Resident training in nursing home care: survey of successful educational strategies

Getting out of silos: an innovative transitional care curriculum for internal medicine residents through experiential interdisciplinary learning

BACKGROUND

Care transitions are common and highly vulnerable times during illness. Physicians need better training to improve care transitions. Existing transitional care curricula infrequently involve settings outside of the hospital or other health care disciplines.

INTERVENTION

We created a curriculum to teach internal medicine residents how to provide better transitional care at hospital discharge through experiential, interdisciplinary learning in different care settings outside of the acute hospital, and we engaged other health care disciplines frequently involved in care transitions.

SETTING/PARTICIPANTS

Nineteen postgraduate year-1 internal medicine trainees at an academic medical center in an urban location completed experiences in a postacute care facility, home health care, and outpatient clinics.

PROGRAM DESCRIPTION

The 2-week required curriculum involved teachers from geriatric medicine; physical, occupational, and speech therapy; and home health care, with both didactic and experiential components and self-reflective exercises.

PROGRAM EVALUATION

The curriculum was highly rated (6.86 on a 9-point scale) and was associated with a significant increase in the rating of the overall quality of transitional care education (from 4.09 on a 5-point scale in 2011 to 4.53 in 2012) on the annual residency program survey. Learners reported improved knowledge in key curricular areas and that they would change practice as a result of the curriculum.

CONCLUSIONS

Our transitional care curriculum for internal medicine residents provides exposure to care settings and health care disciplines that patients frequently encounter. The curriculum has shown positive, short-term effects on learners' perceived knowledge and behavior.

Update on teaching in the long-term care setting

Since the advent of the teaching nursing home, made formal in the 1980s, long-term care has been used to teach geriatric medicine. Despite this, national surveys have indicated a need for more training during residency to facilitate the appropriate care for the frail long-term care patient population. In addition to medical knowledge, the long-term care site is appropriate for teaching the Accreditation Council of Graduate Medical Education's core competencies of "practice-based learning and improvement," "interpersonal and communication skills," and "systems-based practice." Program planners should emphasize opportunities for students to demonstrate their skill in one of these competencies.

Perceived needs for geriatric education by medical students, internal medicine residents and faculty

CONTEXT

Traditional methods of setting curricular guidelines using experts or consensus panels may miss important areas of knowledge, skills, and attitudes that need to be addressed in the training of medical students and residents.

OBJECTIVE

To seek input from medical students and internal medicine residents ("trainees") on their perception of their needs for training in Geriatrics.

DESIGN

Two assessment methods were used (1) focus groups with students and residents were conducted by professional facilitators and the transcripts analyzed for areas of agreement and divergence and (2) geriatric medicine experts and ward attendings were surveyed to examine training gaps raised by trainees during Geriatric Guest Attending Rounds.

RESULTS

Trainees perceived training gaps in caring for elderly patients in the areas of (1) recognizing and addressing the complex, multifactorial nature of illness; (2) setting priorities and goals for work-up and intervention; (3) communication with families and with patients with cognitive disorders; (4) assessment of a patient for discharge from the hospital and the services at different sites in which patients may receive care. They recounted feeling overwhelmed by complex patients and social situations while acknowledging the special aspects of connecting with older patients. The gaps identified by trainees differ from and complement the curriculum guidelines set by expert recommendations.

CONCLUSION

Trainees identified gaps in skills and knowledge leading to trainee frustration and potentially adverse outcomes in caring for elderly patients. Development of curriculum guidelines should include assessment of trainees' perceived learning needs.

A national survey on the current status of general internal medicine residency education in geriatric medicine

OBJECTIVES

The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs.

DESIGN, SETTING, PARTICIPANTS

An original survey was mailed to all the GIM residency directors in the United States (N = 390).

RESULTS

A 53% response rate was achieved (n = 206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education.

CONCLUSIONS

A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.

Barriers to treatment: the unique challenges for physicians providing dementia care

Evaluating and treating dementia is intellectually demanding and enormously satisfying. However, physicians providing dementia care also confront unique challenges that cause discomfort and overwhelming frustration unless they are recognized and overcome. Physicians must care for individuals who do not adopt the "sick role." They must establish and maintain rapport with patients while also approaching collateral sources to obtain a complete history. They must develop a complex alliance with the patient, caregivers, community agencies, and other health professionals to provide effective treatment. Physicians must relate "bad news" to several people at once who are unequally prepared for it, while dealing with their own diagnostic uncertainty. Furthermore, physicians must honor patient autonomy and balance it with the needs of caregivers. Since the demands of providing dementia care are not typical of most medical practice, the special attributes needed are often not taught to students or adequately reimbursed by health insurance. The quality of dementia care will improve when strategies that address these aspects of care for patients with dementia are widely adopted.

Using audit to improve senior house officer training

The British Geriatrics Society has described 16 training objectives for senior house officers (SHOs) in geriatric medicine. We have developed these into an audit standard, and in a controlled trial we consider the effectiveness of audit as a means of monitoring and improving SHO training. SHOs from three hospitals were sent a questionnaire asking about the adequacy of formal and informal training for each objective; there was a response rate of 87%. Results were presented at an audit meeting in one hospital, inadequacies of training identified and the hospital's programme of teaching modified appropriately. Two control hospitals remained unaware of the audit findings and were therefore unable to modify their training programmes. Re-audit at six months completed the audit cycle; the control hospitals showing no change between the two audits. In the intervention hospital the adequacy of training over the 16 objectives improved from 59% at first audit to 73% at re-audit. The initial audit had highlighted three target objectives as needing special attention; here the improvement from 38% to 69% was even more impressive, and statistically significant at p < 0.05 on chi 2 test. Thus, although a questionnaire approach is inevitably subjective and affected by SHO satisfaction, the discipline of audit appeared effective in identifying and correcting deficiencies in an SHO training programme.

Medical practice with nursing home residents: results from the National Physician Professional Activities Census

OBJECTIVE

The study describes the prevalence of medical nursing home practice. Further, it examines the extent to which physician characteristics and local county health care resources predict nursing home involvement. This information is relevant to evaluating and devising strategies that address the future provision of medical care in institutionalized long-term care.

DESIGN

A cross-sectional survey.

SETTING

A national sample of all licensed practicing physicians was obtained from a special Professional Activities (PPA) survey conducted by the American Medical Association (AMA) in 1991.

PARTICIPANTS

Respondents were 21,578 physicians involved in direct patient care.

MEASURES

The typical number of hours spent weekly caring for nursing home patients was obtained from the PPA survey, and physician demographics were obtained from the AMA Masterfile. County health care resources were obtained from the National Institutes of Health Area Resources File.

RESULTS

Most (77%) physicians reported spending no measurable time caring for nursing home patients. In all disciplines, a majority of physicians with a nursing home practice spent less than 2 hours per week with patients. Logistic regressions indicted that family practitioners and internists were most likely to have a nursing home practice, but general practitioners were most likely to spend more time in practice. Only 15% of specialists reported having a nursing home practice. Prevalence of practice was greatest among solo practitioners and physicians in partnerships and least among academic and hospital-based physicians and physicians in group practice or employed by the government. Most county of practice resources were not associated or were modestly associated with nursing home practice, but having a nursing home practice became much more likely as the number of nursing home residents increased and hospital beds decreased. A pattern was found for nursing home practice to be slightly less likely as the county's per capita income and the proportion of proprietary nursing facilities increased.

CONCLUSIONS

With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.

Effects of an inpatient geriatrics rotation on internal medicine residents' knowledge and attitudes

OBJECTIVE

The purpose of this study is to assess the effect of a geriatrics-focused acute medicine inpatient rotation and the presence or absence of a geriatrician as attending physician on knowledge about and attitudes toward older patients and the field of geriatrics.

DESIGN

Randomized trial.

INTERVENTION

A 4-week acute care inpatient internal medicine rotation at a university-affiliated Veterans Affairs Medical Center; experiences included caring for acutely ill, older medical patients, interdisciplinary team meetings, geriatrics-based noon conferences, interaction with geriatrics-trained nurse practitioners, and a syllabus of readings on geriatric medicine.

PARTICIPANTS

Postgraduate year 1, 2, and 3 internal medicine residents were randomly assigned to one of three groups: (1) the intervention with a geriatrics-trained internist attending (n = 44); (2) the intervention with a non-geriatrics-trained internist attending (n = 25); or (3) no exposure to the intervention (n = 24).

INSTRUMENTS

Knowledge was assessed using a 35-item test. Attitudes were evaluated using a 24-item questionnaire.

RESULTS

There were no differences among the three groups of residents in pretest knowledge (p = .971, analysis of variance). There was a significant difference in the changes in scores from the pretest baseline among the three groups (group 1 = .030, group 2 = .051, group 3 = -.009; p = .039). Both groups assigned to the intervention showed significant improvement in knowledge (p = .011); the presence or absence of a geriatrics-trained attending physician did not alter the results. Resident attitude scores were generally positive and did not change after the intervention.

CONCLUSIONS

An intensive integrated acute medicine rotation in geriatrics improved residents' knowledge of geriatric medicine. The presence of a geriatrics-trained attending physician was not necessary for this improvement. Residents' attitudes toward geriatric medicine and their geriatrics education were generally positive and were not influenced by this experience.