Sharon A. Levine

Seven- to 10-year outcome of decompressive surgery for degenerative lumbar spinal stenosis.

Study Design. Retrospective review and prospective follow‐up of 88 patients who had decompressive laminectomy with or without fusion from 1983 to 1986. Objective. To determine the 7‐ to 10‐year outcome of surgery for degenerative lumbar spinal stenosis. Summary of Background Data. There is limited information on the impact of surgery for lumbar spinal stenosis on symptoms, walking ability, and satisfaction, as well as reoperation. Methods. Patients completed standardized questionnaires in 1993 that included items about reoperations, back pain, leg pain, walking capacity, and satisfaction with surgery. Associations between preoperative demographic and clinical variables and outcomes 7 to 10 years after surgery were evaluated in univariate and multivariate analyses. Results. Average preoperative age was 69 years and eight patients received fusion. Of 88 patients in the original cohort, 20 (23%) were deceased and 20 (23%) had undergone reoperation by 7‐ to 10‐year follow‐up. Fifty‐five patients answered questionnaires. Average duration of follow‐up was 8.1 years. Thirty‐three percent of the respondents had severe back pain at followup, 53% were unable to walk two blocks, and 75% were satisfied with the results of surgery. The severity of current spine‐related symptoms was a stronger correlate of physical functional status at the time of follow‐up than age or nonspinal comorbid conditions. Conclusions. Seven to 10 years after decompressive surgery for spinal stenosis, 23% of patients had undergone reoperation and 33% of respondents had severe back pain. Despite a high prevalence of nonspinal problems in this elderly cohort, spinal symptoms were the most important correlate of reduced functional status.

Development and Implementation of an Objective Structured Clinical Examination to Provide Formative Feedback on Communication and Interpersonal Skills in Geriatric Training

Teaching and assessment of communication and interpersonal skills, one of the American Council for Graduate Medical Education–designated core competencies, is an important but difficult task in the training of physicians. Assessment of trainees offers an opportunity to provide explicit feedback on their skills and encourages learning. This article describes a pilot study in which clinician‐educators affiliated with the geriatrics training programs at Beth Israel Deaconess Medical Center and Boston University Medical Center designed and piloted a novel Objective Structured Clinical Examination (OSCE) to assess the communication and interpersonal skills of medical, dental, and geriatric psychiatry fellows. The OSCE consisted of three stations where geriatricians and standardized patients evaluated candidates using specifically designed checklists and an abbreviated version of the Master Interview Rating Scale. Communication skills were assessed through performance of specific “real life” clinical tasks, such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills were assessed through the effect of the communication between doctor and standardized patient on fostering trust, relieving anxiety, and establishing a therapeutic relationship. This pilot study demonstrated that the OSCE format of assessment provides a valid means of evaluating the communication and interpersonal skills of interdisciplinary geriatric trainees and provides a valuable forum for formative assessment and feedback. Given that geriatricians and non geriatricians involved in elder care both need communication and interpersonal skills, this novel OSCE can be used for assessment of these skills in trainees in diverse healthcare subspecialties.

American geriatrics society identifies another five things that healthcare providers and patients should question

Since 2012, the American Geriatrics Society (AGS) has also been collaborating with the American Board of Internal Medicine (ABIM) Foundation, joining its “Choosing Wisely” campaign on two separate lists of Five Things Healthcare Providers and Patients Should Question. The campaign is designed to engage healthcare organizations and professionals, individuals, and family caregivers in discussions about the safety and appropriateness of medical tests, medications, and procedures. Participating healthcare providers are asked to identify five things—tests, medications, or procedures—that appear to harm rather than help. Providers then share this information in a published article about these things on the ABIM campaigns website (www.choosingwisely.org). The first AGS list was published in February 2013.

Practicing Physician Education in Geriatrics: Lessons Learned from a Train‐the‐Trainer Model

Evidence of poor performance in the evaluation and management of common geriatric conditions suggests the need for changing physician behavior in these areas. Traditional lecture‐style continuing medical education (CME) has not been shown to be effective. Expert faculty initially trained 60 nonexpert peer educators to conduct small‐group, learner‐centered CME using tool kits on memory loss, incontinence, and depression. Peer educators presented 109 community‐based sessions to 1,309 medical practitioners. Surveys were administered to community participants immediately and 6 months after a session. Evidence of effectiveness included statistically significant increases in self‐reported knowledge, attitudes, and office‐based practices on the target topics at the time of training and at the 6‐month follow‐up (P<.001) and two‐thirds of respondents reporting continued use of three or more tools at 6 months. Participants reported that the interactive presentation aided their understanding of and ability to use the tool kits more than an off‐the‐shelf review (mean rating±standard deviation 4.1±0.71, with 1=not at all and 5=significantly). After the formal evaluation period, additional information about the project dynamics and tool kits was obtained through a small interview sample and an on‐line survey, respectively. Receiving copies of the tool kits was an important factor in enabling educators to offer sessions. Barriers to offering sessions included finding time, an audience, and space. Findings suggest that modest positive changes in practice in relation to common geriatric problems can be achieved through peer‐led, community‐based sessions using principles of knowledge translation and evidence‐based tool kits with materials for providers and patients.

What Is a Geriatrician? American Geriatrics Society and Association of Directors of Geriatric Academic Programs End-of-Training Entrustable Professional Activities for Geriatric Medicine

Entrustable professional activities (EPAs) describe the core work that constitutes a disciplines specific expertise and provide the framework for faculty to perform meaningful assessment of geriatric fellows. This article describes the collaborative process of developing the end‐of‐training American Geriatrics Society (AGS) and Association of Directors of Geriatric Academic Programs (ADGAP) EPAs for Geriatric Medicine (AGS/ADGAP EPAs). The geriatrics EPAs describes a geriatricians fundamental expertise and how geriatricians differ from general internists and family practitioners who care for older adults.

Chief Resident Immersion Training in the Care of Older Adults: An Innovative Interspecialty Education and Leadership Intervention

Chief residents (CRs) play a crucial role in training residents and students but may have limited geriatrics training or formal preparation for their CR role. A 2‐day off‐site chief resident immersion training (CRIT) addressed these challenges. Objectives were to foster collaboration between disciplines in the management of complex older patients, increase knowledge of geriatrics principles to incorporate into teaching, enhance leadership skills, and help CRs develop an achievable project for implementation in their CR year. Three cohorts totaling 47 trainees and 18 faculty mentors from 13 medical and surgical disciplines participated over 3 successive years. The curriculum, developed and taught by a multidisciplinary team, featured an interactive surgical case, mini‐lectures on geriatrics topics, seminars to enhance teaching and leadership skills, and one‐on‐one mentoring to develop a project in geriatric care or education. Evaluation included pre‐ and postprogram tests and self‐report surveys and two follow‐up surveys or interviews. In 2006 and 2007, scores on a 12‐item objective knowledge test increased significantly (P<.001) from before to immediately after CRIT. Self‐report knowledge and confidence in teaching geriatrics also increased significantly (P<.05) in all formally covered topics. Mean enhancement of CR skills was 4.3 (1=not at all, 5=very much). Eleven months after CRIT, all but five CRs had implemented at least part of their action projects. CRs reported improved care of older patients, better leadership skills, more and better geriatrics teaching, and more collaboration between disciplines. A 2‐day interactive program for CRs can increase institutional capacity regarding geriatrics teaching and care of elderly patients across medical specialties.

Multisite geriatrics clerkship for fourth-year medical students: a successful model for teaching the Association of American Medical Colleges' core competencies.

As the population ages, it is important that graduating medical students be properly prepared to treat older adults, regardless of their chosen specialty. To this end, the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation convened a consensus conference to establish core competencies in geriatrics for all graduating medical students. An ambulatory geriatric clerkship for fourth‐year medical students that successfully teaches 24 of the 26 AAMC core competencies using an interdisciplinary, team‐based approach is reported here. Graduating students (N=158) reported that the clerkship was successful at teaching the core competencies, as evidenced by positive responses on the AAMC Graduation Questionnaire (GQ). More than three‐quarters (80–93%) of students agreed or strongly agreed that they learned the seven geriatrics concepts asked about on the GQ, which cover 14 of the 26 core competencies. This successful model for a geriatrics clerkship can be used in many institutions to teach the core competencies and in any constellation of geriatric ambulatory care sites that are already available to the faculty.

Use of an Online Curriculum to Teach Delirium to Fourth‐Year Medical Students: A Comparison with Lecture Format

Web‐based learning methods are being used increasingly to teach core curriculum in medical school clerkships, but few studies have compared the effectiveness of online methods with that of live lectures in teaching the same topics to students. Boston University School of Medicine has implemented an online, case‐based, interactive curriculum using videos and text to teach delirium to fourth‐year medical students during their required 1‐month Geriatrics and Home Medical Care clerkship. A control group of 56 students who received a 1‐hour live delirium lecture only was compared with 111 intervention group students who completed the online delirium curriculum only. Evaluation consisted of a short‐answer test with two cases given as a pre‐ and posttest to both groups. The total possible maximum test score was 34 points, and the lowest possible score was −8 points. Mean pre‐ and posttest scores were 10.5 ± 4.0 and 12.7 ± 4.4, respectively, in the intervention group and 9.9 ± 3.5 and 11.2 ± 4.5, respectively, in the control group. The intervention group had statistically significant improvement between the pre‐ and posttest scores (2.21‐point difference; P < .001), as did the control group (1.36‐point difference; P = .03); the difference in test score improvement between the two groups was not statistically significant. An interactive case‐based online curriculum in delirium is as effective as a live lecture in teaching delirium, although neither of these educational methods alone produces robust increases in knowledge.

Professionalism and evolving concepts of quality.

For much of the twentieth century, quality of care was defined specifically in terms of physician characteristics and behaviors. High-quality physicians were well trained, knowledgeable, skillful, and compassionate. More recently, quality of care has been defined in terms of systems of care. High-quality organizations develop and adopt practices to reduce adverse events and optimize outcomes. This essay discusses this transformation from physician-based to organization-based concepts of quality and the consequences for patient care and medical professionalism.

Models of physician education for alzheimer's disease and dementia : Practical application in an integrated network

ABSTRACT Two models were used to provide ongoing education about Alzheimers disease for primary care physicians in a Veterans Health Administration (VHA) network including 8 facilities. The Train the Trainer model developed by the John A. Hartford Foundation and the American Geriatrics Society was used to prepare physician leaders to conduct Memory Loss Tool Kit sessions for colleagues in their VHA settings. Videoconference techniques were used to present case-based Grand Rounds about best practices around particular patient situations. Methods and evaluation of both programs are discussed. Successful follow-through by physician leaders requires ongoing incentives and support. The Videoconference Grand Rounds Program requires skill to initiate and maintain effective technology. Both programs demonstrate successful outcomes.