Nov 15, 1989 - Roy Alan Fox, MD,FRCPC, FRCP. Avram Mark ... Reprint requests to: Dr. Roy Alan Fox, Division of Geriatric. Medicine ..... Skyline Hotel, Ottawa.
I Educa
dion
Competencies required for the practice of geriatric medicine as a consultant physician Roy Alan Fox, MD, FRCPC, FRCP Avram Mark Clarfield, MD, CCFP, CSPQ, FRCPC David Bryan Hogan, MD, FRCPC, FACP
Geriatric medicine in Canada is now being viewed not merely as an academic specialty but, rather, more broadly as a service specialty providing consulting support to other physicians. Any redesigning of training programs will have to be done with this fact in mind. We drew up a list of competencies required for consultant practice in the field and presented them to other practitioners of geriatric medicine and members of the Canadian Society of Geriatric Medicine for feedback. We believe that the resulting list of competencies can be used as a starting point for redesigning training programs in geriatric medicine. Au Canada on considere maintenant la geriatrie non seulement comme une discipline scientifique mais, de facon plus large, comme une specialite dont le praticien se met au service de ses confreres non geriatres par voie de consultation. On devra en tenir compte en restructurant les programmes de formation. Les auteurs ont etabli une liste des elements de competence necessaires h celui qui exercera de cette facon; ils ont demande k leurs collegues gfriatres et aux membres de la Societe canadienne de geriatrie de la commenter. Ils croient que la liste ainsi amendee pourrait servir de point de depart k la restructuration dont il est question. Dr. Fox is a professor with the Department of Medicine and head of the Division of Geriatric Medicine, Dalhousie University, Halifax, Dr. Clarfield is an associate professor with the departments of Family Medicine and Internal Medicine, associate director of the McGill Centre for Studies on Aging and director of the Division of Geriatrics, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, and Dr. Hogan is an assistant professor with the Department of Medicine, Division of Geriatric Medicine, Dalhousie University.
Reprint requests to: Dr. Roy Alan Fox, Division of Geriatric Medicine, Camp Hill Hospital, 1763 Robie St., Halifax, NS B3H3G2
G eriatric medicine was recognized as a medical specialty in Canada by the Council of the Royal College of Physicians and Surgeons of Canada in 1977.1 At that time it was decided to restrict entry for the certification examination to those with prior qualification in internal medicine in spite of strong sentiment within the Committee on Specialties of the Royal College to open entry to other specialties such as psychiatry, physical medicine and rehabilitation, and neurology.2 Recognition of the specialty was not universally accepted. Bodies such as the College of Family Physicians of Canada and the CMA expressed reservations. Within the Royal College itself the Specialty Committee in Internal Medicine twice passed a motion deploring the establishment of a specialty of geriatrics.3'4 It appears that the primary role foreseen for the specialty was academic (i.e., teaching and research); it was not envisioned that specialists in geriatric medicine would be involved to any great extent in pure service activities. The precise role for specialists in geriatric medicine continues to be discussed in Canada. The recent report on health care of the elderly published by the CMA has stimulated renewal of the debate, which has centred on the recommendation "that geriatric medicine become a primary specialty for certification of the [Royal College]"5 and the suggestion that prior training in family medicine be recognized as fulfilling part of the requirements for Royal College certification. Related concerns have been expressed about the specifics of training programs, such as how much time is spent in which rotations. We feel this discussion is still premature. A new perspective of geriatric medicine appears to be evolving. The field is no longer being viewed as merely an academic specialty. Rather, it is being viewed more broadly as a service specialty providing consulting support to other physicians to improve the management of a subset of elderly Canadians. Any redesigning of training programs will have to be done with this fact in mind. There CMAJ, VOL. 141, NOVEMBER 15, 1989
1045
is no support within such bodies as the Canadian Society of Geriatric Medicine for the specialty's becoming a primary care service for elderly people. Harden6 outlined several essential steps in planning an educational program. The first is to determine needs relative to the "product" of the training program. In this article we outline the competencies (the "needs") that we believe are required for consultants in geriatric medicine. We feel that there is general support for these competencies within the Canadian Society of Geriatric Medicine and that any redesigning of training programs in geriatric medicine should use them as a starting point. We did not determine specific objectives for instruction and evaluation in geriatric medicine; this is a closely allied but separate question.6'7
Methods We first reviewed four published lists of training objectives in geriatric medicine.8-11 One of us (R.A.F.) then carried out a task analysis of his practice. He defined the competencies that he felt were required in his everyday clinical duties as a busy consultant in geriatric medicine. Eleven competencies were itemized and sent to 13 colleagues practising geriatric medicine in Canadian academic centres with residency training programs
and to members of the executive of the Canadian Society of Geriatric Medicine. After initial feedback the list of competencies was expanded and categorized into the areas of knowledge, attitudes and skills. We sent the revised list to all 131 members of the Canadian Society of Geriatric Medicine and asked for their input. Fourteen thoughtful written replies were received. On Sept. 23, 1988, a meeting was held in Ottawa to discuss training in geriatric medicine. This meeting coincided with the a-nnual meeting of the society as part of the annual meeting of the Royal College. Approximately 45 practitioners and trainees in geriatric medicine attended the meeting and were given the opportunity to respond to the proposed list of competencies. At every stage alterations were made in response to feedback. Following is a list of the delineated competencies.
* To demonstrate an awareness and knowledge of sensory losses resulting from aging and disease, as well as familiarity with current modes of treatment. * To demonstrate particular expertise in areas of clinical neurology and assessment of musculoskeletal problems as they relate to the elderly. * To demonstrate awareness and competence in dealing with psychiatric problems - in particular, acute confusional states, the dementing illnesses, depression and the paranoid states. * To have a mastery of the principles of rehabilitative medicine as it relates to frail elderly patients with coexistent acute and chronic illnesses. * To have an awareness and a comprehension of social issues as they relate to the care of individual patients. * To demonstrate appropriate knowledge of basic gerontology, including areas such as the biology of aging and the relevant social sciences. * To have knowledge of the epidemiologic issues of aging, diseases of the aged, health care delivery, health promotion and disease prevention. Attitudes
* To manifest the appropriate attitudes required for managing ill, elderly patients and their families. The practitioner needs to be compassionate, patient and sensitive to negative stereotyping of elderly patients (ageism) and be able to educate others about such stereotyping. * To practise a comprehensive (holistic) type of medicine, the various factors that come into play in the appropriate management of elderly patients being kept in mind. This individualization of care underscores the emphasis given to ensuring as much patient autonomy as possible in decisionmaking. * To demonstrate appropriate attitudes toward other members of the health care team, to recognize their unique contributions as health care professionals and to foster an interdisciplinary team approach. To demonstrate appropriate attitudes to all care providers in various settings, including nursing homes and other long-term-care institutions. Skills
Competencies required Knowledge * To demonstrate competence in general intemal medicine, which is required for effective diagnosis and therapy of disease in elderly patients referred for consultation. This includes knowledge of pharmacologic alterations associated with aging and the special problems of polypharmacy, overmedication and iatrogenic disease. 1046
CMAJ, VOL. 141, NOVEMBER 15, 1989
* To perform or interpret a comprehensive geriatric assessment (including assessment of physical health, mental health, functional status, socioeconomic status and environmental factors) and to evaluate the following clinical problems: confusion or memory failure, falling or postural instability, reduced mobility, incontinence of urine, bowel dysfunction (constipation or fecal incontinence) and difficulties in activities of daily living. * To deal effectively with patients with sever-
al interacting problems that may be related to specific diseases, aging or various combinations. To perform preoperative assessments in such patients and provide support in postoperative management. * To develop a critical approach to the interpretation of scientific information and foster research involvement to improve understanding of aging as well as diseases of the aged and to apply these skills to clinical practice. * To demonstrate an awareness of the dangers of inappropriate use of technology in the management of elderly patients and to demonstrate a balance between excessive intervention and a nihilistic approach. This would require knowledge of the precepts of medical ethics. * To deal with interpersonal relationships and family dynamics. * To demonstrate a knowledge of group dynamics and the ability to work effectively in the setting of health care teams. * To have an understanding of and be able to participate in health care planning and policymaking as it relates to the management of elderly patients. * To know when to use the various resources that may be called into play to meet the needs of elderly patients, including health services, social programs, informal help from families and various support groups (e.g., the Alzheimer Society of
Canada). * To demonstrate competence as a physician working with patients in long-term-care institutions and to provide consultant support to primary care physicians and other health care professionals in this setting. Discussion In view of the changing realities of Canadian specialty geriatric practice, we feel that it is essential to reassess our training programs. We believe that in spite of the initial success, the specialty has outgrown its strict academic origins and become a more generally available and desired consulting service. We certainly do not view geriatric medicine as becoming a primary care field, encroaching on the domain of family physicians. We hope that the competencies listed will help bring into focus the requirements for our training programs. It should be emphasized that specialists in geriatric medicine do not claim a monopoly on any of the competencies noted. We advocate that training programs in geriatric medicine pay particular attention to the affective domain. There is a tendency in setting instructional objectives to be satisfied with less important aims because of the availability or ease of evaluation.7 We believe that this would be a mistake. Much of the success of geriatric medicine results from a positive attitude to the elderly patient. This is an area of particular concern as there is evidence that the typical teaching hospital experience may
foster negative attitudes toward the elderly.9,12'13 The competencies listed are wide ranging. To us they underscore the point that geriatric medicine is not solely the "internal medicine of old age". For example, functional assessments are critically important in elderly patients. A framework of function with altered therapeutic goals does not come easily to most physicians trained solely in internal medicine.14 This is not to denigrate the importance of a grounding in internal medicine for exemplary practice in geriatric medicine but, rather, to emphasize the other skills that are required and not usually taught in the context of internal medicine training programs. What should the next steps be? We feel that these competencies should be converted into specific behavioural goals. The content of the curriculum in specialty training programs in geriatric medicine should then be reviewed, with particular attention as to how the various experiences should be organized. This will be a major problem area. The answers are not clear-cut, and the water is muddied by political considerations. We agree with the current movement within the Royal College to decrease the time required in core internal medicine from 3 to 2 years, with a resultant increase from 2 to 3 years in the time spent in a geriatric residency. We believe that this would ease entry into geriatric training programs and would also increase the flexibility of these training programs to help foster the required competencies. It must be emphasized that the opinions expressed in this article are ours alone and not the opinion of any organization. Our hope is to engender constructive debate. On the other hand, we do feel that the competencies listed accurately reflect a consensus among Canadian geriatricians as to the competencies required for consultant practice in the field. If they are used as a starting point, we believe that the potentially divisive issues facing the field can be more rationally approached. Until now all discussion has occurred within the small group of Canadian specialists in geriatric mhedicine. Our hope is that this paper will broaden the base of expertise and experience brought to bear on the question What does (and should) a geriatrician do, anyway?
References 1. Minutes of the Council of the Royal College of Physicians and Surgeons of Canada, Ottawa, Jan 23-24, 1977 2. Minutes of the Committee of Specialties of the Royal College of Physicians and Surgeons of Canada, Ottawa, Dec 3, 1976 3. Minutes of the Specialty Committee in Internal Medicine of the Royal College of Physicians and Surgeons of Canada, Ottawa, Feb 8, 1979 4. Minutes of the Specialty Committee in Internal Medicine of the Royal College of Physicians and Surgeons of Canada, Ottawa, June 11, 1979 5. Health Care of the Elderly -Today's Challenges, Tomorrow's Options, Can Med Assoc, Ottawa, 1987: 41-42 6. Harden RM: Ten questions to ask when p1anniihg a course
CMAJ, VOL. 141, NOVEMBER 15,1989
1047
or curriculum. Med Educ 1986; 20: 356-363 7. Kibler RJ, Cegala DJ, Barker LL et al: Objectives for Instuction and Evaluation, Allyn, Boston, 1974 8. Medical Education in Geriatrics (Health Manpower rep 1/77), Dept of National Health and Welfare, Ottawa, 1977 9. Calkins E: Residency training in geriatric medicine. Bull NY Acad Med 1985; 61: 534-548 10. Steel K, Applegate W, Barry P et al: Guidelines for fellowship training programs in geriatric medicine. J Am Geriatr Soc 1987; 35: 792-795
Spedalty Training Requirements in Geriatric Medicine, Royal College of Physieians and Surgeons of Canada, Ottawa, 1983 12. Spence DL, Feigenbaum EM, Fitzgerald F et al: Medical student attitudes toward the geriatric patient. I Am Geriatr Soc 1968; 16: 976-983 13. Rezler AG: Attitude changes during medical school - a review of the literature. IMed Educ 1974; 49: 1023-1030 14. Libow LS, Cassel CK: Fellowship in geriatrics. Bull NY Acad Med 1985; 61: 547-557
Upcoming Meetings
Mar. 10-17, 1990: 2nd Annual Winter Symposium Whistler Conference Centre, Whistler, BC Continuing Medical Education, Faculty of Medicine, Queen's University, Kingston, Ont. K7L 3N6; (613) 545-2540
continued from page 1035 Feb. 16-21, 1990: "East Meets West" Medical Congress on Recent Advances in Medicine and Surgery (sponsored by the General Practitioner Association of Thailand, the Section of General Practice, British Columbia Medical Association, and the British Columbia Chapter, College of Family Physicians of Canada) Bangkok and Pattaya, Thailand Pat Muss, BC Chapter, College of Family Physicians of Canada, 115-1665 W Broadway, Vancouver, BC V6J 5A4; (604) 736-5551, FAX (604) 736-4675 Feb. 22-23, 1990: The Treatment of Schizophrenics Health Sciences Centre, University of Calgary Continuing Medical Education, Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, Alta. T2N 4N1; (403) 220-7240, FAX (403) 270-2330 Feb. 23-25,1990:. Paediatric Orthopaedics Delta Mountain Inn, Whistler, BC Continuing Education in the Health Sciences, 105-2194 Health Sciences Mall, University of British Columbia, Vancouver, BC V6T 1W5; (604) 228-2626
11.
Mar. 14-16, 1990: Focus on the Future: a National Conference on the Challenge of Health and Safety (in cooperation with Alberta Occupational Health and Safety, Canadian Society of Safety Engineers and Canadian Occupational Health Association) Westin Hotel, Calgary Alberta Hospital Association Education Services, 10009 108 St., Edmonton, Alta. T5J 3C5; (403) 423-1776, ext. 408
Mr. 14-16, 1990: Pediatrics, Obstetrics and Newborn Care Course Health Sciences Centre, University of Calgary Continuing Medical Education, Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, Alta. T2N 4N1; (403) 220-7240, FAX (403) 270-2330 Mar. 16-18, 1990: "Caring Together": a national conference for the AIDS caregiver (sponsored by the Federal Centre for AIDS Working Group on HIV Infection and Mental Health) Delta Bow Valley, Calgary Bruce Mills, conference facilitator, 1589 St. Bernard St., Gloucester, Ont. KlT 3H8; (613) 739-8836, FAX (613) 739-0274
Feb. 25-Mar. 2,1990: 3rd Annual Update in Emergency Medicine Delta Mountain Inn, Whistler, BC Credits: 25 hours, AMA category 1, Canadian Association of Emergency Physicians and CFPC Continuing Medical Education, Faculty of Medicine, Medical Sciences Building, University of Toronto, Toronto, Ont. M4S 1A8; (416) 978-2718
Apr. 5-6, 1990: Calgary Therapeutics Course Health Sciences Centre, University of Calgary Continuing Medical Education, Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, Alta. T2N 4N1; (403) 220-7240, FAX (403) 270-2330
Mar. 8-10, 1990: Therapeutics Program for Internists Kananaskis Lodge, Kananaskis, Alta. Continuing Medical Education, Faculty of Medicine, University of Calgary, 3330 Hospital Dr. NW, Calgary, Alta. T2N 4N1; (403) 220-7240, FAX (403) 270-2330
Apr. 5-6, 1990: 12th Annual Drugs and Geriatric Care Conference Royal York Hotel, Toronto Jill Birch, program manager, Conference and Seminar Services, Humber College Professional Services, 205 Humber College Blvd., Etobicoke, Ont. M9W 5L7; (416) 675-5077, FAX (416) 675-0135
Mar. 9-11,1990: "Cang Together": a national conference for the AIDS caregiver (sponsored by the Federal Centre for AIDS Working Group on HIV Infection and Mental Health) Skyline Hotel, Ottawa Bruce Mills, conference facilitator, 1589 St. Bemard St., Gloucester, Ont. KlT 3H8; (613) 739-8836, FAX (613) 739-0274 1048
CMAJ, VOL. 141, NOVEMBER 15, 1989
Apr. 5-6,1990: Urology Update Ambassador Convention Centre, Kingston, Ont. Continuing Medical Education, Faculty of Medicine, Queen's University, Kingston, Ont. K7L 3N6; (613) 545-2540
continued on page 1064 1
