Rotation Description

A 4-week geriatrics rotation is required for all IM postgraduate year (PGY)–2 residents at NYPH-WCC. Each resident has 3 weeks of inpatient geriatrics (2 weeks of day coverage and 1 week of night coverage providing direct care for 8 to 10 patients with medical illnesses from the community and nursing homes) and 1 week (5 weekdays) in an outpatient SBP module (SBP-OM). The PGY-1 residents do not participate, while PGY-3 residents are assigned to the rotation to ensure adequate coverage, but do not repeat the SBP experience. The inpatient team is led by a faculty geriatrician. The home base is the 19-bed ACE unit, but the unit is not closed and the team is not strictly geographic.

The SBP-OM represents a multicomponent intervention with exposures to different sites of care and resources available to older adults. These exposures include observation, direct patient care, team meetings, and private tutorials. Residents have opportunities for self-directed learning through readings and an online module. table 1 outlines the weeklong SBP-OM, and the 2011–2012 handout describing each activity is provided as online supplemental material.

TABLE 1 Systems-Based Practice (Outpatient) Week Schedule

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Evaluation Methods

On the final day of the SBP-OM, residents complete a 10-item survey unique to the rotation, rating the educational value of each component on a 5-point Likert scale along with space for qualitative feedback via open-ended comments. Residents also are evaluated via a case presentation during the weekly geriatrics division meeting, and with an oral examination.

A member of the geriatrics faculty (T.D.C. 75% of the time) administers an oral examination. The examination is designed to ensure residents read, contemplate, and integrate their experiences, and is graded pass/fail. It consists of a written case the resident is asked to analyze; the resident's case presentation of a patient whom the resident evaluated during the week; and the answers to 2 questions integrating SBP topics.

A written examination testing knowledge of services and programs available to older adults was administered in June 2012 to IM residents of all levels, independent of the geriatrics rotation. It asked residents about their interest in geriatrics and whether those exposed to the SBP-OM had applied what they had learned. This was scored and analyzed with standard statistical methods using SPSS version 19 (IBM Corp).

The American College of Physicians administers an In-Training Examination (ITE) each fall. We tabulated average ITE percentile for overall and geriatrics content for 2010–2013, the years for which the residency program had summary statistics.

Approval to analyze data for study purposes was obtained from the Weill Cornell Medical College Institutional Review Board.

Residents' Evaluation of the SBP-OM

In 2011–2012, 49 residents rotated through geriatrics, and 47 residents took the examination and completed the evaluation. The mean scores for the evaluation of the SBP-OM are shown in table 2. All components except the online elder abuse self-study achieved scores of greater than 4 out of 5. The self-study discontinued halfway through the year, and residents learned about elder abuse through their long-term care experience. A modification for the 2012–2013 year included an experience at a community-based agency to give residents more exposure to healthy, community-dwelling older individuals.

TABLE 2 Resident Evaluation of the Components of the Systems-Based Practice Week^a

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The mean overall score was 4.76. The 2 highest-rated experiences were the case presentation at team meeting (4.78) and the geriatric home visits (4.73), with 1 resident commenting on the positive experience:

Overall, [I] very much appreciated seeing the aspects of care for geriatrics (or really any) patients such as care in a nonhospital setting, rehab and nursing facilities, and private care management, which we typically only see in acutely ill hospitalized patients. Enjoyed the home visits as well, very enlightening.

Evaluation of the Residents' Performance

In advance, residents were provided 10 possible questions they might be asked during the oral examination; 2 were randomly chosen at the time of the examination. Topics included the following: (1) hospice: what it is, its levels of care, and eligibility; (2) pharmacologic and nonpharmacologic (including hospice) care for someone actively dying at home; (3) what Program of All-Inclusive Care of the Elderly (PACE) is, how it works, and how it is funded; (4) differences and similarities between PACE and private geriatric care management services; (5) programs that enable the patient to remain at home and how they are accessed; (6) senior housing options and how they are paid for; (7) specific services a homebound patient can receive at home and how they are paid for; (8) how different programs manage care transitions; (9) benefits and barriers of doing house calls; and (10) environmental problems faced by older patients and how the home can be modified. All residents passed their oral examination.

Evaluation of SBP Knowledge

A written questionnaire, based on the assigned readings, was administered in June 2012 to residents from all 3 years (the complete questionnaire is available from the authors). At the time, the PGY-2 residents were the only residents who had been exposed to the SBP-OM. The PGY-3 and PGY-1 residents who had not participated in the intervention were used as comparison groups. Responses from incoming interns (starting June 2012) were used to determine baseline knowledge of geriatrics before residency. There were a few statistically significant differences among the 4 classes, but none reflected a training effect.

Self-Assessment About Geriatrics

Residents were asked to rate interest in geriatrics before and after participating in the SBP-OM. Only 1 reported lower interest, and 13 (56%) reported an improved interest (Z  =  −2.952; P  =  .003; Wilcoxon signed rank test).

Residents also were asked if they had applied what they had learned about systems of care clinically outside the geriatrics rotation. Of 23 PGY-2 residents who answered, 18 (78%) said yes; 22 of 25 PGY-2 residents (88%) reported they learned from other residents or taught other residents about their own geriatrics experiences.

The third set of questions asked if the SBP-OM had a lasting impact. More than 90% (21 of 23) of participating residents reported the module left a lasting impression on how they care for their patients, and nearly 95% (22 of 23) reported their knowledge of geriatrics was enhanced.

Standardized Measure of Geriatrics Knowledge

We examined the aggregate ITE scores (by percentile) for the PGY-2 and PGY-3 classes during the past 3 years to assess whether there was an impact on geriatrics knowledge. These scores are presented in table 3. The PGY-2 residents in 2010, before the initiation of the new rotation, scored in the 41st percentile in geriatrics and the 53rd percentile overall. In 2011 (approximately halfway through the first year of the new rotation), the same cohort scored in the 63rd percentile in geriatrics (49th percentile overall). The PGY-2 residents in 2011 scored in the 82nd percentile in geriatrics in 2011 (84th percentile overall), and as PGY-3 residents in 2012 they scored in the 76th percentile in geriatrics (62nd percentile overall). Current PGY-2 residents scored in the 89th percentile in geriatrics and 79th percentile overall in 2012. The improvement was not sustained in 2013, where PGY-3 performance dropped markedly in geriatrics, although not to prerotation levels.

TABLE 3 Comparative In-Training Examination Performance by Year^a

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Feasibility

Faculty time to develop the curriculum, including visiting the out-of-hospital sites, was approximately 0.5 full-time equivalent once a week. Coordinating schedules and managing the evaluations require 5% effort with additional concentrated effort (another 20 hours) at the end of the year for program assessment and improvement. The outside agencies received no reimbursement; they valued the relationship and the potential for patient referrals.

Our 4-week mandatory geriatrics rotation for PGY-2 residents has had a positive impact by a variety of measures. The SBP-OM was highly rated; residents were able to answer questions in an oral examination based on its content, and reported that their experience enhanced their awareness of geriatrics and left a lasting impression on how they would care for older patients.

Our intervention has limitations. It was implemented at a single institution, and the results may not generalize. To capture knowledge about clinical geriatrics, we used ITE scores, and improvements may also have been due to changes in rotation structure or a cohort effect.

The results of the 2012 written SBP test of knowledge, however, failed to support the SBP-OM effectiveness. This failure may be due to a variety of possibilities, alone or in combination. Although based on the SBP-OM, the test may have failed to capture what residents actually learn. Mediocre test performance may have reflected resident priorities; they may appreciate the acquaintance with programs and services but remain uninterested in the specific details that other professionals, such as social workers, know. We have eliminated testing of specific knowledge and instead plan to focus more on objective measures of behavioral change and translation into entrustable professional activities.

Overall, results suggest that the addition of the SBP-OM was a positive complement to our geriatric curriculum, even though the results of the 2012 written SBP test of knowledge failed to support the SBP-OM effectiveness.