Stanford University Geriatric Education Resource Center  

HB70: Cluster Group Process for the Collaborative Development of Faculty and Curriculum in Primary Care Geriatrics

Table of Contents.

The importance of primary care geriatrics training 3
Impediments to innovation 3
The cluster group process - a programmatic corrective 4
Who should comprise the cluster group? 4
Are some types of individuals more suited than others to participating in a collaborative exercise such as a cluster group? 5
How often will the cluster group meet? 5
What happens at the first meeting? 5
How should the geriatrician specialist conduct the first meeting? 6
What is the medical educator's role at cluster group meetings? 7
What happens at the second meeting of the cluster group? 7
What happens after the second meeting? 8
What happens at the third meeting? 8
What are some of the danger signs that the cluster group process is not working? 9
What can be done about a dysfunctional cluster group? 9
What does the cluster group process ultimately produce? 10
Table 1: "Must Know" Principles of Functional Assessment 11
Table 2: What's a Meeting? 12
Table 3: Positive and Negative Qualities in Meetings 13
Table 4: Why Did Mr. Smith Fall? 14
Table 5: Symptoms of Resistant and Obstructionist Behavior 15
Appendix: Cluster Group-produced Curriculum Materials
Depression and Behavioral Disturbances in Dementia

"Must Know" Concepts X-1
Key Content Outline X-2
Portfolio of Cases X-8
Annotated Bibliography X-9

The importance of primary care geriatrics training
Most residency training programs in the US pay scant attention to the practice of medicine for the elderly patient-- that is, to the nuances of presentation and diagnosis and to drug therapy and polypharmacy, much less to aspects of treatment that lie beyond the realm of traditional internal medicine, such as geriatric psychiatry, social supports, and rehabilitation. Instead, in most training curricula, geriatrics is tacitly "weaved into the experience," without explicit identity or focus.

The shortsightedness of this approach is evidenced not only by the demographic imperatives of a rapidly aging US population, but also by the emergence of managed care as an organizing principle for delivering health care services to patients of all ages. Nearly all geriatric medical care in the US is currently being delivered by non-geriatrician primary care physicians acting in their role as principal providers, and there is every indication that this trend will continue well into the next millennium.

For the new generation of primary care physicians in-training, therefore, issues of capitation and primary prevention are going to be as important as diagnosis and treatment of their elderly patients. As a group, they will need to know much more than they do now, for example, about elderly patients who fall and how to prevent recurrence. Almost every elder who falls with an injury fell previously without injury. Why does this happen? The question not only has diagnostic but also economic significance. One fall with an injury, and the elderly patient will use a year's worth of capitation in the hospital, for which someone has to pay.

Impediments to innovation
It is a reasonable goal of graduate medical education in the US that primary care generalists (i.e., internists and family physicians) be better trained in how to deliver excellent geriatric clinical care during their three-year core residencies. Yet when chairmen/chairwomen of primary care programs are confronted with the inevitable requests for additional funding or space or staffing, they typically respond, not untruthfully, "But I already have so many other things to add to the curriculum."

One contributing factor is inertia. Most residency training programs remain committed to teaching residents the same way they have always taught them, the same way many of their faculty were themselves taught -- through a series of didactic conferences covering problems commonly encountered by residents on their ward rotations. Yet, as many program administrators report, maintaining a schedule of conferences that is attractive and relevant to both faculty and residents and that transfers the requisite information effectively can be problematic. Some faculty regard presenting at these conferences as an onerous task that receives little institutional recognition. Others find it easier to use cases and material originally prepared for delivery to a more specialized or experience audience, and these are not necessarily well-suited to the educational needs of first, second, and third-year residents.

The pedagogical effectiveness of didactic conferences can also be compromised by the presence of multiple training sites. Standard practice is to ask staff physicians at each teaching hospital to present topics in their field of expertise at their own institution. But without coordination among faculty counterparts, differences in opinion or emphasis as expressed in these lectures can cause confusion among residents and dissension within the training program.

The Cluster Group Process - a programmatic corrective
The cluster group process is intended to address these classic programmatic deficits by providing an organizational framework wherein geriatrician specialists and primary care generalists can work together to create case-based materials that will reinforce and enhance the primary care resident's understanding of core topics in geriatric medicine.

The process assumes that in the typical academic setting most of the teaching is done by generalists who instruct residents at various, scattered sites. The aims of the cluster group process therefore are:

Managing the cluster group process is not akin to scaling Everest. It is easy to do, as well as an educational experience in itself for all members of the group, and also - according to many who have gone through it - a lot of fun.

In addition, successful completion of the cluster group process disproves the contention that important new pedagogical initiatives must await new funds, new space, or new faculty. A great deal can be accomplished by talented faculty leaders who are given clear authority and encouragement by residency program directors to develop innovative instructional programs in geriatrics - as, hopefully, cluster groups convened at your academic institution will demonstrate.

Who should comprise the cluster group?
The cluster group should be comprised of teaching physicians and medical educators who are "stakeholders" in the educational/training process - typically, one or two specialists in a particular field of geriatric medicine; several generalists who recognize the need to improve understanding of geriatrics among residents in primary care medicine and who have themselves expressed an interest in the topic area, and a medical educator who is familiar with your institution's didactic curriculum and can effectively link the case-based teaching materials created by the group to it.

All members join the topic - centered cluster group because they have something to gain by their participation.

The generalists, especially, stand to benefit. As a consequence of their participation in a cluster group, they will, predictably, become known to their colleagues in practice as modest experts in the topic area, and be sought out by peers and trainees as a source of information and advice. Given their felt responsibility to patients and colleagues, they will continue learning about the topic, thus becoming over time if not bona fide experts, then very nearly so.

Are some types of individuals more suited than others to participating in a collaborative exercise such as a cluster group?
Probably, yes. Cluster group members should be individuals who can tolerate ambiguity and conflict, and who are good listeners. They should be able to question each other in order to clarify and extend ideas, and to summarize each other's ideas accurately before elaborating upon them. People who are insistent that their opinion is the only one that matters, or who instinctively tend to personalize disagreements, are usually not well suited to collaborative, interdisciplinary work.

Footer Links: