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General education of physicians in the care of older individuals
Abstract
The population of older Canadians is large and will grow over the coming years. As a group they place unique and substantive demands on the health care system. The general education of Canadian physicians in their care has been a long-standing concern. In this article we review undergraduate, postgraduate (excluding training in care of the elderly, geriatric medicine, and geriatric psychiatry), and continuing medical education. A series of recommendations are made to further the agenda of improved training in the care of older persons for physicians who are not undergoing specialty training in geriatrics.
Objective: Little attention has been given to medical human resources in the long-term care (LTC) sector. Our objective was to seek LTC physicians' opinions about medical services in LTC and strategies for recruitment and retention. Methods: A survey was mailed to 272 physicians currently or previously working in LTC facilities across Canada identified by LTC medical directors. The main outcome measures involved responses to open- and closed-ended questions and Likert-type scales. Results: The response rate was 49%. One hundred thirteen (83.7%) physicians surveyed reported they were currently providing LTC care. The average age of respondents was 50 years. The majority (75.3%) reported satisfaction with their role as LTC physicians, but 82.7% felt that there is a shortage of physicians working in LTC and 45.8% had seriously considered leaving their position. The major sources of satisfaction identified were clinical, and the major sources of dissatisfaction were remuneration for LTC work, on-call coverage, and excessive paperwork. Physicians suggested increases to fee schedules as the main recruitment and retention strategy, although most felt that more exposure to LTC during residency would increase recruitment. The majority believed that working in a teaching nursing home would not increase their work satisfaction. Conclusion: Physicians working in LTC facilities appear to get satisfaction from the work, but many are considering leaving their position. Without an increase in the number of physicians willing to work in LTC, there may be a greater shortage of LTC physicians in the future. The responses provided may be helpful to guide strategies to recruit and retain physicians.
Background: Medical students and residents will care for a growing number of older patients in their future practices. A previous survey (1993) found limited geriatric content in the undergraduate curricula of Canadian medical schools. This current survey was undertaken to update that data and to provide information on mandatory and elective geriatric rotations in residency programs. Materials and Methods: A survey was sent to a designated geriatrician at each Canadian medical school requesting data on undergraduate and postgraduate teaching in geriatrics. Results: The mandatory geriatric content of the undergraduate curricula ranged between 7 and 196 hours, with a mean of 78 hours (65 h in 1992-1993). Eight of 16 schools had a mandatory clerkship rotation supervised by an internist geriatrician, a family physician with extra training/expertise in care of the elderly, or a geriatric psychiatrist. Fifteen family medicine and 15 psychiatry residency programs had a mandatory rotation in geriatric medicine/care of the elderly and geriatric psychiatry, respectively. Geriatrics was a mandatory rotation for six core internal medicine programs. Six neurology, five physiatry, three emergency medicine, and one orthopedic program had required geriatric rotations. Although elective opportunities were widely available, relatively few medical students or residents chose one. Conclusions: Overall, the geriatric content has increased in undergraduate medical curricula in Canada over the past 12 years, but the hours are still limited and there is a wide range across schools. With the exception of family medicine and psychiatry, fewer than half of postgraduate programs require a rotation in geriatrics.
An invitational meeting on the future of geriatrics in Canada was held in Banff, Alberta, on the 19th of April 2007. The purpose of the meeting was to examine the challenges facing the field and explore potential strategies for overcoming them. Participants agreed on eight recommendations for moving geriatrics forward in our country: (1) a national coalition should be established for raising the profile of aging and improving its image; (2) the Canadian Geriatrics Society (CGS) should strike a working group to develop a document identifying what distinguishes geriatricians from other physicians; (3) geriatricians need to join those committees and organizations both within and outside government where funding decisions are made; (4) CGS should determine by appropriate methods what best practices in Canada are for specialized geriatric services and the management of common clinical challenges encountered in older patients such as delirium and falls; (5) CGS should determine by appropriate methods which health outcomes are relevant to the care of older patients and sensitive to the impact of specialized geriatric services; (6) while continuing to allow entry for those with an internal medicine background into subspecialty training in geriatric medicine, the addition of other entry routes into geriatric medicine training programs should be explored; (7) a meeting of the Royal College of Physicians and Surgeons of Canada Specialty Committee in Geriatric Medicine and the College of Family Physicians of Canada Care of Elderly Committee should be held to explore areas of common interest in the education of physicians with additional training in geriatrics; and (8) CGS should review its current expenditures on education and examine their effectiveness. Based on this review, CGS should develop and implement a long-term educational strategy that would include mechanisms to evaluate its effectiveness in promoting recruitment into geriatrics.
At the 2011 Annual Business Meeting of the Canadian Geriatrics Society (CGS), an ad hoc Work Group was struck to submit a report providing an estimate of the number of physicians and full-time equivalents (FTEs) currently working in the field of geriatrics, an estimate of the number required (if possible), and a clearer understanding of what has to be done to move physician resource planning in geriatrics forward in Canada.
It was decided to focus on specialist physicians in geriatrics (defined as those who have completed advanced clinical training or have equivalent work experience in geriatrics and who limit a significant portion of their work-related activities to the duties of a consultant).
In 2012, there are 230-242 certified specialists in geriatric medicine and approximately 326.15 FTE functional specialists in geriatrics. While this is less than the number required, no precise estimate of present and future need could be provided, as no attempts at a national physician resource plan in geriatrics based on utilization and demand forecasting, needs-based planning, and/or benchmarking have taken place.
This would be an opportune time for the CGS to become more involved in physician resource planning. In addition to this being critical for the future health of our field of practice, there is increasing interest in aligning specialty training with societal needs (n = 216).
To examine the practice patterns and clinical and academic roles of family physicians who have care of the elderly training.
Cross-sectional survey.
Family medicine practices or specialized geriatric services programs.
Fifty-two family physicians, surveyed in 2005 and 2006, identified as having 6 or 12 months' care of the elderly training.
Self-reported practice type and description of clinical and academic roles.
Surveys were sent to 103 physicians; the response rate was 50.5% (N = 52). Respondents were relatively young, with a mean age of 42 years. Slightly more respondents had completed 6 months of training than had completed a full year of training (54.9% vs 45.1%). More than half (55.8%) described their medical practice areas as "general family medicine." The remainder worked in "restricted practices" (25.0%) or provided "specialist care" (17.3%); 1 physician was no longer practising medicine. Many provided some care within specialized geriatric service areas, most commonly in-hospital consultation and rehabilitation. More than half (51.9%) provided active hospital care, and a substantial number worked in long-term care facilities as physicians or medical directors. More than 20% provided newborn care, although only a small percentage (7.7%) performed obstetric services. Respondents were actively involved in teaching and other academic activities, including resident supervision.
Care of the elderly physicians provide comprehensive family medicine services, but also often provide care in other areas currently facing physician shortages. Care of the elderly physicians play relevant clinical and academic roles in both family medicine training and specialized geriatric services.
A series of telephone interviews were conducted to assess geriatric psychiatry content at each of Canada's 16 medical schools. Nearly all schools included geriatric psychiatry content and most of the teaching took place in the pre-clerkship. Geriatric psychiatrists are teaching and participating in the planning of the curriculum at most medical schools and most of the clinical experiences in geriatric psychiatry are occurring with inpatients. In order to enhance the teaching of geriatric psychiatry Canadian medical schools should increase the amount of ambulatory and community-based teaching, integrate more geriatric psychiatry teaching with geriatric medicine and increase the profile of geriatric psychiatry within the psychiatry clerkship rotation.
Directors of postgraduate internal medicine programs face many problems in program design, particularly when numbers of house staff continue to decrease. This paper examines the training requirements of a resident in internal medicine and proposes a curriculum based on set rotations in the three key areas of training--subspecialty services, critical care and the clinical teaching unit. The distribution of time in these three areas and the balance of exposure to inpatients and outpatients are discussed in detail. This program design ensures exposure to all the key elements of internal medicine in 3 years and should prevent significant gaps in knowledge at the time of certification. The implications for "service" in major teaching hospitals is discussed. Hospital departments and administrators must confront the prospect of hospital units without house staff. Most important, program directors must resist sacrificing the pedagogic essentials of a training program for service requirements.
Introduction: Physicians without additional training in geriatrics are responsible for most of the health care provided to older Canadians. Explicit educational standards for the care of the elderly have been established by the College of Family Physicians of Canada. (CFPC) The objective of this study was to review how the training objectives and content requirements for specialties and subspecialties recognized by the Royal College of Physicians and Surgeons of Canada (RCPSC) deal with the care of older patients. Methods: The texts of the RCPSC specialty and subspecialty training objectives and specific training requirements were searched for a number of key words (age, aged, aging, elderly, geriatric, geriatrics, old, older, senile). The documents for geriatric medicine were used to validate the terms chosen. The search was limited to those fields likely to be involved in the clinical care of older individuals. Results: Forty of the 59 specialties and sub-specialties (67.8 per cent of the total) were selected for examination. The terms were used a total of 63 times, which translates to an average of 1.575 (range 0 to 8) per specialty or subspecialty. When used, the terms often referred solely to younger patients, the entire age spectrum or were ambiguous. Only three (7.5 per cent of the total examined) gave specific training requirements in the care of older patients. Interpretation: Specific references to older patients and/or geriatrics were rare in the documents reviewed. There is a need to more thoroughly integrate geriatrics within medical and surgical specialties.
Recent curriculum changes at McGill University include a mandatory 4-week clerkship for third-year medical students. The basis of this clerkship is the assessment and management of frail elderly who have a combination of complex acute and chronic medical problems and functional disabilities. It includes the understanding of the need for continuity of care across settings and the transition from hospital to the community. Our main purpose is to offer students a learning experience based upon self-reflection, access to technology, interactive learning and permanent feedback. To accomplish the technological goals, didactic sessions were mostly electronic-based with two main components: web-based interactive modules that include the contents in seven web-based interactive lectures complemented with pre- and post-tests, and an electronic portfolio to assess students' acquisition of skills and attitudes. We expect that implementation of this model of clinical clerkship will prepare future physicians, not only for the practice of geriatric medicine, but also for different medical and surgical specialties, and will enhance the attitudes, knowledge, and skills practitioners need to care for older people.
Many medical school faculty are now recognising the need for students to learn more geriatric content; yet, they may hesitate to add geriatrics because their general faculty has limited expertise in geriatrics, few geriatricians, and most geriatricians are already over-committed. Problem-based learning is one possible solution without adding new faculty, nor requiring much extra teaching time. This article summarizes the educational and psychological principles supporting problem-based learning in medical education, and describes how geriatrics has been incorporated into a problem-based medical curriculum at McMaster University. Aging issues are introduced throughout the program including a three week block focusing on the health care needs of the elderly. Some of the problems and the benefits encountered in the development of he curriculum are discussed.
The present geriatric content of undergraduate education in Canadian pharmacy schools was examined. A 35-item survey covering a range of educational topics was sent to relevant faculty members at each of the Canadian schools of pharmacy. All nine Canadian faculties of pharmacy responded. Only three schools had a separate geriatric course, the rest had integrated geriatric content. Both clinical and didac- tic courses were taught primarily by pharmacy faculty, and rarely by medicine faculty. Established guide- lines surrounding inappropriate prescribing practices in the elderly were specifically taught in most schools. Innovative strategies included role playing, geriatric therapeutics "hot-lines" manned by pharma- cy students, geriatric education modules, and geriatric pharmacology textbooks written by faculty mem- bers. The variability in the geriatric curriculum could be addressed with a mandatory geriatric issues phar- macy course. Partnerships with academic divisions of geriatric medicine and clinical pharmacology could further enrich the educational experience for pharmacy and medical students.
No abstract available. (C) 1992 Association of American Medical Colleges
Undergraduate training at McMaster University medical school is based on small group tutorials and self-directed learning by the students. The undergraduate program is three years in length and had not been altered since its inception in 1969 until a new unit was added in 1985. This includes a two and a half week module involving exposure to geriatric medicine. The class of 100 students is divided into groups of six, with a tutor who is a physician, but not usually a geriatrician. Each student has the opportunity to take a history from and examine an old person. For the class, a plan was developed that involved geriatricians, geriatric psychiatrists, general internists, and family physicians who served the dual purpose of finding a pool of appropriate geriatric patients, and also provided students with experience in different settings and with elders of varied health status. These experiences were shared with other members of the class, increasing their exposure to the different issues in the limited time available. Other components of the aging subunit are described.
The US population is getting older, with persons over 85 years of age the fastest growing segment. The prolongation of life is perhaps the success story of the 20th century, but inherent is a challenge to the medical profession: how to provide enough faculty and practitioners with expertise in geriatrics to care for the nation's older patients. During the past decade, medical schools have begun to respond to the challenge by increasing the time devoted in the curriculum to the care of elders. Despite these efforts, an insufficient number of physicians are being educated. In this paper, we describe the expanding need for geriatrics expertise, the efforts being made to meet it, and recommend ways of assuring that older persons receive the highest possible quality of care.
Despite exhortations in the geriatric literature, medical faculties have not included geriatric medicine in curricula to any significant extent. The establishment of professorships in geriatrics in a few medical schools may have had some local effect but has not spread widely. Rather than continue the exhortations, the explanation for this recalcitrance should be sought and new approaches tried. Recently the trend in medical teaching has been away from didactic lectures and towards student self teaching, with earlier specialization including family medicine. Should geriatrics be identified at an early stage of students' training with a view to producing a small number of geriatric specialists, or should the principles, attitudes and relevant information about the aging process, preventive and preservative measures and management be identified and promulgated by many teachers in different ways? The latter approach is being followed at McMaster Health Science Division and the teaching program is being developed in cooperation with other members of the faculty. This is appropriate to that system which emphasizes self teaching, problem solving and small group learning without lectures and without formal examinations, but could perhaps be adapted to any system and be better accepted in current teaching philosophy.
As the absolute numbers and percentage of older people rises in Canada, surgeons are required to treat an increasing number of elderly patients. Recognizing the need to enhance the quality of health care for these people by continuing medical education of health care professionals, the Canadian Medical Association sponsored an invitational workshop in May 1992. The workshop group addressing surgery and its specialties identified three essential underprinnings: knowledge of the aging process (altered physiology and response to illness); decision analysis for interventions (risks, benefits and ethical dimensions); and communication skills. Three priorities for continuing education were recommended: improving knowledge of the physiologic changes that impact on the recovery of elderly patients from surgery; management of postoperative care; and improved knowledge and skills in prescribing medications for older surgical patients. Strategies to implement these priorities are outlined.
To explore physicians' responses to the needs for education in geriatrics identified by a community needs survey.
Interviews conducted during a cross-sectional survey.
Private family practices in Calgary.
Randomly selected family physicians in Calgary who had previously recruited patients for a community needs survey. Thirty of 60 volunteer physicians randomly selected for phase 1 of the study were interviewed. One physician recruited patients for phase 1 but declined to be interviewed.
Demographic variables, practice characteristics, and opinions on urgency of potential topics for continuing medical education.
Physicians agreed with community informants that they need more education about medication for the elderly, medical management, and mental health issues. Physicians did not perceive pressing needs for education in communication skills with patients, in compassion, or in health promotion for patients. Physicians identified many barriers to meeting needs identified by the community. Among the most notable obstacles were inadequate time, inadequate remuneration, and lack of accessible community resources.
Continuing medical education should help physicians recognize the community's needs and design programs that will address them.
A geriatric education retreat in oncology was held in February 1997 to develop a plan to integrate geriatrics into oncology.
A group of 42 geriatricians and medical oncologists convened to assess the means of incorporating the contents of geriatrics into oncology training. The basic science and clinical aspects of the pathogenesis, diagnosis, and treatment of cancers in older persons and the geriatric aspects of aging were presented.
This comprehensive review of the problems of aging and cancer provided encouragement to representatives of both disciplines to stimulate further research and clinical training relating to the problems of aging and cancer. The overall conclusions considered means to reach this goal.
The use of the Internet makes it possible to bring together learners and teachers from rural areas and academic centers and to deliver well-accepted educational materials quickly and effectively. The objective of this study was to determine feasibility and the effectiveness of a problem-based small-group learning (PBSGL) intervention conducted via the Internet in a randomized controlled trial. A group of 23 family physicians from rural Northern Ontario practices and across Canada were randomly assigned to a study group (n = 11) and a control group (n = 12). The study group spent two months discussing the topic of depression in the elderly with the help of a facilitator and two geriatric psychiatrists. The control group was given similar educational resources via the Internet but without the benefit of the small-group interaction. Outcome measures included qualitative feedback from the learners and teachers as well as a Multiple Choice Questions (MCQ) test before and after the study. The study provided important insight into the feasibility, keys to success, utility of Internet-assisted education from an education and evaluation perspective. Although the MCQ testing used revealed no significant differences between the study group and the control group, the usefulness of the measure is considered within the context of the educational approach. It is unclear whether this method of continuing medical education (CME) represents an effective way to conduct such activities.
Although adults aged 65 years and older constitute the most rapidly growing segment of the U.S. population, geriatric issues
have not typically been a focus of training in infectious diseases (ID). Underrecognition of the unique aspects of geriatric
care, apathy toward this population, and the feeling that “we're all geriatricians” (and thus know geriatric medicine) all
contribute to this problem. This article summarizes the recent meeting focused on integrating geriatric principles within
ID training at all levels. The ID/geriatric interface as an attractive area for basic and clinical research is emphasized.
Internet-based learning is a growing trend in continuing education for health professionals. We have developed an on-line version of four workshops for practising physicians, tracing a patient's course from the initial diagnosis of dementia to end-of-life care. We have also developed an on-line dementia toolkit that could evolve with changing knowledge. The toolkit consisted of reference material collected from a variety of sources and vetted by our team of experts to address the common complaint that the sources of on-line reference materials are often unauthenticated. The Geriatric Forum provides an array of resources for health professionals.
The world's population is aging. Older age is associated with an increase in the incidence of cancer, especially cancer of the breast, lung, prostate, and colon. The management of older patients with cancer is biased by the simple fact of their chronologic age. Underscreening, understaging, less aggressive therapy, lack of participation in clinical trials, or no treatment at all reflect this bias. Although an age-related reduction in the physiologic function of many organs occurs with age, these are not contraindications to treatment with surgery, radiation therapy, or chemotherapy. Chronologic age alone should not be used as a guide for cancer management. Rather, physiologic function or existence of comorbid conditions should be major factors in determining treatment. As a result of the impending need for improved cancer management in older persons, a new subspecialty is evolving: geriatric oncology. This field stresses an important interaction between geriatricians and oncologists, development of research directed at the problems of cancer in older persons, and education at all levels with respect to cancer prevention, cancer detection, and cancer therapy. Physicians and oncologists need to be prepared for the projected increase of cancer in older persons.
The overall goal of chronic care is not to cure, but rather to help persons with chronic conditions maintain independence and a high level of functioning. Geriatricians bring special expertise to the management of patients with chronic conditions across multiple sites of care. As the health care system evolves to meet the many challenges of chronic care (3,5), geriatricians, in collaboration with primary care physicians, specialists, policymakers, and other health care professionals, will be ideally positioned to improve the health and well-being of persons with chronic conditions and disabilities across the continuum of age.
Geriatric medicine grand rounds (GMGR) from the University of Alberta are videoconferenced weekly to health-care providers at up to 9 urban and 14 rural sites across Alberta. A questionnaire was given to all participants attending 20 consecutive GMGR presentations from January 2002. The response rate was 85% (n = 625) for all participants and 99% (n = 123) for physicians alone. The audience was composed of registered nurses (42%), physicians (17%) and other health-care professionals. 'Interest in topic' was cited by 95% as the main reason for attendance. Doctors and nurses cited continuing medical education as an additional factor. The highest attendance was for the topics vascular dementia, behavioural problems in dementia, the genetics of dementia and falls prevention. Participants at the remote sites gave lower evaluations of quality of the GMGR presentations than those at the hub site. The measurement, care and treatment of dementia appeared to be the main concerns of health-care providers across the province. The videoconferencing of GMGR appears to be an effective method of meeting the demands of physicians and allied health professionals for education in geriatric medicine.
