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How to integrate geriatrics into a surgical residency training program Walter E. Pofahl, MD, FACS You have just finished an uneventful elective sigmoid colectomy on a 75-year-old gentleman with colon cancer. He has well-controlled hypertension, but no other obvious comorbidities were detected during his preoperative office visit. Things are going well until postoperative day three when he develops mental status changes. Subsequent evaluation reveals that he has intra-abdominal sepsis from an anastomotic leak. Appropriate treatment is instituted. When the case is discussed at a morbidity and mortality conference (M&M), what would be the focus of questions and discussions at your institution? Our population is aging, with the greatest growth in people ages 65 and over. This subpopulation also represents the group most likely to require an operation. There is already an overwhelming amount of knowledge required to be mastered, so how do we integrate education on care of the elderly patient into resident training? This article will examine the requisites for the incorporation of geriatrics into a residency training program, including barriers to integration, and keys to success. Many of these principles also apply to the integration of any subject area into residency training. The mission for integrating geriatrics into resident training must be to improve the care of elderly patients. Attempts to integrate it because of mandate or regulation are doomed to failure. There are a number of drivers pushing for this integration. The main impetus is the volume of aging patients faced by most clinicians. This population is being cared for as scrutiny of outcomes and quality of care is just beginning to be examined for surgeons and other health care providers across a broad spectrum of practice settings. Additionally, the care of elderly patients fits in well with current models of systems-based care. Optimal care requires the integration of surgeons, geriatricians, the nursing staff, social workers, and advanced level practitioners. The American Board of Surgery has recognized the need for “familiarity with the special requirements of geriatric surgical patients, including operative care and counseling of patients and families.” Finally, the recognition that elderly patients have unique physiology and other requirements has stimulated interest in geriatric surgery, which is now a viable career path with numerous funding opportunities. There are also a number of barriers to integrating geriatrics into residency training. The most significant of these is the perception that older people are merely normal older adults. However, just as pediatric patients are not smaller, younger adults, elderly patients are not simply older adults. They have unique problems and issues. Another significant barrier is trainees do not find the issues related to geriatrics interesting or “sexy.” Issues like delirium, functional status, and medication prescription practices have a difficult time competing with our technology-driven health care system and training. Integration may be further hampered by a lack of understanding of the problem and/or resources at your institution. Fortunately, there are several keys to the successful integration of geriatrics into a surgical residency training program. It must be important to you (or whoever is leading the charge). As previously stated, the objective to improve the care of older patients must be a priority that you practice and exemplify. Trainees are remarkably perceptive of hypocrisy. You must practice what you preach/teach. If you do not exemplify optimum care of elderly patients, how can you train residents to do so? How can you expect them to provide a level of care that you don’t? The integration must occur in a clinical context. The case scenario described earlier represents an example from common clinical practice. Every elderly patient represents an opportunity to discuss, teach, and demonstrate preoperative assessment and risk determination, goals of care, operative approaches, and postoperative care directed at detecting, preventing, and mitigating complications, especially those unique to elderly patients. Use a multifaceted approach. A significant barrier is lack of interest in geriatric-specific topics. These topics are best approached by limiting lectures and didactic teaching. Instead, address the topics in the context of the daily care of elderly patients. For example, certain medications are contraindicated in elderly patients. Instead of requiring a lecture on the topic, it is much more effective to instruct trainees on this subject by providing them with resources outlining the medications (see Resources) and setting up a system to check for these medications in elderly patients. Use other members of the “team.” Elicit the help of nurses, social workers, and advanced level practitioners. Geriatricians are an invaluable resource and are typically underutilized. All of these professionals have recognized the importance of quality care in elderly patients and are a great resource. Take advantage of “teachable moments” involving elderly patients. Several examples are listed below: Outpatient Clinic: Demonstrate and teach residents how to perform geriatric-specific evaluations that include comorbidity assessment, functional assessment, and cognitive assessment. Excellent tools are found in Geriatrics at Your Fingertips and on the Portal of Geriatric Online Education Web site. Most geriatricians are happy to teach these skills. The outpatient clinic is also an excellent place to discuss perioperative expectations with the patient, their family, and the residents. These expectations should include plans for medications, delirium prevention, functional recovery, and anticipated postoperative care needs. Operating Room: This is the ideal setting to reinforce thermoregulation, appropriate fluid replacement, and the need for a technically perfect operation. Postoperative Unit: Teaching behaviors here should focus on recognition, prevention, and management of complications. Have the residents review the patient’s medication daily. Ask them about side effects, dosages, and interactions in their elderly patients. Help the residents identify and mitigate risk factors for delirium. A team approach that incorporates nurses, social workers, and geriatricians will teach the residents to use a system-based approach to the care of elderly patients. Demonstrate differences in recovery between elderly and younger patients. Conferences: Geriatric-specific topics should have a place in the didactic curriculum. Potential topics include wound healing, nutrition, cognitive changes, and preoperative assessment. The American Geriatrics Society publishes the Geriatrics Syllabus for Specialists. This can serve as an excellent outline for teaching conferences. Skills: Specific assessment skills can be taught and evaluated. The ones of greatest use to surgeons are functional assessment (Activities of Daily Living and Instrumental Activities of Daily Living), ambulation (Get Up and Go Test), and cognitive assessment (Mini Mental Status Exam), all of which are described in Geriatrics at Your Fingertips. Evaluation: Include a case in your mock oral exam process. For the case outlined at the beginning of this article, what would be your line of questioning in M&M? Would it only focus on the technical aspects of the anastomotic leak? Or would you use this as an opportunity to educate trainees on the appropriate preoperative evaluation of elderly patients, including on the topics of functional status, cognitive assessment, and advanced directives? Would you use this opportunity to educate on postoperative cognitive changes and complications in elderly patients? Bringing these areas to focus goes a long way toward acceptance of the importance of geriatrics and its integration into resident training. Resources American Geriatrics Society The American Geriatrics Society (AGS) has a section for surgical and related medical specialties. The section sponsors a program in conjunction with the annual meeting of the AGS. The AGS has a number of resources, including syllabi, monographs, and position statements that can be accessed through their Web site. Geriatrics at Your Fingertips This is a pocketbook published by the AGS. The online and PDA versions are available free of charge. There is a nominal charge for the printed version. This has a multitude of useful information, such as medication information and algorithms for the assessment of common geriatric conditions. New Frontiers in Geriatrics Research This monograph provides an extensive literature review of geriatric diseases across numerous surgical and related specialties, a research agenda for future work, and area that cross multiple specialties. It is available online free of charge. Beers’ list of inappropriate medications Fick DM, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 2003;163:2716-2724 (http://mqa.dhs.state.tx.us/QMWeb/MedSim.htm) This is the updated version of the original list of inappropriate medications. A consensus panel evaluated and revised the original list. Four medications were modified, 11 were removed from the list, and 44 were added to the list. American College of Surgeons Web Portal The Web portal includes a geriatric surgery community. Links to organizations, publications, practice information, and guidelines are provided. Portal of Geriatric Online Education (POGOe) Online December 8, 2006 |
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