Stanford University Geriatric Education Resource Center  

HB65: Generalist Faculty Development Program in Geriatric Medicine

Table of Contents.

Introduction 2 Program Elements 4 Recruitment of Faculty 6 Small Group Sessions Session 1: Overview 7 Session 2: Learner-centered teaching in small groups 9 Session 3: Giving and receiving feedback 16 Session 4: Precepting one-on-one; Strategies to improve geriatrics teaching 25 Session 5: Mental status assessment 31 Session 6: Falls evaluation 51 Session 7: Urinary incontinence 62 Session 8: Review of geriatric topics; Faculty presentations of individual projects 75 Session 9: Faculty presentations of individual projects 76 Evaluation 77 Final Notes 88

Introduction

A significant barrier to geriatric education of residents and other trainees is the paucity of attending physicians with the knowledge, skills, and confidence to discuss geriatric topics during informal and formal teaching sessions. Inadequate numbers of teaching faculty with the Certificate of Added Qualifications in Geriatrics (CAQ) exist today and for the near future. In addition, the acquisition of a CAQ does not itself ensure that attending physicians will successfully teach pertinent geriatric issues, particularly in all clinical settings.

Many residency program directors state that their residents learn geriatrics because many of the patients cared for by the residents are older. This is akin to saying that trainees learn cardiology because all of their patients are equipped with a heart. Trainees acquire skills, knowledge, and attitudes when relevant clinical issues are addressed regularly through both clinical experiences and formal (reading, conferences) teaching. For geriatric medicine to be learned 'in the bone,' it must be taught in relevant settings - clinic, hospital, home, and nursing home - and by a broad spectrum of attending physicians - generalists and subspecialists, as well as geriatricians.

With limited numbers of geriatricians, medical schools and residency programs may need to create programs for faculty development in geriatrics. For family practice and internal medicine programs, faculty development is of critical importance. In these programs, generalist teachers often have substantial teaching responsibilities, contacts with trainees, and potential to influence future behavior. The heavy clinical schedule of many generalist teachers allows little opportunity to participate in longitudinal educational programs, particularly those that involve clinical experiences. Therefore, a realistic faculty development program will intrude minimally upon ongoing responsibilities.

During previous programs we noted that generalist teachers often know more geriatrics than is demonstrated by observing their interactions with individual older patients or precepting sessions with residents, or by reviewing charts. That is, written test scores of geriatric knowledge are reasonably good, with a few exceptions (e.g., urinary incontinence, falls evaluation). In addition, attitudes about elders are positive. Generalist faculty have often participated in CME-type courses or seminars at national meetings on geriatric topics. Generalist faculty are not likely to have had equal exposure to experiential educational activities. Therefore, the application of knowledge, and the acquisition of 'habits' conducive to excellent quality of care for older persons became the focus for the University of Connecticut faculty development program.

As generalist attendings are often judged on their teaching skills and derive great personal satisfaction from functioning as role models and mentors, we decided to blend two programs, a course on teaching skills and one on geriatric topics. This combining of educational goals met several needs: 1) generalists' strong interest in teaching skills, 2) our goal that attendings with enhanced geriatric knowledge also would be well-equipped to teach that content, and 3) Program Director and Department Chair interest in the most efficient use of scarce faculty time. At a minimum, our generalists were freed from clinical or other duties to attend the program over a nine month period; some physicians had additional time freed to a maximum of one half day per week.

The most frequently asked question by participating generalists was, "What does a geriatrician do differently with older persons than we do?" Program clinical experiences emphasized observation of a skilled geriatrician during clinic and acute hospital rounds. The formal teaching sessions focused on review of geriatric content, strategies to teach the content, role play teaching the content, and other confidence-building tactics. To maximize long-term success, we also worked with each generalist participant to "geriatricize" his/her main teaching site through the addition of suitable instruments, handouts, prompt/flow sheets, and other materials relevant to the patient population at that site. At some sites, this process became part of a quality improvement program for adult care.

Program Elements


I. 5 Half-day Geriatric Clinic Sessions


Faculty select one, or at most two, different clinics for all five sessions. To this point, faculty have given two reasons for choosing a particular geriatrician to observe: 1) reputation as skilled teacher of geriatrics or 2) geriatrician works in same clinic system as the participant, and therefore is available for future follow-up questions and patient referrals. Clinics utilized in the program have included: geriatric primary care, geriatric assessment, and osteoporosis clinics. The schedule is determined by mutual convenience, and most visits occur over a three to four month period. An essential component for success is having the sessions scheduled by support staff, who ascertain the availability of geriatrician and generalist, and send to each participant: the final clinic sessions schedule, directions to the clinic site, estimated travel time, and phone number. Busy faculty do not have the time to set up the clinic sessions; if left to their own devices, clinic sessions may be postponed indefinitely.

II. 2 Acute Hospital Rounds with a Geriatrician

Faculty are scheduled to round with a geriatrician at their teaching hospital site, unless the hospital has no faculty geriatricians. In this case, faculty choose a preferred site and geriatrician. These latter choices have been based on perceived teaching reputation of the geriatrician in an acute care setting. Each observed rounds session lasts approximately 90 minutes and is scheduled at mutual convenience, again by support staff.

III. 9, 90-Minute Conferences on Geriatric Content and Teaching Strategies

Faculty meet as a group with the geriatric faculty development program director for 90-minute interactive sessions scheduled when all participants can attend, usually nine evenings over a six month period. Faculty have input into both the content and order of the sessions. The sessions contained in this guide should be used as a starting point for discussions with your generalist faculty, and modified as needed to suit the needs and interests of the group. Some groups will prefer greater or lesser attention to teaching skills and geriatric content; some may request additional time to review particular topics. Whenever possible, these interactive sessions should address the issues relevant to the primary teaching sites of the participants.

IV. Individual Projects

Each participant, after discussion with the geriatric faculty development program director, selects at least one teaching project to complete during the nine month program. The criteria are: 1) project concerns geriatric topics or older patients, 2) project can continue to be used in teaching or career development beyond the duration of the development program, and 3) the project will enhance the teaching credentials or promotion potential of the participant. Examples of selected projects include: grand rounds, ambulatory conferences on geriatric topics, assessment materials and flow chart for resident continuity clinic older patients, structured home assessment program for targeted patients from resident continuity clinic, and quality improvement project on use of advance directives in resident continuity clinic.

V. Participation in Evaluation Activities

Evaluation is exceedingly useful to improve the program for future participants. We ask faculty to participate in a number of evaluation activities during the program. As faculty time is at a premium, verbal feedback can be obtained over the telephone through use of a structured instrument administered by knowledgeable but neutral program faculty. Pre or posttests can be done during the small group conferences or at the end of a clinic session. Evaluation staff or program coordinator can observe the faculty participant in his/her own clinic setting during patient visits or precepting sessions. Clinic charts also can be reviewed.

User Comments

I liked the cases and the pretest and posttest for generalists.

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