Meeting Geriatric Competencies: Are Internal Medicine Residency Programs in New Jersey Meeting Expectations for Quality Care in Older Adults

Abstract

There has long been recognition for improved education and training in aging and geriatrics. As the number of older individuals in the United States increases, with 20% being older than 65 years by 2030, it will become increasingly important for internists and medical subspecialty trainees to have proper training in the care of older adults. A survey was developed and administered to Internal Medicine Program Directors, to perform an educational needs assessment. The survey was administered during the beginning of the 2015 academic year via email. The survey assessed general program characteristics, details regarding required geriatric and palliative medicine teaching, opportunities for electives, barriers encountered at each training site, and future recommendations for improving the structure of resident education. Analysis of survey responses indicated that geriatric and palliative care education is lacking. Although all training programs provided some aspect of geriatric and palliative medicine training to internal medicine residents, only 27% of training programs had a formal curriculum in geriatric and palliative medicine. The majority had an informal curriculum. Very few programs reported using a multimodality approach; most used isolated experiences in either an inpatient or an outpatient setting. Although all residency directors believed curricular developments in geriatric and palliative medicine were important, very few have available faculty needed to facilitate curricular improvements. Almost all identified that they would use a restructured curriculum if it were readily available. Investment in developing content and a standardized curriculum in geriatric and palliative medicine would be very valuable and well received in New Jersey.

Keywords

internal medicine residency education training curriculum

Introduction

Across the United States today, there is a need for education reform in geriatric and palliative medicine. Several years ago, the American Geriatrics Society (AGS) highlighted the need to develop curricular content in the following specific areas: epidemiology and physiology of aging, geriatric clinical pharmacology, geriatric assessment, geriatric-oriented screening, detection and prevention, common geriatric syndromes, and symptom management and supportive care, with particular attention to the care of the dying (Williams et al., 2010).

Many adults today are living longer and are developing chronic conditions that limit one’s ability to perform many of the activities of daily life. Older adults thus have increased need for health care services, while the number of geriatric physicians practicing in the United States declines each year (Section for Enhancing Geriatric Understanding and Expertise Among Surgical and Medical Specialists [SEGUE] & AGS, 2011). Many medical schools and residency programs have struggled to integrate geriatric knowledge and skills into curriculum and clinical processes of training. Surveys and self-ratings of medical residents have highlighted perceived deficiencies in geriatric care (Reuben et al., 2009; Sedhom & Barile, 2017; Warshaw, Murphy, Kahn, Hejduk, & Singleton, 2003; Williams et al., 2010). As a consequence, primary care and specialty health care professionals, who care for a large number of older patients, continue to feel inadequate when caring for older adults (SEGUE & AGS, 2011). In addition, the Accreditation Council for Graduate Medical Education (ACGME) does not specify required geriatrics training for fellowship programs preparing specialists who are likely to care for many older adults, such as cardiology and oncology (Kovner, Mezey, & Harrington, 2002).

Medical residents are the physicians who spend the most time providing direct geriatric care in teaching hospitals. However, little is known regarding the quantity or quality of geriatric training for residents in internal medicine programs in New Jersey. The Dartmouth Atlas Project suggests poor quality in the care of older adults in the State of New Jersey. Almost one third of chronically ill Medicare beneficiaries in the state are admitted to intensive care during their final hospitalization (“Dartmouth Atlas: Overtreatment Still Common,” 2008). In addition, patients received more aggressive care in the final 6 months of life, have higher utilization of medical specialists, and fewer referrals to hospice care when compared with matched cohorts across the country (Keating et al., 2016). In fact, New Jersey boasts the highest level of spending during the last 2 years of life—almost US$40,000 per person, almost double the national average (Keating et al., 2016).

Previous studies have shown that residents are often unaware of the many issues related to care of older adults (Fernandez, Callahan, Likourezos, & Leipzig, 2008). Because geriatric clinical training is not required for medical students in the United States, many graduate without an essential knowledge base. At the same time, medical education shifts toward competency-based attainment. The goal transitions from what should students and residents learn, to how they perform (Irby, Cooke, & O’Brien, 2010). For clinician educators, the changing landscape is concurrent with increased demands for clinical productivity, further decreasing time allocated for teaching (Mehta, Hull, Young, & Stoller, 2013).

Residency provides great opportunities to influence care and may alter lifelong practices (DeVita, Arnold, & Barnard, 2003). Understanding how residents approach the care of older adults is a critical step to optimize and improve quality of care. It is of great need within the state of New Jersey—a state with fragmented care, a paucity of primary care providers, and very few certified geriatrician or palliative care providers. Many residents will serve as educators of future health professional trainees, patients, and caregivers; training programs must ensure adequate training in the care of older adults. Therefore, to assess if medicine programs were addressing these educational needs, a survey-based study was performed.

Method

A survey examining the need for geriatric and palliative medicine content for internal medicine residency programs was developed. The survey inquired about program characteristics, including local faculty expertise and presence of a geriatric- and palliative-specific education. Care domains included were identified by geriatric faculty input, published minimum competencies for internal medicine, and a literature review on geriatric education for trainees (Cumbler, 2009; Podrazik et al., 2008). Respondents were then asked a series of questions focused on four domains, including (a) rating agreement regarding the importance of a geriatric and palliative medicine curriculum and, if available, whether it would be utilized; (b) a description of current geriatric and palliative medicine curriculum, if any, at their program; (c) identifying and prioritizing the most important topics for such a curriculum; and (d) recommendations regarding the format of the curriculum to enhance the uptake and utilization by medicine residents. This survey was distributed during the 2015-2016 Academic Year.

Data were collected using self-administered web-based survey instruments. The survey was developed with input from two geriatricians. Medians were used as measures of central tendency. Categorical data were described as frequencies and percentages. Chi-square testing was used to calculate differences in proportions. A p value of 5% was considered statistically significant. Analyses were performed using SPSS version 10.1.0.

Results

There were a total of 19 surveys distributed, of which 14 responded with a completed survey, representing a response rate of 74%. With the 14 respondents, 74% of the training programs in New Jersey were represented (Table 1). The respondents were all either Program Directors or Associate Directors (71% and 29%, respectively). They were predominately male (64%). The majority, 79%, of training programs represented had some institutional faculty expertise or interest in either geriatrics or palliative medicine (Table 1). None of the programs offered the possibility of a geriatric or palliative medicine specialty-training pathway or track.

Table 1.

Demographics of Programs Surveyed (N = 14).

	%
Role
Program director	79
Associate director	21
Gender
Male	64
Female	36
Institutional faculty expertise and availability
Training in geriatrics or palliative medicine	50
Interest in geriatric medicine	29
None	21

In examining the curricular content of these programs, the survey revealed that only 27% of training programs had a formal curriculum for geriatric and palliative medicine (Table 2). The majority (73%) had an informal curriculum. Those programs with a geriatric and palliative medicine curriculum most often used clinical experience only, and rarely a multimodality approach (29%) consisting of a combination of clinical experience, journal clubs, and lectures/case-based conferences. Only one program had a formal curriculum regarding communication techniques at end of life and how to deliver bad news.

Table 2.

Geriatric–Palliative Medicine Curriculum Needs Assessment (N = 14).

	%
Geriatric and palliative medicine curriculum
Formal	27
Informal	73
Current approaches to teaching geriatric and palliative medicine
A. Clinical experience only	64
B. Reading/journal club only	0
C. Lecture and case conferences only	7
Mixed A and B	0
Mixed A and C	7
Mixed B and C	0
Mixed A and B and C	22
Internal medicine curriculum should increase time dedicated to geriatric and palliative medicine
Agree	92
Disagree	8
Would use a geriatric and palliative medicine curriculum as part of training program if available
Agree	92
Neutral	8
Disagree	0
Important geriatric and palliative curriculum topics	Important	Rank in top 3
1. Evidence-based guidelines of geriatric management	92	92
2. Communication skills training at end of life	92	100
3. Pharmacodynamics and aging	86	92
4. Assessment of the geriatric patient	64	48
5. Biology and physiology of aging	57	36

Moreover, almost all program directors agreed that they would like to increase geriatric and palliative medicine training time and that both are among the most important components in internal medicine residency training. Ninety-two percent would use a curriculum if it were available (Table 2). In terms of important topics that should be covered in a geriatric and palliative medicine curriculum, the strongest emphasis was placed on evidence-based guidelines of geriatric management (92%), communication skills training at end of life (92%), and pharmacodynamics and aging (86%), assessment of older patients presenting to the hospital (64%), biology and physiology of aging (57%), and recognizing geriatric syndromes (42%). Interestingly, very few rated prognostication as important. Interestingly, 92% of respondents felt a web-based curriculum would be an effective means of delivery.

Discussion

This study demonstrates that most internal medicine residency directors (a) believe improving the curriculum in geriatric and palliative medicine is important and (b) would use a curriculum if it were readily available. Unfortunately, very few have faculty with either training or interest in geriatric and palliative medicine that could facilitate innovative or improved curriculum delivery. Most programs incorporate training and education with respect to older patients only informally, and primarily through either clinical exposure or a combination of clinical exposure with occasional journal clubs and/or case conferences. Clearly, there are topics that would be very relevant to any internist or medical subspecialist in practice or at an academic center that could and should be addressed via a geriatric- and palliative-based curriculum.

With today’s changing educational landscape, there are ample resources, instructional, and assessment materials that allow educators to focus more on knowledge application than knowledge acquisition. Innovations in education should similarly focus on teaching geriatrics and palliative care in ways that meet learners’ needs in coordination with competency-based metrics (Borleffs & ten Cate, 2004; Fok & Wong, 2014; Holmboe et al., 2017). There will never be enough skilled geriatricians or palliative care providers to care for the expanding population of older adults. As our results are reflective of other training deficiencies nationwide, the approach to training and marketing of the discipline needs to be reconsidered to adequately care for the rising population of older adults (Kolb & Weißbach, 2015; Warshaw et al., 2003).

We support processes that abandon attempts to increase the numbers of board-certified geriatricians and palliative care providers. Focus should instead be shifted toward developing an elite workforce that can teach these principles to all health professionals. All providers should attain a level of specific geriatric competency as applicable to their field of interest. Subspecialists should similarly advocate for research and trials specific to a geriatric population. Geriatric champions have increasingly taken the responsibility for teaching their trainees core geriatric content and providing quality care for older adults (Litrivis & Smith, 2011; Morrison & Liao, 2008; Solomon, 2010). In addition, accrediting integrated fellowships can create pipelines for such leaders. Internal medicine programs could similarly develop geriatric and palliative care tracks to promote leaders in the field.

Within the state of New Jersey, only one fellowship in geriatrics exists, despite the majority of patients being above the age of 65 years (“Dartmouth Atlas: Overtreatment Still Common,” 2008). To obtain specialty palliative care training, providers in New Jersey need to train elsewhere. Underserved states and underserved areas remain underserved. For trainees interested in obtaining expertise, geographical flexibility may be limited, thus limiting the number of physicians willing to undergo additional training. Academic geriatric and palliative care fellowships may consider sharing positions and network with programs in need to provide multifaceted training in diverse settings (Simpson, Leipzig, Sauvigné, & Donald W. Reynolds Geriatrics Education Collaborative, 2017). Such a network can build sustainable geriatric programs in areas underserved by geriatricians, such as the state of New Jersey.

There are many limitations to this study. It used a convenience sample of program directors in a single state, which may be a biased sample. Because it was an anonymous survey, nonresponders could not be identified to compare the characteristics of respondents with nonrespondents. Nevertheless, the issues highlighted from this survey are consistent with the result of surveys in other internal medicine subspecialties (Callahan et al., 2017; Chan, Yu, Leung, Chan, & Hui, 2016; Cumbler, 2009; Podrazik et al., 2008; Ritchie et al., 2010; SEGUE & AGS, 2011). In addition, several community programs were surveyed which may not have all of the resources of a large academic center, but are still responsible for training many future internists and subspecialists.

Ideally, geriatrics should receive the same attention and commitment as is given to pediatrics early on in medical school. Geriatric assessments, geriatric syndromes, differentiating dementias, long-term care, issues with caregiving, surrogate decision makers, and community care are important in the future of almost all physicians. There is no greater specialty to communicate and teach systems-based practice, communication and interpersonal skills, and professionalism.

As the proportion of older individuals in the United States continues to increase, it will become increasingly important for internal medicine trainees to have directed curriculum in geriatric and palliative medicine. As our survey suggests, many programs may not have access to geriatricians or internists with geriatrics training. The development of portable online content should be considered an area of need. Survey participants supported the development of web-based curriculum that was easily accessible.

The results of this survey suggest that despite increased awareness on the side of medical education, not much has changed in the past 30 years (Cox, Smith, & Lichtveld, 2012; Williams et al., 2010). There exists a dire need to improve training in geriatric and palliative medicine. Leaders in geriatric and palliative medicine need to work with the American Board of Internal Medicine to ensure that certification and re-certification exams include questions specific to the issues related to the older adult patient. Evaluations and feedback of recent graduates should be encouraged to identify topics that would be most helpful. This information serves as a needs assessment specific to the state of New Jersey, but likely generalizable across the country. There is still work to be done to improve the care of older adults that resident physicians provide. We hope that our results motivate faculty to continue to develop and disseminate useful geriatrics curricula and encourage health care systems to incorporate standards specific to the care of older adults into daily work.

Footnotes

Authors’ Note

All authors contributed equally in the writing of this article. Written consent was obtained from the participants in the study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Ramy Sedhom

Author Biographies

Ramy Sedhom was chief resident at Rutgers Robert Wood Johnson Medical School in the internal medicine program. He is currently a first year oncology fellow at the Johns Hopkins School of Medicine.

Daniel Sedhom is a third year resident in internal medicine at Rutgers Robert Wood Johnson Medical School.

David Barile is the director of Geriatric and Palliative Care at Penn Medicine, University Hospital of Princeton at Plainsboro. He is also the founder of a non-profit, Goals of Care Foundation.

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