Gearing up for a graying generation: Training more doctors in geriatrics skills

Myrtle Croasdale
http://www.ama-assn.org

Baby BoomerWhen the first of the 78 million baby boomers turn 65 in 2011, physicians across specialties will see more older patients in their practices. By 2030, the surge will peak, with nearly 70 million Americans 65 or older, according to the American Geriatrics Society.

Today, there are about 7,100 geriatricians. By 2030, there will be an estimated 8,000, but the nation will need 36,000 geriatricians, according to an Institute of Medicine report released in April.

The report called for an increase in geriatric competency throughout the health care work force. The American Medical Association supported the directive, stating that all physicians who treat older adults need to become proficient in geriatric care.

Advocates for seniors have been aware of the need for more geriatric expertise among physicians. Many projects are under way at medical schools, teaching hospitals and medical societies, funded by philanthropies such as the Donald W. Reynolds Foundation and The John A. Hartford Foundation.

Here is a look at how medical students, residents and practicing physicians are being prepared to care for the geriatric population:

Medical students get hip to aging

In 2000, the University of South Carolina School of Medicine started integrating geriatrics into course work and clinical clerkships, including a senior mentor program that pairs medical students with senior volunteers.

The mentor program, one of about 30 nationwide, features set tasks for students throughout medical school.

Many assignments, such as taking the mentor’s medical history and doing a physical exam, teach general medical skills and geriatric knowledge. Others are more senior specific, such as a dietary review, a mental health assessment and a home safety assessment. All assignments coincide with lecture topics.

When course work covers pharmacology, students meet with senior mentors to list their prescribed and over-the-counter medications and supplements. Students do a computer search for potentially harmful drug interactions, then review the drugs and findings with a geriatrician and a pharmacist, before going over the results with their mentors.

“All medical students need to take care of older adults well,” said G. Paul Eleazer, MD, director of the university’s geriatrics division. “It doesn’t matter what specialty. Even pediatricians — who have grandparents taking care of grandchildren — should be able to recognize dementia in that grandparent.”

Research on the program found it improved students’ attitudes and knowledge about older adults. Results have been strong enough that the Medical University of South Carolina has asked the school to help it replicate the program.

Miriam Anthony, 78, has been a mentor at the USC School of Medicine for four years. “It’s nice for the younger students to get used to old people,” she said.

Megan Wilson, MD, who graduated in May, was one of two students assigned to Anthony. Thanks in part to the experience, she hopes to include geriatrics in her practice someday. “You get to work with one person, really get to know them,” said Dr. Wilson, who will start a residency combining pediatrics and internal medicine at the University of Michigan in July. “Throughout medical school you don’t get a lot of continuity. To have a patient who was always yours was neat.”

Such mentor programs are a way for schools to meet the recommended minimum geriatric competencies for medical students. The competencies, informally known as the “don’t kill granny” curriculum, were developed by education leaders last year at a national consensus conference on geriatrics education. The intent of the competencies is to teach students what they need to know so they “don’t kill granny” during their first month in residency, educators said.

Crash course for resident leaders

Reaching residents across specialties is also key to caring for the growing senior population, educators said. At Boston University School of Medicine, Sharon A. Levine, MD, an associate professor in geriatrics, is teaching residents to treat seniors through a model called Chief Resident Immersion Training.

The training takes place during a weekend retreat residents attend with their program directors. They participate in two days of lectures and small group learning. A case study walks them through an emergency admission of a senior and the age-related, pre- and postoperative complications that arise, along with how to plan a safe discharge.

The course has proven successful enough that the Assn. of Directors of Geriatric Academic Programs is sponsoring a national demonstration project to roll out the training model at 13 institutions during the next three years. To date, residents from specialties, such as anesthesiology, general surgery and urology, have participated in the 4-year-old program.

“This is a group of trainees who are real opinion leaders,” Dr. Levine said. “They are role models in an institution.”

Other residents and medical students look to them for instruction, Dr. Levine said, which is why she wants to equip the chiefs with a deeper understanding of geriatrics and give them teaching skills, such as how to handle a reluctant learner.

During the immersion weekend, residents also hear from panels made up of patients’ family members.

Last year, a panel included relatives of a retired 80-year-old physician who died after being hit by a car and sustaining three broken limbs and intracranial bleeding. The family talked about what it was like to deal with the shock, Dr. Levine said.

Miguel Ariza, MD, internal medicine chief resident at Boston Medical Center, found the experience valuable.”You could see how geriatrics permeates all aspects of medicine, not just internal medicine.”

For his action plan, Dr. Ariza organized, for the internal medicine residents, a monthly morning report session dedicated to geriatric care. During the sessions, he or a specialist discussed topics such as falls, delirium, pharmaceutical concerns and care of geriatric patients at home.

Such training paid off for Dr. Ariza. For example, when his residents were stumped by an elderly patient who was failing to thrive at home, losing weight and showing signs of cognitive impairment, he was able to suggest a referral for home-based care.

With services such as nursing care and physical therapy, ” a lot of house staff don’t realize not only can it be ordered from an inpatient setting but also from your own clinic,” Dr. Ariza said.

Practical help for practicing doctors

Practicing physicians may be the most difficult segment for educators to reach. Traditional continuing medical education is not the best format for changing physicians’ practices, experts said.

David Reuben, MD, geriatrics chief at the University of California, Los Angeles, and American Geriatrics Society past president, said researchers are focusing on practice redesign and innovative health care delivery.

The American Academy of Family Physicians and American College of Physicians are expanding on such research to reach members.

Dr. Reuben is working with the ACP on one project called Assessing Care of Vulnerable Elders or ACOVE Prime. The project is being piloted at five community-based practices with a focus on how to diagnose, evaluate and treat falls and urinary incontinence.

“The goal is to come up with a better model of care that can be folded into practice without taking an extraordinary amount of time,” Dr. Reuben said.

Physicians Health Alliance, a large multispecialty group in Dunmore, Pa., is one of the practices. Since it started the ACOVE project two years ago, the group has designed evaluation forms that cover falls and incontinence.

“It’s definitely made a difference,” said Julie Speicher, MD, an internist at the practice. “It was a real eye-opener for myself. I had never talked to anyone about a fall, and I don’t see a lot of urinary incontinence. Now, I’m more aware of what needs to be asked and how to treat.”

That includes referring patients who need to improve balance to a tai chi class or a nearby balance clinic.

Meanwhile, the AAFP has added a geriatrics module to its online course series, Measuring, Evaluating and Translating Research Into Care, or METRIC, which teaches physicians how to develop a quality improvement plan on a variety of topics. The AAFP also developed the Practice Enhancement Forum, or PEF, a two-day course that elaborates on quality improvement strategies and connects physicians with a local quality improvement mentor to help them develop and implement goals related to their chosen METRIC module.

Bruce Bagley, MD, AAFP medical director for quality improvement, said that with the geriatrics module in use for only two months, it is too soon to know if it has been a success. However, he said 90% of physicians who take part in a PEF report they made a permanent change in some part of their practices. He expects similar results for the geriatrics course.

Dr. Bagley said the AAFP will further develop its geriatric programs with a $2.9 million grant it was awarded in April.

“Although it’s true we need more geriatricians, it’s not practical,” Dr. Bagley said. Geriatrics “needs to be integrated into the primary care work force.”

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