July 23, 2018 12:05 pm Sheri Porter – Are America's primary care physicians-in-training ready to face a tidal wave of aging patients? An article titled "Assessing Resident Attitudes and Confidence After Integrating Geriatric Education Into a Primary Care Resident Clinic" that was published in June in The American Journal of Medicine tackles this issue.
In it, the authors detail the outcomes of a project that explored a relatively easy and cost-effective way to help primary care residents become more comfortable with and knowledgeable about providing health care to their older patients.
In their introduction, the authors point out that the Institute of Medicine (now the NAtional Academy of Medicine) sounded the alarm in 2008 with the release of Retooling for an Aging America: Building the Health Care Workforce, a report brief that called for more geriatrics-trained health care professionals.
Now, a decade later, U.S. Census Bureau calculations indicate that by 2030, one in five U.S. residents will be age 65 or older.
Managing the health needs of geriatric patients is part of the continuum of care family physicians provide to their patients. AAFP President Michael Munger, M.D., shown here with patient Thelma Maze, is no exception.
John Moriarty, M.D., an associate professor of medicine at Yale School of Medicine in New Haven, Conn., and program director at the Yale Primary Care Internal Medicine Residency Training Program, co-authored the article. As a general internist, Moriarty sees patients and teaches residents in both the outpatient clinic and hospital settings.
He told AAFP News that the skills outlined in the article are important to internal medicine- and family medicine-trained physicians. "Learning targeted at common geriatric syndromes would be very valuable for anyone in practice with patients over the age of 65," he said.
Moriarty lamented the imbalance between the country's growing aging population and the insufficient number of clinicians trained to provide geriatric care.
"Primary care providers are on the front lines and will be the initial point of contact for many patients with geriatric syndromes; thus, having some basic knowledge, skills and attitudes in geriatric principles will aid in initial geriatric assessments by these frontline providers," he said.
In 2015, Yale and its community partners were selected to participate in a three-year Geriatric Workforce Enhancement Program funded in part by the Health Resources and Services Administration's Bureau of Health Workforce.
The project, dubbed the Connecticut Older Adult Collaboration for Health (COACH) took place at the Yale Primary Care Residency Program's continuity clinic and included the integration of geriatrics curriculum and geriatrics point-of-care teaching.
Residents received a didactic curriculum component that included 30-minute small-group lectures on core geriatric topic areas described as mobility and cognitive assessment, medication management, Alzheimer's disease and related dementias, and patient preferences about goals of care.
In addition, a geriatrics attending physician was embedded in the clinic for one half-day a week during the academic year to participate in clinical interactions with patients older than 65. As a co-preceptor, this physician added to a patient's care plan and provided observations, feedback and teaching to residents.
As part of the program's evaluation process, residents responded to follow-up survey questions in which they rated their attitudes toward geriatric patients and their confidence treating those patients before and after exposure to the COACH project.
Authors noted that after participating in the program, residents' perceptions about older patients changed. Researchers wrote: "Fewer residents agreed with the statement that medical care for the elderly uses up too many resources" and "other attitudes toward older adults remained positive."
Regarding their level of confidence treating these patients, residents' confidence after participation improved significantly in the following areas:
The only area in which improved resident confidence did not reach a level of statistical significance was in conducting assessments of geriatric patients with cognitive impairment, a finding Moriarty theorized was due, in part, to the "relatively high baseline confidence in this area by our residents."
In summing up the model's potential for residency education, the authors wrote, "Our model is unique in that it evaluated resident education in a longitudinal primary care environment. This model involved relatively few resources, requiring only four half-days a month … of geriatric teaching time and limited material costs," making the model "feasible even in resource-limited settings."
Moriarty said he was not aware of any residency programs that had incorporated the kind of training outlined in the study. "I would like to see more programs focus geriatric training in ambulatory settings and less training in inpatient settings, given that the majority of older patients are seen in the ambulatory area," he noted.
Former AAFP President Rick Kellerman, M.D., serves as professor and chair of the Department of Family and Community Medicine at the University of Kansas School of Medicine-Wichita. As such, he has overseen family medicine education for medical students -- as well as three family medicine residency programs sponsored by the medical school -- for more than two decades.
In an interview with AAFP News, Kellerman agreed that all medical specialties are seeing more patients age 65 and older, both in the office and the hospital setting, due to national demographic changes. However, "as a family physician, I view my older patients as just part of the continuum within the family," he said.
"Family physicians do, of course, follow specific screening guidelines for their older patients, but the family medicine perspective is unique in that we don't segment older patients into one group, babies into another. It's just a philosophical difference."
Kellerman shared that even as a resident, he's always enjoyed his older patients, but it wasn't until he aged a bit himself that he really began to appreciate them.
"When you're in medical school at age 26 or so, it's hard to fully appreciate the contextual and quality-of-life issues that are important to your older patients," said Kellerman. "For instance, I have a female patient right now who has urinary incontinence. A resident might just focus on treatment with medication or surgery. But I can see how that one problem is forcing this woman to be a shut-in."
Kellerman recognized the challenges of recruiting vibrant, healthy older people into residency program clinics. "Patients don't like their doctors to leave every three years. Unfortunately, if residents' only experience with aging patients is with those in long-term care settings, the residents may not gain a broad view of the needs of patients 65 and older," he said.
"Most seniors live in their own homes," he added.
"The rewards of seeing older patients come with managing challenges that include multiple medical problems, medication interactions and social problems -- and all within the context of what is important to the patient," said Kellerman.
Study authors referred to the Accreditation Council for Graduate Medical Education (ACGME) requirements for internal medicine training in geriatrics as "minimal," saying the ACGME calls for "only a requirement for 'an assignment in geriatric medicine.'"
ACGME requirements for family medicine are more specific, said Kellerman.
He pointed out that those requirements include a statement that a total of 165 patient encounters -- 10 percent of the 1,650 encounters required in a resident's three years of training -- must be with patients 60 or older.
Kellerman also noted the philosophical differences between family medicine and other medical specialties. "Family physicians see patients within the context of the family and the larger community," he said.
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