Danelle Cayea

Individualising Therapy for Older Adults with Diabetes Mellitus

The goal when treating patients with diabetes mellitus is to achieve the maximum longevity consistent with an optimal quality of life. To achieve this goal, treatment is typically focused on management of hyperglycaemic symptoms and prevention of microvascular and macrovascular complications. While appropriate for most individuals, including many older adults with robust health, this focus is often too limited for older adults facing diminished life expectancy and co-existing medical illness, frailty and disability. Creating a treatment plan that optimises health and function, and reduces the risk for morbidity and mortality, requires individualised therapy that judiciously manages symptoms and multiple competing health risks while remaining consistent with the patient’s or his/her caregiver’s healthcare preferences. Physicians caring for older adults with diabetes must be adept at recognising conditions commonly associated with diabetes, including the interplay with co-morbid illness, and be able to assess the patient’s health status and use this information to recommend a treatment plan that is consistent with the patient’s personal goals for care.The majority of older adults with diabetes will benefit from management of cardiovascular risk, including intensive management of hypertension, lipids, use of aspirin (acetylsalicylic acid) and smoking cessation, and screening for common geriatric syndromes. For a significant minority of older adults with life expectancy of ≥10 years, it is reasonable to consider intensive management of hyperglycaemia (glycosylated haemoglobin [HbA1c] target ≤7%). For frail older adults with life expectancy of ≤5 years, strategies for reducing medical burden, improving function and moderate glucose control (HbA1c ≈8%) is reasonable and sufficient to control hyperglycaemic symptoms.

Primary Care Practitioners' Views on Incorporating Long-term Prognosis in the Care of Older Adults.

IMPORTANCEnClinical practice recommendations increasingly advocate that older patients life expectancy be considered to inform a number of clinical decisions. It is not clear how primary care practitioners approach these recommendations in their clinical practice.nnnOBJECTIVEnTo explore the range of perspectives from primary care practitioners on long-term prognosis, defined as prognosis regarding life expectancy in the range of years, in their care of older adults.nnnDESIGN, SETTING, AND PARTICIPANTSnA qualitative, semistructured interview study was conducted in a large group practice with multiple sites in rural, urban, and suburban settings. Twenty-eight primary care practitioners were interviewed; 20 of these participants (71%) reported that at least 25% of their patient panel was older adults. The audiorecorded discussions were transcribed and analyzed, using qualitative content analysis to identify major themes and subthemes. The study was conducted between January 30 and May 13, 2015. Data analysis was performed between June 10 and September 1, 2015.nnnMAIN OUTCOMES AND MEASURESnThe constant comparative approach was used to qualitatively analyze the content of the transcripts.nnnRESULTSnOf the 28 participants, 16 were women and 21 were white; the mean (SD) age was 46.2 (10.3) years. Twenty-six were physicians and 2 were nurse practitioners. Their time since completing clinical training was 16.0 (11.4) years. These primary care practitioners reported considering life expectancy, often in the range of 5 to 10 years, in several clinical scenarios in the care of older adults, but balanced the prognosis consideration against various other factors in decision making. In particular, patient age was found to modulate how prognosis affects the primary care practitioners decision making, with significant reluctance among them to cease preventive care that has a long lag time to achieve benefit in younger patients despite limited life expectancy. The participants assessed life expectancy based on clinical experience rather than using validated tools and varied widely in their prognostication time frame, from 2 years to 30 years. Participants often considered prognosis without explicitly discussing it with patients and disagreed on whether and when long-term prognosis needs to be specifically discussed. The participants identified numerous barriers to incorporating prognosis in the care of older adults including uncertainty in predicting prognosis, difficulty in discussing prognosis, and concern about patient reactions.nnnCONCLUSIONS AND RELEVANCEnDespite clinical recommendations to increasingly incorporate patients long-term prognosis in clinical decisions, primary care practitioners encounter several barriers and ambiguities in the implementation of these recommendations.

Complexity in Graduate Medical Education: A Collaborative Education Agenda for Internal Medicine and Geriatric Medicine

ABSTRACTInternal medicine residents today face significant challenges in caring for an increasingly complex patient population within ever-changing education and health care environments. As a result, medical educators, health care system leaders, payers, and patients are demanding change and accountability in graduate medical education (GME). A 2012 Society of General Internal Medicine (SGIM) retreat identified medical education as an area for collaboration between internal medicine and geriatric medicine. The authors first determined a short-term research agenda for resident education by mapping selected internal medicine reporting milestones to geriatrics competencies, and listing available sample learner assessment tools. Next, the authors proposed a strategy for long-term collaboration in three priority areas in clinical medicine that are challenging for residents today: (1) team-based care, (2) transitions and readmissions, and (3) multi-morbidity. The short-term agenda focuses on learner assessment, while the long-term agenda allows for program evaluation and improvement. This model of collaboration in medical education combines the resources and expertise of internal medicine and geriatric medicine educators with the goal of increasing innovation and improving outcomes in GME targeting the needs of our residents and their patients.

The Short-Term and Long-Term Impact of a Brief Aging Research Training Program for Medical Students

Summer training in aging research for medical students is a strategy for improving the pipeline of medical students into research careers in aging and clinical care of older adults. Johns Hopkins University has been offering medical students a summer experience of mentored research, research training, and clinical shadowing since 1994. Long-term outcomes of this program have not been described. The authors surveyed all 191 participants who had been in the program from 1994–2010 (60% female and 27% underrepresented minorities) and received a 65.8% (N = 125) response rate. The authors also conducted Google and other online searches to supplement study findings. Thirty-seven percent of those who have completed training are now in academic medicine, and program participants have authored or coauthored 582 manuscripts. Among survey respondents, 95.1% reported that participation in the Medical Student Training in Aging Research program increased their sensitivity to the needs of older adults. This program may help to build commitment among medical students to choose careers in aging.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training

BackgroundPhysicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill.MethodsOne hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE).ResultsInterns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing ‘a’ from ‘v’ waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE.ConclusionsA comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

Incorporating prognosis in the care of older adults with multimorbidity: description and evaluation of a novel curriculum

BackgroundPrognosis is a critical consideration in caring for older adults with multiple chronic conditions, or “multimorbidity”. Clinicians are not adequately trained in this area. We describe an innovative curriculum that teaches internal medicine residents how to incorporate prognosis in the care of older adults with multimorbidity.MethodsThe curriculum includes three small-group sessions and a clinical exercise; it focuses on the assessment, communication, and application of prognosis to inform clinical decisions. The curriculum was implemented with 20 first-year residents at one university-based residency (intervention group). Fifty-two first-year residents from a separate residency affiliated with the same university served as controls.Evaluation included three components. A survey assessed acceptability. A pre/post survey assessed attitude, knowledge, and self-reported skills (Impact survey). Comparison of baseline and follow-up results used paired t-test and McNemar test; comparison of inter-group differences used t-test and Fisher’s exact test. A retrospective, blinded pre/post chart review assessed documentation behavior; abstracted outcomes were analyzed using Fisher’s exact test.ResultsThe curriculum was highly rated (4.5 on 5-point scale). Eighteen intervention group residents (90xa0%) and 29 control group residents (56xa0%) responded to the Impact survey. At baseline, there were no significant inter-group differences in any of the responses. The intervention group improved significantly in prognosis communication skills (5.2 to 6.6 on 9-point scale, pu2009<u20090.001), usage of evidence-based prognostic tools (1/18 to 14/18 responses, pu2009<u20090.001), and prognostic accuracy (1/18 to 9/18 responses, pu2009=u20090.005). These responses were significantly different from the control group at follow-up.Of 71 charts reviewed in each group, prognosis documentation in the intervention group increased from 1/25 charts (4xa0%) at baseline to 8/46 charts (17xa0%) at follow-up (pu2009=u20090.15). No prognosis documentation was identified in the control group at either time point. Inter-group difference was significant at follow-up (pu2009=u20090.006).ConclusionWe developed and implemented a novel prognosis curriculum that had significant short-term impact on the residents’ knowledge and communication skills as compared to a control group. This innovative curriculum addresses an important educational gap in incorporating prognosis in the care of older adults with multimorbidity.

A handy clue: palmar fasciitis and polyarthritis syndrome.

PRESENTATION Rheumatologic symptoms signaled a deadly underlying disorder. A 48-year-old woman presented with progressive pain and functional impairment of both hands. She was in her usual state of good health until 3 months prior to admission, when she developed pain and stiffness associated with swelling of the proximal and distal interphalangeal joints. Her joint symptoms were more pronounced in the morning, improving over the course of the day. Yet, difficulty flexing and extending all fingers continued, significantly compromising her ability to carry out routine daily activities. Meloxicam was prescribed but offered little relief. Treatment with hydroxychloroquine and a brief prednisone taper followed, and while this transiently helped resolve some of the articular swelling, stiffness, and pain, it did not alleviate the impaired finger dexterity. The patient also reported that a 13-pound unintentional weight loss had occurred with the onset of her joint symptoms. She had a poor appetite, dyspepsia, and occasional episodes of facial flushing, but no dysphagia, Raynaud’s phenomenon, or prior history of skin or joint disorders. Her past medical history was significant for hypertension since she was 35-years-old. She also had a 30-pack-year history of cigarette smoking. Her family history was notable for lung cancer, colon cancer, and ovarian cancer.

Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention

ABSTRACT This study aimed to assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients with multimorbidity after an educational intervention, and resident and patient perspectives regarding these visits. Assessment used mixed-methods. The authors assessed the frequency and content of prognosis discussions through residents’ self-report and qualitative content analysis of audio-recorded clinic visits. The authors assessed the residents’ perceived effect of incorporating prognosis on patient care and patient relationship through a resident survey. The authors assessed the patients’ perceived quality of communication and trust in physicians through a patient survey. The study included 21 clinic visits that involved 12 first-year residents and 21 patients. Residents reported incorporating patients’ prognoses to inform clinical decisions in 13/21 visits and perceived positive effects on patient care (in 11/13 visits) and patient relationship (in 7/13 visits). Prognosis communication occurred in 9/21 visits by self-report, but only in six of these nine visits by content analysis of audio-recordings. Patient ratings were high regardless of whether or not prognosis was communicated. In summary, after training, residents often incorporated patients’ prognoses to inform clinical decisions, but sometimes did so without communicating prognosis to the patients. Residents and patients reported positive perceptions regarding the visits.

Defining and Assessing the 21st-Century Physician in Training.

We are experiencing a paradigm shift in medical education. Education has moved away from using “time” as a determinant of learner readiness to advance to the next stage and ultimately onto independent practice, to the current competency-based paradigm that focuses on a learner’s mastery of specific professional activities as a measure of their fitness for unsupervised practice. This approach creates opportunities for more individualized, developmental-based learning, and how we define competency will drive curriculum development and assessment. For example, defining the specific competencies needed to provide high-quality care may identify gaps in existing curricula. Competency-based education lends itself to “assessment for learning” in which learners utilize regular feedback from multiple sources to improve performance in a set of defined skills and behaviors along a developmental continuum.1 Structures that support this model include clearly described competencies that link entrustable professional activities (EPAs) (which represent the work that competent physicians perform when synthesizing and contextualizing knowledge and information to care for patients) to learning experiences that occur in authentic clinical environments with opportunities for individualized assessment coupled with meaningful real-time feedback.2 n nTo achieve the full benefit of competency-based education, learners and teachers must have a shared frame of reference around the expectations required to demonstrate competency, and faculty must be skilled assessors who are capable of making valid and reliable decisions regarding entrustment.3 n nThe tasks for today’s educators are to define the competencies that appropriately describe the 21st-century physician most capable of providing high-quality care in an increasingly complex system, and then to design methods that accurately and reliably assess those competencies in a way that promotes deep and meaningful learning among physician trainees. The articles in this issue by Hauer et al.4 and Hemmer et al.5 outline steps for achieving these tasks. Hauer and colleagues provide a roadmap that uses a rigorous approach to defining EPAs for medical students. They employed a holistic approach and engaged stakeholders to build a common framework for shared understanding of a competent graduate. Hemmer and colleagues demonstrate that faculty development involving timely and specific descriptions of learner behaviors based on a shared frame of reference improved validity and reliability of medical student assessments. These two processes are necessary components for assessment for learning. Faculty responsible for guiding students through their professional development must have both a shared understanding of the relevant behaviors and the ability to provide specific feedback about a student’s trajectory to aid their advancement. n nHauer et al. set out to define EPAs for medical students, starting from a community-based perspective, and then defining the health needs of the communities their graduates will serve and imagining the “ideal physician graduate” to address those needs. From this vision, physician roles and competencies were identified and described. They then proceeded to operationalize the competencies into EPAs, a challenge many before them have struggled to do successfully.6 Throughout this iterative process, they enlisted a broad coalition of stakeholders, including current students, who were firmly invested in the work. Building a broad coalition ensures that the identified EPAs have face validity (this was followed by demonstration of content validity using a variety of techniques) and that there is a shared “frame of reference” among stakeholders around the expectations for demonstrating mastery of the identified professional activities. Finally, the process and the investment in building a shared frame of reference creates a culture that recognizes the changing nature of medical education and may be more flexible and nimble in responding to future needs. n nBy embedding the work of EPA development into a curricular reform process, development and assessment of curricula can proceed hand-in-hand in order to ensure that teaching and assessment methods promote meaningful learning and desired outcomes. Although not explicitly mentioned by Hauer et al., while clearly demonstrated in the article by Hemmer and colleagues, this process should also drive faculty development initiatives. However, having a shared frame of reference is not a guarantee that faculty are prepared to lead learners to mastery, as many faculty do not have training in the “emerging” domains identified by Hauer et al., and thus the need for comprehensive faculty development is even more pressing.7 n nWhile the process at UCSF was closely tied to the unique institutional mission of the medical school, the authors compared institutional competencies and EPAs with national standards from the Association of American Medical Colleges and reviewed their EPAs with residency program directors to ensure alignment with expectations for new residents. Finally, the authors’ plan for piloting the individual EPAs should enhance student engagement and, with faculty involvement in the form of rich individualized qualitative feedback on performance for learners, will likely pave the way for true assessment for learning. n nCompetency-based assessment and assessment for learning require that faculty are able to accurately observe, describe, and feed back to learners their strengths and specific next steps in their development. Hemmer et al. demonstrated that faculty attendance at face-to-face evaluation sessions improved adherence to a shared framework (RIME) for evaluating medical students and also improved validity compared to course director ratings. The authors hypothesized that faculty discussion with course and site directors would allow everyone to share the same frame of reference for student performance. These face-to-face meetings also produced a wealth of information about student performance, which was transcribed into a document that each student received at the end of their clerkship. Detailed narratives such as these allow a more transparent and informative evaluation process for students. As we move forward with competency-based assessment, training of faculty in narrative evaluation around a shared frame of reference can help them in providing the information that students need to guide their further development. These comments are often also a source of information about learners’ performance in complex areas that cut across individual EPAs and professional behaviors, and that provide valuable insight about their learning trajectory across the curriculum.8 Faculty development workshops and feedback can improve the quality of narrative evaluation and are worthwhile investments for medical schools.9 Learners report that these narratives are helpful for self-assessment but that they also desire the involvement of trained faculty to help make sense of them.10 Faculty must be able to provide real-time feedback and to help students synthesize narrative assessments into individualized plans for mastery learning. n nThe simultaneous promise and challenge of competency-based education continues to drive innovation and the creation of an evidence base in medical education. The work of Hauer and Hemmer and their colleagues demonstrates a path for moving forward.W e are experiencing a paradigm shift in medical education. Education has moved away from using Btime^ as a determinant of learner readiness to advance to the next stage and ultimately onto independent practice, to the current competency-based paradigm that focuses on a learner’s mastery of specific professional activities as a measure of their fitness for unsupervised practice. This approach creates opportunities for more individualized, developmental-based learning, and how we define competency will drive curriculum development and assessment. For example, defining the specific competencies needed to provide high-quality care may identify gaps in existing curricula. Competency-based education lends itself to Bassessment for learning^ in which learners utilize regular feedback from multiple sources to improve performance in a set of defined skills and behaviors along a developmental continuum. Structures that support this model include clearly described competencies that link entrustable professional activities (EPAs) (which represent the work that competent physicians perform when synthesizing and contextualizing knowledge and information to care for patients) to learning experiences that occur in authentic clinical environments with opportunities for individualized assessment coupled with meaningful real-time feedback. To achieve the full benefit of competency-based education, learners and teachers must have a shared frame of reference around the expectations required to demonstrate competency, and faculty must be skilled assessors who are capable of making valid and reliable decisions regarding entrustment. The tasks for today’s educators are to define the competencies that appropriately describe the 21st-century physician most capable of providing high-quality care in an increasingly complex system, and then to design methods that accurately and reliably assess those competencies in a way that promotes deep and meaningful learning among physician trainees. The articles in this issue byHauer et al. andHemmer et al. outline steps for achieving these tasks. Hauer and colleagues provide a roadmap that uses a rigorous approach to defining EPAs for medical students. They employed a holistic approach and engaged stakeholders to build a common framework for shared understanding of a competent graduate. Hemmer and colleagues demonstrate that faculty development involving timely and specific descriptions of learner behaviors based on a shared frame of reference improved validity and reliability of medical student assessments. These two processes are necessary components for assessment for learning. Faculty responsible for guiding students through their professional development must have both a shared understanding of the relevant behaviors and the ability to provide specific feedback about a student’s trajectory to aid their advancement. Hauer et al. set out to define EPAs for medical students, starting from a community-based perspective, and then defining the health needs of the communities their graduates will serve and imagining the Bideal physician graduate^ to address those needs. From this vision, physician roles and competencies were identified and described. They then proceeded to operationalize the competencies into EPAs, a challenge many before them have struggled to do successfully. Throughout this iterative process, they enlisted a broad coalition of stakeholders, including current students, who were firmly invested in the work. Building a broad coalition ensures that the identified EPAs have face validity (this was followed by demonstration of content validity using a variety of techniques) and that there is a shared Bframe of reference^ among stakeholders around the expectations for demonstrating mastery of the identified professional activities. Finally, the process and the investment in building a shared frame of reference creates a culture that recognizes the changing nature of medical education and may be more flexible and nimble in responding to future needs. By embedding the work of EPA development into a curricular reform process, development and assessment of curricula can proceed hand-in-hand in order to ensure that teaching and assessment methods promote meaningful learning and desired outcomes. Although not explicitly mentioned by Hauer et al., while clearly demonstrated in the article by Hemmer and colleagues, this process should also drive faculty development initiatives. However, having a shared frame of reference is not a guarantee that faculty Published online July 15, 2015

Medical students’ perceptions of low-value care

Medical schools are creating high‐value care (HVC) curricula in undergraduate medical education; however, there are few studies identifying what are the most pressing low‐value care (LVC) practices, as observed by students. This study is a multicentre, targeted needs assessment comparing medical student perceptions of LVC at four institutions, after completion of their internal medicine clerkship, to identify areas of focus for future HVC curriculum development.