Journal of General Internal Medicine

, Volume 29, Issue 6, pp 940–946

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

  • Anna Chang
  • Helen Fernandez
  • Danelle Cayea
  • Shobhina Chheda
  • Miguel Paniagua
  • Elizabeth Eckstrom
  • Hollis Day
Perspective

ABSTRACT

Internal 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.

KEY WORDS

medical education graduate assessment/evaluation geriatrics aging care transitions comorbidity 

REFERENCES

  1. 1.
    Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513–6.PubMedCrossRefGoogle Scholar
  2. 2.
    Iglehart JK. Health reform, primary care, and graduate medical education. N Engl J Med. 2010;363(6):584–90.PubMedCrossRefGoogle Scholar
  3. 3.
    Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system–rationale and benefits. N Engl J Med. 2012;366(11):1051–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Lynn LA, Hess BJ, Conforti LN, Lipner RS, Holmboe ES. Clinic systems and the quality of care for older adults in residency clinics and in physician practices. Acad Med. 2009;84(12):1732–40.PubMedCrossRefGoogle Scholar
  5. 5.
    Lynn L, Hess BJ, Weng W, Lipner RS, Holmboe ES. Gaps in quality of diabetes care in internal medicine residency clinics suggest the need for better ambulatory care training. Health Aff. 2012;31(1):150–8.CrossRefGoogle Scholar
  6. 6.
    Holmboe ES, Sherbino J, Long DM, Swing SR, Frank JR. The role of assessment in competency-based medical education. Med Teach. 2010;32(8):676–82.PubMedCrossRefGoogle Scholar
  7. 7.
    Green ML, Aagaard EM, Caverzagie KJ, Chick DA, Holmboe E, Kane G, et al. Charting the road to competence: Developmental milestones for internal medicine residency training. J Grad Med Educ. 2009;1(1):5–20.PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542–7.PubMedCrossRefGoogle Scholar
  9. 9.
    Caverzagie KJ, Iobst WF, Aagaard EM, Hood S, Chick DA, Kane GC, et al. The internal medicine reporting milestones and the next accreditation system. Ann Intern Med. 2013;158(7):557–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Brotherton SE, Etzel SI. Graduate medical education, 2011–2012. JAMA. 2012;308(21):2264–79.PubMedCrossRefGoogle Scholar
  11. 11.
    Chang A, Bowen JL, Buranosky RA, Frankel RM, Ghosh N, Rosenblum MJ, et al. Transforming primary care training-patient-centered medical home entrustable professional activities for internal medicine residents. J Gen Intern Med. 2012 Sep 21.Google Scholar
  12. 12.
    Landefeld CS, Callahan CM, Woolard N. General internal medicine and geriatrics: Building a foundation to improve the training of general internists in the care of older adults. Ann Intern Med. 2003;139(7):609–14.PubMedCrossRefGoogle Scholar
  13. 13.
    Thomas DC, Leipzig RM, Smith LG, Dunn K, Sullivan G, Callahan E. Improving geriatrics training in internal medicine residency programs: Best practices and sustainable solutions. Ann Intern Med. 2003;139(7):628–34.PubMedCrossRefGoogle Scholar
  14. 14.
    Williams BC, Warshaw G, Fabiny AR, Lundebjerg Mpa N, Medina-Walpole A, Sauvigne K, et al. Medicine in the 21st century: Recommended essential geriatrics competencies for internal medicine and family medicine residents. J Grad Med Educ. 2010;2(3):373–83.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    The portal of geriatrics online education [Internet]: ADGAP; 2013 [updated 2013; cited December 13, 2013]. Available from: http://www.pogoe.org/.
  16. 16.
    Heflin MT, Bragg EJ, Fernandez H, Christmas C, Osterweil D, Sauvigne K, et al. The Donald W. Reynolds consortium for faculty development to advance geriatrics education (FD AGE): A model for dissemination of subspecialty educational expertise. Acad Med. 2012;87(5):618–26.PubMedCrossRefGoogle Scholar
  17. 17.
    American Academy of Family Physicians. Joint principles of the patient-centered medical home. Del Med J. 2008;80(1):21–2.Google Scholar
  18. 18.
    Boyd CM, Boult C, Shadmi E, Leff B, Brager R, Dunbar L, et al. Guided care for multimorbid older adults. Gerontologist. 2007;47(5):697–704.PubMedCrossRefGoogle Scholar
  19. 19.
    Counsell SR, Callahan CM, Buttar AB, Clark DO, Frank KI. Geriatric resources for assessment and care of elders (GRACE): A new model of primary care for low-income seniors. J Am Geriatr Soc. 2006;54(7):1136–41.PubMedCrossRefGoogle Scholar
  20. 20.
    Leff B, Burton L, Mader SL, Naughton B, Burl J, Inouye SK, et al. Hospital at home: Feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005;143(11):798–808.PubMedCrossRefGoogle Scholar
  21. 21.
    Gentili A. Falls Clinical Evaluation Exercise (Mini-CEX). [Internet] POGOe - Portal of Geriatric Online Education; 2011; cited December 13, 2013. Available from: http://www.pogoe.org/productid/20915
  22. 22.
    Cumbler E, Guerrasio J. Competency-Based Test of Inpatient Geriatric Management Skills. [Internet] POGOe - Portal of Geriatric Online Education; 2009; cited December 13, 2013. Available from: http://www.pogoe.org/productid/20596
  23. 23.
    Parry C, Min SJ, Chugh A, Chalmers S, Coleman EA. Further application of the care transitions intervention: Results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q. 2009;28(2–3):84–99.PubMedCrossRefGoogle Scholar
  24. 24.
    AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults [Internet]: The American Geriatric Society; 2012; cited December 13, 2013. Available from: http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2012
  25. 25.
    Ehrlich A, Freeman K. Clinical Evaluation Exercise (Mini-CEX) Mini-Cog. [Internet] POGOe - Portal of Geriatric Online Education; 2011; cited December 13, 2013. Available from: http://www.pogoe.org/productid/20814
  26. 26.
    C. Bree Johnston. MMSE CEX. [Internet] POGOe - Portal of Geriatric Online Education; 2009; cited December 13, 2013. Available from: http://www.pogoe.org/productid/20544
  27. 27.
    Paniagua M, van Zuilen R, Silver I. The “Three D’s” of Cognitive Impairment: An Interactive Card-sorting Exercise. [Internet] MedEdPORTAL; 2006; cited December 13, 2013. Available from: www.mededportal.org/publication/243
  28. 28.
    Roche V, Oksenberg L. Systems-Based Approach to Delirium for Multiple Learners-Interactive Web Module. [Internet] POGOe - Portal of Geriatric Online Education; 2011; cited December 13, 2013. Available from: http://www.pogoe.org/productid/20815
  29. 29.
    Marengoni A, Angleman S, Melis R, Mangialasche F, Karp A, Garmen A, et al. Aging with multimorbidity: A systematic review of the literature. Ageing Res Rev. 2011;10(4):430–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Three or More – Managing Multiple Health Problems in Older Adults, Guiding Principles for the Care of Older Adults with Multimorbidity [Internet]: The American Geriatric Society; 2012; cited December 13, 2013. Available from: http://www.americangeriatrics.org/health_care_professionals/clinical_practice/multimorbidity
  31. 31.
    Catherine DuBeau. CHAMP (Curriculum for the Hospitalized Aging Medical Patient): Foley Catheter Use. [Internet] POGOe - Portal of Geriatric Online Education; 2009; cited December 13, 2013. Available from: http://www.pogoe.org/productid/18925
  32. 32.
    Axon N, Moran W. Aging Q3 Curriculum to Improve Discharge Summary Quality. [Internet] POGOe - Portal of Geriatric Online Education; 2012; cited December 13, 2013. Available from: http://www.pogoe.org/productid/21011
  33. 33.
    Wang M. Discharge Assessment Tool (dCEX). [Internet] POGOe - Portal of Geriatric Online Education; 2011; cited December 13, 2013. Available from: http://www.pogoe.org/productid/20808
  34. 34.
    Thompson K. Interprofessional Team Encounter: Skills Self-Assessment and Reflective Writing Assignment for Internal Medicine Residents. [Internet] POGOe - Portal of Geriatric Online Education; 2012; cited December 13, 2013. Available from: http://www.pogoe.org/productid/21208
  35. 35.
    Ehrlich A, Greenberg D. Communication Skills for Geriatrics Fellowship: Clinical Evaluation Exercise (CEX): Videotaped Interview of a Geriatric Patient. [Internet] POGOe—Portal of Geriatric Online Education; 2013; cited December 13, 2013. Available from: http://www.pogoe.org/productid/21024
  36. 36.
    Caverzagie KJ. Lens for assessment of competence. 2013; Society of General Internal Medicine Annual Meeting Workshop.Google Scholar
  37. 37.
    The alliance for academic internal medicine resident end-of-training entrustable professional activities [Internet]: The Alliance for Academic Internal Medicine; 2013; cited December 13, 2013]. Available from: http://www.im.org/AcademicAffairs/milestones/Pages/EndofTrainingEPAs.aspx.
  38. 38.
    Salas E, Almeida SA, Salisbury M, King H, Lazzara EH, Lyons R, et al. What are the critical success factors for team training in health care? Jt Comm J Qual Patient Saf. 2009;35(8):398–405.PubMedGoogle Scholar
  39. 39.
    Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: Effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD000072. doi(3):CD000072.Google Scholar
  40. 40.
    Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: An insidious contributor to medical mishaps. Acad Med. 2004;79(2):186–94.PubMedCrossRefGoogle Scholar
  41. 41.
    Sochalski J, Jaarsma T, Krumholz HM, Laramee A, McMurray JJV, Naylor MD, et al. What works in chronic care management: The case of heart failure. Health Aff. 2009;28(1):179–89.CrossRefGoogle Scholar
  42. 42.
    Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team-based care interventions for hypertension. Arch Intern Med. 2009;169(19):1748.PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Saba GW, Villela TJ, Chen E, Hammer H, Bodenheimer T. The myth of the lone physician: Toward a collaborative alternative. Ann Fam Med. 2012;10(2):169–73.PubMedCentralPubMedCrossRefGoogle Scholar
  44. 44.
    Mitchell, Pamela, et al. “Core principles & values of effective team-based health care.” Discussion Paper (2012).Google Scholar
  45. 45.
    Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the medicare fee-for-service program. N Engl J Med. 2009;360(14):1418–28.PubMedCrossRefGoogle Scholar
  46. 46.
    Robinson S, Howie-Esquivel J, Vlahov D. Readmission risk factors after hospital discharge among the elderly. Popul Health Manag. 2012;15(6):338–51.PubMedCrossRefGoogle Scholar
  47. 47.
    Snow V, Beck D, Budnitz T, Miller DC, Potter J, Wears RL, et al. Transitions of care consensus policy statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. J Hosp Med. 2009;4(6):364–70.PubMedCrossRefGoogle Scholar
  48. 48.
    Njeim M, Chiha M, Whitehouse S, Baker-Genaw K. System-based approach to educating internal medicine residents on preventable hospital readmissions. J Grad Med Educ. 2012;4(4):505–9.PubMedCentralPubMedCrossRefGoogle Scholar
  49. 49.
    Record JD, et al. “Reducing heart failure readmissions by teaching patient-centered care to internal medicine residents”. Arch of Intern Med. 2011;171(9):858.CrossRefGoogle Scholar
  50. 50.
    American Geriatrics Society. Beers Criteria Update Expert Panel. American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.CrossRefGoogle Scholar
  51. 51.
    American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. Patient-centered care for older adults with multiple chronic conditions: A stepwise approach from the American Geriatrics Society: American Geriatrics Society expert panel on the care of older adults with multimorbidity. J Am Geriatr Soc. 2012 Oct;60(10):1957–68.Google Scholar
  52. 52.
    Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009 Sep 16;9:166,6963-9-166.Google Scholar

Copyright information

© Society of General Internal Medicine 2014

Authors and Affiliations

  • Anna Chang
    • 1
  • Helen Fernandez
    • 2
  • Danelle Cayea
    • 3
  • Shobhina Chheda
    • 4
  • Miguel Paniagua
    • 5
  • Elizabeth Eckstrom
    • 6
  • Hollis Day
    • 7
  1. 1.Division of Geriatrics, Department of MedicineUniversity of California San FranciscoSan FranciscoUSA
  2. 2.Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.Division of Geriatric Medicine and GerontologyJohns Hopkins University School of MedicineBaltimoreUSA
  4. 4.Division of General Internal Medicine, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  5. 5.Division of General Internal MedicineSaint Louis University School of MedicineSt LouisUSA
  6. 6.Division of General Internal Medicine & GeriatricsOregon Health & Science UniversityPortlandUSA
  7. 7.Division of General Internal MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA

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