.9-point increase in posttest scores (P<.001). There was also a 10-point improvement in pretest scores over the course of the year (P=.03). Fifty-seven percent of residents had an improvement in attitude. This study shows that an increase in geriatric and palliative teaching opportunities provided by the establishment of a geriatric and palliative medicine division improves residents' knowledge significantly.     

A curriculum to teach internal medicine residents to perform house calls for older adults

Physician house calls are an important but underused mode of delivering health care to a growing population of homebound elderly patients. One major barrier to internal medicine physicians making house calls is a lack of training in this setting. This article describes a needs assessment survey of residents from nine internal medicine residency programs for a house call curriculum that combines a longitudinal clinical experience with Internet-based learning. Implementation of the curriculum was begun in July 2006, and data will be collected and results evaluated for at least 2 years. Several educational outcomes from the intervention are anticipated, including increased learner knowledge of house call medicine, improved learner confidence in making house calls, and program director satisfaction with the curriculum. This early work lays the foundation for determining the effect of a carefully designed curriculum on the number of practicing internists with the skills, knowledge, and attitudes necessary to meet the growing need for physician house calls.     

Academic Detailing to Teach Aging and Geriatrics

Geriatric education is a required component of internal medicine training. Work hour rules and hectic schedules have challenged residency training programs to develop and utilize innovative teaching methods. In this study, the authors examined the use of academic detailing as a teaching intervention in their residents’ clinic and on the general medicine inpatient wards to improve clinical knowledge and skills in geriatric care. The authors found that this teaching method enables efficient, directed education without disrupting patient care. We were able to show improvements in medical knowledge as well as self-efficacy across multiple geriatric topics.     

Survey of medicine/pediatrics residency training programs

The American Board of Internal Medicine and the American Board of Pediatrics agreed in 1967 to create combined medicine/pediatrics residency training programs. These programs span four years and provide 24 months of training in each discipline, leading to Board eligibility in both. Little is known about their curricula because there is no separate residency review committee to critique the current programs. The directors of the 65 current programs were surveyed by mail. Fifty-seven (88%) responded to questions about: lengths of time programs had been in operation, attitudes toward quality of residents, program structures and curricula, and performances of graduates taking the Boards. More than half of the programs were established after 1980. Forty of the programs’ graduates have passed the Medicine Boards, and 48 have passed the Pediatrics written Boards. Most programs were structured to have residents switch specialties every six months. Program Directors, both in Medicine and in Pediatrics, rated the quality of combined program residents the same as or slightly better than that of residents in non-combined programs. Medicine/pediatrics residencies have become a successful and important source of training for generalists’ careers in and outside of academe, and in both primary and specialty care. Received from the Department of Medicine and the Department of Pediatrics, West Virginia University, Morgantown, West Virginia. Presented in part at the session for Medicine/Pediatrics program directors at the Association of Program Directors in Internal Medicine in New Orleans, October 26, 1986.     

Proficiency of internal medicine residents in outpatient care of patients with HIV infection

To determine internal medicine residents’ knowledge of HIV care, the authors conducted a survey of residents from four internal medicine programs in the San Francisco Bay area. On a knowledge test, the mean score was 42.4/55, 77% correct. The residents performed relatively worse on questions regarding didanosine and zalcitabine, tuberculosis prophylaxis, and risk of cervical neoplasia in HIV-infected women. Predictors of greater knowledge were specific residency program, higher postgraduate year, primary care residency track, and more extensive HIV experience. Primary care internal medicine residencies and programs with more exposure to HIV patients are most effective in producing knowledgeable residents. Supported by the AIDS Clinical Research Center, University of California San Francisco, VA Medical Center (141A), 4150 Clement Street, San Francisco, CA 94121; and National Institute of Mental Health Grant: MH44045 (Dr. Cooke). Dr. Bindman is a Robert Wood Johnson Generalist Physician Faculty Scholar. This research was conducted, in part, while Dr. Schultz was a fellow in general internal medicine and clinical epidemiology in the Division of General Internal Medicine, San Francisco General Hospital, San Francisco, California.     

Program directors’ views of the importance and prevalence of mentoring in internal medicine residencies

Program directors establish priorities for residency programs. Their views of mentoring likely influence the tone about and availability of mentoring programs. This survey to all internal medicine program directors assessed attitudes toward mentoring, existence of formal mentoring programs, and features of the mentoring programs. The response was 60%. The majority (>60%) favored mentoring. Forty-nine percent of the residencies had structured mentoring programs. Programs differed in frequency of meetings, use of evaluations, and presence of curriculum. Overall, although program directors' attitudes are favorable and at least half have formal mentoring programs, the programs are largely unstructured, loosely monitored, and underevaluated.     

General internal medicine and geriatrics: building a foundation to improve the training of general internists in the care of older adults

Internists--"doctors for adults"--provide most of the medical care given to older Americans, especially those with serious chronic disease. Nonetheless, the United States lacks an adequate physician workforce with mastery in caring for older persons and with expertise in building knowledge about how best to provide this care. This supplement aims to strengthen the physician workforce by fostering incremental and sustained improvements in the training of internal medicine residents in the care of older adults and in the development of geriatrics-oriented general internal medicine faculty. It identifies 3 major barriers to these improvements: lack of adequately trained teachers and mentors, the belief that explicit training in geriatrics has little to offer the generalist, and inadequate funding. Three strategies offer particular promise in overcoming these barriers: engaging directors of internal medicine residency programs, funding centers to promote collaboration between teaching and research programs in general internal medicine and geriatrics, and providing substantial incremental funding on the national level to pay for the time required to care for frail older patients and to teach and do research about this care. The barriers and strategies identified in this supplement may also inform efforts to enhance the skills of practicing physicians and improve training and faculty development in family medicine and other disciplines.     

Teaching of geriatric health in India: Mapping the terrain

ABSTRACT

India is currently undergoing a rapid demographic transition along with a dramatic upsurge in the number of elderly adults. Creating a cadre of specialized health care professionals in geriatric medicine is clearly vital to address the health care needs of this growing population. The authors undertook a mapping of the available academic programs in geriatric health in India and examined their content, duration, architecture, and student intake. A total of 20 programs were identified in geriatric health, thus highlighting a paucity of training options in this field. Compared to Western countries, relatively few programs are offered in clinical and public health geriatrics in India. This is further compounded by an insignificant thrust of geriatrics in undergraduate health professional curricula. Our results underscore the need for a national-level curricular initiative to strengthen and mainstream the teaching of geriatric health in the country. Alternative educational strategies such as blended learning and interprofessional education should be explored to enhance geriatric health workforce competence.