Herding Cats: Leverage Points for Geriatric Medical Education in 2011

1. Herding Cats:Leverage Points for Geriatric Medical Education in 2011 Rosanne M. Leipzig, MD, PhD Brookdale Department of Geriatrics and Palliative Medicine Mount Sinai School of Medicine

2. Table of Organization

3. Medical Education Table of Disorganization School Program Accreditation Professional Certification Professional Licensing NBME LCME Medical Students ACGME ABMS FSMB Residents + Fellows ACCME ABMS Practicing Physicians FSMB

4. Getting Change in Medical Education is Like Herding Cats Medical Education

5. Geriatricizing Medical Education Leverage Points Make it easier to teach Make it easier to assess Faculty development Geriatrics in High Stakes Examinations Geriatrics requirements for accreditation Advocacy

6. That Was the Year That Was2010 Leveraging Geriatrics Medical Education

7. Making it Easier to Teach Leverage Point

8. Geriatric Competencies by Learner Anesth ENT Ob-Gyn Surgical Specialty Residents Geriatric Fellows Residents Sub-Specialty Fellows Medical Students Practicing MDs Emergency Medicine Internal Medicine Family Medicine Surgery

9. Falls Competencies Med Student: Ask about falls, watch the patient rise from a chair and walk, record and interpret In a faller, construct a differential diagnosis and evaluation plan to address the multiple etiologies identified. IM/FM Resident: Yearly screen all ambulatory elders for falls or fear of falling. If positive, assess gait and balance, evaluate for potentially precipitating causes, and implement interventions In hospitalized medical and surgical patients, evaluate at admission and regularly for fall risk……and institute appropriate corrective measures

10. Falls competencies Geriatric Fellow: Recognize abnormal gaits associated with specific conditions, and perform and interpret common gait and balance assessments. Conduct an appropriate evaluation of patients who fall, implement strategies to reduce future falls, fear of falling, injuries, and fractures, and followup on referrals. Implement strategies to reduce falls in patients in all health care settings.

11. Dentistry Medicine Nursing Nutrition Occupational Therapy Pharmacy Physical Therapy Physician Assistants Psychology Social Work Partnership for Health in Aging (PHA) Competencies

13. Still Need to Get Teaching Materials Geriatrics Genetics/Genomics NO TIME!! QI projects End-of-Life Care EBM ACGME Competencies Cultural Competency

14. Blended Learning • LEARNERS: acquire knowledge prior to face time with faculty • FACULTY: with student on knowledge application • Direct observation and modeling • Formative feedback on performance • Iterative performance till competency achieved

15. The Portal of Geriatric Online Education www.POGOe.org “One-Stop Shopping” for Geriatric Education Materials Sponsored by the Association of Directors of Geriatric Academic Programs through a grant from the Donald W. Reynolds Foundation, managed by the Mount Sinai School of Medicine

16. POGOe Products

17. POGOe Collaborations • Hartford Geriatrics Nursing Initiative (HGNI) • formalized 2010 • 11 products posted, more to come (113 potential) • Geriatrics-for-Specialists Initiative (GSI) • began 2003 • 7 posted products thus far

18. G-Wiz (Geriatric Wizard) • Identifies the best POGOe products for each medical student competency

19. G-Wiz (Geriatrics Teaching Wizard)

20. POGOe Product Reviews • JAGS e-learning section • Examples: • New Mexico's  Health Care Decision Making • Harvard’s Web-Based Module to Train and Assess Competency in Systems-Based Practice • Arizona’s Elder Care Provider Fact Sheets • Editor’s Choice on POGOe and in monthly newsletter

21. Video Library

22. ReCAP

24. POGOe Works in Progress

25. Virtual Clerkship • Medical student curriculum that students can use independently • Clerkship Directors will be able to: • Customize or use as pre-packaged curriculum (plug and play) • Track student usage • View statistics page capturing student activity • Pilot funded to develop 1 domain

26. Updated Search

27. At This Meeting • Town Halls • Geriatric Fellows Competencies • POGOe Users Group • Feedback on POGOe: help make it suit your needs • Input on virtual clerkship and other features • POGOe booth: (Beta) Test drive new search engine and get a chocolate treat!

28. Making it Easier to Assess Leverage Point:

29. The Reynolds Trans-Institutional Evaluation Group (R-TIEG) • Anne Fabiny (Harvard) • Jim Powell (Vanderbilt) • Donna Rosenstiel (Vanderbilt) • Renee Porier (Vanderbilt) • Gail Sullivan (U Conn) • Brent Williams (Michigan)

30. R-TIEG: ‘Best’ ways to assess each student competency • Spearheaded by U Cal consortium • Knowledge: shelf-like exam. • Performance in practice • Direct observation: mini-clinical exam (Cex) checklists. • Clinical skills • Objective Structured Clinical Exams (OSCEs), standardized patients, simulations, etc.

31. TIREG: Assessment Tool Rating • Developed an assessment rating instrument • Beta tested the instrument • Now- Using the instrument to evaluate existing assessment tools (Looking for volunteers) • Next steps: Map tools to competencies • Will be available (and searchable) on POGOe (estimated date: AGS 2011)

32. POGOe Assessment Tools Mostly Knows, Knows How, Shows Policy for securing and releasing assessment materials Some materials not directly accessible on POGOe “Human Firewall” released upon request and verification of requester’s faculty status

33. Learner Assessments

34. ACGME Milestones ACGME mandate Develop milestones of competency Help to interpret the ACGME core competencies for each specialty Assist with the assessment of competency Provide specific feedback to learners regarding progression towards competence.

35. IM Milestones ACGME Competency Patient Management Developmental milestone Provide appropriate preventive care and teach patient regarding self-care Approximate timeframe by which this should be achieved 6 months General Evaluation Strategies Chart review

36. IM/FM Competencies / Milestones Relationship Brent Williams work 11 competencies are specific instances of one or more Milestones 11 competencies not directly addressed identify unrecognized problems that are NOT a complaint or presenting problem, in individual encounters with patients at high risk. case-finding and targeted risk assessment for syndromes are rarely addressed in the milestones

37. IM/FM Competency / Milestones Relationship 4 competencies are not reflected in Milestones. Advance care planning. Determining decision-making capacity. Actively identifying and addressing patient-specific barriers to communication. Identifying with the patient, family and care team when goals of care and management should transition to primarily comfort care.

38. How does the milestone crosswalk make it easier to teach and assess geriatrics? ABIM interested in having residency programs pilot this as competency-based learning

39. Internship OSCEs: Geriatric Stations • University of Michigan • 15- minute encounter of a patient about to be discharged from the hospital focusing on two dimensions: • Geriatric Assessment (ADLs, IADLs, Mini-cog, depression screen, continence, falls) AND • Communication skills (separate rating, verbal and non-verbal communication skills, getting glasses on, etc.)

40. At This Meeting • Evaluator’s Toolbox working group • Assessment Fair • NBME workshops • Clinical Skills sessions • Learner Assessments 101 • 360 assessments • DDx of Delirium: training to competence Speak with Anne Fabiny or Brent Williams if interested in reviewing Assessment tools with the new rating instrument

41. Faculty Development Leverage Point

42. GACAs 2010 • 105 eligible applications received • 80 new; 25 renewals • 68 funded • 66 MDs, 1 psychology, 1 physical therapy.  • 56 new; 12 renewals • Assuming level funding, the next round of GACAs will be in 2015.

43. Faculty Development Possibility • Adapting ABIM Faculty Development course in assessment to geriatric competencies

44. Geriatrics in High-Stakes Examinations Leverage Point

45. Changes to ABIM Internal Medicine Examination • Blueprint changed • Previously 10% cross content geriatrics, 0% primary geriatrics • Now geriatrics is a primary content area. • 4% of the test • Will test geriatric syndromes and the care of geriatric patients, rather than just diseases in older adults. • 8% of the test will be cross content geriatrics

46. 2010 Exams Reviewed • NBME subject (shelf) exams • USMLE • Step 1 • Step 2 Clinical Knowledge • Step 2 Clinical Skills • Step 3 • Computer-based simulation cases • ABIM • ‘Geriatric’ pool (cross-content items)

47. 2010: Exam Reviewers • Christine Arenson • Lynn Bickley • Jan Busby-Whitehead • DanelleCayea • Anne Fabiny • Lisa Granville • Bree Johnston • Reena Karani • Rosanne Leipzig • Sharon Levine • Joanne Schwartzberg • Amit Shah • Gail Sullivan Funded by AMA

48. A Geriatric Question involves one of the 26 geriatrics competencies, and/or involves one of ABIM’s 16 geriatric syndromesand/or involves a “geriatric” disease/condition: not covered by a competency, predominantly affects 65+, testing what is typically seen in an older adult, if the examinee gets it wrong – could hurt an older adult Eg, differential diagnosis of abdominal pain in an older adult

49. ABIM Geriatric Syndromes Constipation and fecal incontinence Delirium Dementia Depression Dizziness / lightheadedness Falls and gait disorders Frailty Hearing loss Immobility Malnutrition Pain Pressure ulcers Sleep disorders Urinary incontinence Vision impairment Failure to thrive • From ABIM Geriatric Medicine Maintenance of Certification Examination Blueprint, http://www.abim.org/pdf/blueprint/geri_moc.pdf accessed 8/10/2010, with modifications to include content from the Blueprint Geriatric Psychiatry and Functional Assessment and Rehab categories

50. Geriatric Diseases PMR/TA Osteoporosis (OP) BPH Examples of others being considered Mesenteric ischemia AAA Volvulus Myasthenia Gravis Multiple Myeloma