The May issue of Academic Medicine contained a special mini-section of three papers focused on geriatrics education and training. All three highlight interesting programs from foundation partners aimed at improving the preparation of the health care workforce to meet the needs of its principal customers--older adults. Two of the papers give us good news about the impact of programs funded by the Donald W. Reynolds Foundation. First, Mitch Hefflin and colleagues from all over the country described the Reynolds-funded faculty development consortium, FD-AGE (Faculty Development to Advance Geriatric Education). And, second, William Moran of the Medical University of South Carolina (MUSC), one of the 40 medical schools that have received major Reynolds educational grants in the last ten years, described the impact of the Aging Q3 project—Quality Education, Quality Care, Quality of Life.
The Good
Both projects described impressive results: In six years, the FD-AGE consortium has supported 84 fellows for advanced (post-clinical) training as educators. It provided mini-fellowships or intensive review courses to 899 current physician faculty, mostly non-geriatricians, greatly expanding the nation's teaching capacity. And it has sent consulting teams to 65 individuals or institutions concerned about improving teaching about geriatric care. As for MUSC, its project designs a comprehensive, multipronged effort built upon the ACOVE criteria to improve the training of medical residents.
The Ugly
However, the remaining paper, funded by our colleagues at the Josiah Macy Jr. Foundation and by the American Board of Internal Medicine Foundation, shows how far we have to go to improve the care of older adults and how hard it may be. This paper is really a companion to a descriptive paper published almost three years ago, which I've called the Most Terrifying Ever. In the original paper, Eric Holmboe and Lorna Lynn and their colleagues at the American Board of Internal Medicine (ABIM) described the abysmal quality of care of older adults as assessed by the ACOVE criteria and the profound lack of infrastructure for teaching good chronic care in a large sample of internal and family medicine residencies. This new paper is the other shoe to drop—a report of the results of the quality improvement intervention designed to improve the practices' performance.
In this paper, "Comparative Trial of a Web-Based Tool to Improve the Quality of Care Provided to Older Adults in Residency Clinics: Modest Success and Tough Road Ahead," we finally see on paper the disturbing results many of us in the field heard about a few years ago. First, the ugly baseline data: As reported in 2009, the percentage of indicated care delivered at baseline by the 17 residency programs the authors studied (as measured by audit of the medical charts) was disappointing. For non-geriatric specific processes, the programs delivered between 30 and almost 90 percent of indicated care, spanning from recording level of exercise to recording presence of chronic medical conditions. For geriatric issues, the rates were much lower, ranging from below 10 percent for screening for assessing end-of-life preference, around 15 percent for screening for fall risk, up to just over 30 percent for documenting vision testing.
For the study, the 17 programs were randomized to work on improving their falls screening or end-of-life planning (their choice) via the COVE PIM (Care of Vulnerable Elderly Practice Improvement Module), the ABIM's authorized practice improvement module designed to be part of the mandatory maintenance of board certification process. Some 525 residents participated in the intervention arm, with the authors extracting data from 668 patients, plus 677 residents with 910 patients in the control group, making this a very substantial undertaking indeed.
The Bad
The news from the trial isn’t so much bad as mediocre. On the plus side, the COVE PIM intervention seems to have worked; in every domain that practices focused on, intervention practices improved more than the control practices. The bad news is that the improvements weren't large and the endpoint was substantially below what anyone would say was acceptable. The rate of screening for falls risk rose in intervention clinics from around 11 percent to 34 percent--much bigger than the increase from 11 percent to 21 percent in control groups, but still not reaching anything like the reliable delivery of indicated care we would like to expose trainees to in their formative years. Similarly, while improvements in end-of-life care were significantly greater in practices targeting those issues than control practices, performance still capped out below 20 percent, meaning residents documented the care preferences or surrogate decision maker of only one in five appropriate patients.
I must say that I found the paper extremely thoughtful and technically excellent. The quality of the research far exceeds the norm for empirical studies in Academic Medicine. And the authors are entirely professional, measured, and cautious. Nevertheless, they write, "In conclusion, we believe that medical educators should feel— and act on— a sense of urgency both to advance the care of older adults seen in training settings and to move QI research forward in training across multiple sites."
If you put this all together, it tells me that we know a lot about how we could improve training. The Reynolds’ programs, as well as our own Centers of Excellence and work in the internal medicine specialties and surgical specialties, have yielded powerful training tools and examples. But there is still a lack of will on the part of leaders in health professions education and health delivery systems to give the care of older adults the attention it deserves. I don't know what we can say that we haven't already said, but I invite any and all suggestions as to how we can spread that "sense of urgency" we need to drive change.