Historically, internal medicine residency programs have provided little geriatrics-specific instruction. As the proportion of U.S. individuals over 65 continues to rise, studies indicate that general internists and subspecialists desire more training in geriatrics.
Researchers at Brigham and Women’s Hospital recently spoke with faculty who are core clinical teachers about how to better integrate geriatrics education into internal medicine residency. They asked about the strengths and weaknesses of current educational programs and perceived barriers and facilitators of improvement.
Julia Loewenthal, MD, a geriatrician in the Division of Aging and assistant program director in the Internal Medicine Residency Program, Subha Ramani, MBBS, PhD, MPH, director of the Scholars in Medical Education Pathway and director of Resident Evaluation in the Internal Medicine Residency Program, Andrea Schwartz, MD, MPH, associate director of clinical innovation in the VA New England Geriatrics Research Education and Clinical Center, and a colleague report the results in the Journal of the American Geriatrics Society.
The Brigham has approximately 170 residents in its three-year internal medicine (IM) residency program with 36 faculty with educational leadership positions at the time of the study. During the second year, all residents participate in a two-week Geriatric Medicine rotation, combining clinical and didactic experiences in outpatient, inpatient, and rehabilitation settings.
Study participants were recruited from two groups of faculty: board-certified geriatricians and leaders of the IM residency program. They were invited to attend a focus group with colleagues from the same department (geriatrics vs. IM) or participate in a one-on-one semi-structured interview if they could not schedule a focus group. Dr. Loewenthal conducted all focus groups and interviews between January and May 2021.
Eight geriatricians and seven IM residency program leaders participated: four geriatricians in one focus group, two geriatricians in a second, and two geriatricians and seven internists in one-on-one interviews.
Analysis of participant narratives identified five key themes:
The need for professional role models
- Role modeling (e.g., apprenticeship) comprises a large part of residency education
- Working with a geriatrician normalizes geriatric clinical care and geriatrics as a career choice
- Negative role modeling may reinforce non-age-friendly behavior or, conversely, serve as motivation to improve
- One’s attitudes toward aging may affect one’s view of teaching/learning geriatrics
- Limited geriatrics training affects interest and attitudes toward aging
The powerful influence of patients
- Patient experience is a teaching tool
- Patients may influence a resident’s style of doctoring and career choice
Clinical complexity of geriatrics
- The need to use holistic (vs. disease-based) frameworks when caring for older patients
- The need to integrate knowledge of the physiology of aging into clinical reasoning
The need for “branding” and greater prestige of the geriatrics field
- The boundaries between geriatrics and other specialties may be blurred
- Cohesive, positive messaging about the field may address learner misperceptions (e.g., “help people age successfully” and “quality of life is just as important as saving a life”)
Enhancing Geriatrics Education
Faculty had multiple suggestions for creating “age-friendly” IM residencies:
- Increase required geriatrics clinical time for residents
- Co-manage patients with geriatricians
- Implement geriatrics e-consults
Formal educational strategies
- Teach a standardized approach to geriatric medical education (e.g., the 4 M’s: What Matters [healthcare goals and care preferences], Medication, Mentation and Mobility)
- Increase dedicated geriatrics didactics
- Invite a geriatrician as discussant to case reports and conferences
- Disseminate geriatrics educational resources more widely (e.g., via the residency website)
- Increase the use of educational technology (e.g., videos, podcasts)
Faculty development strategies
- Create “age-friendly champions” within the residency program and department
- Develop standardized teaching materials for geriatricians
As demographics continue to change, ensuring adequate care for U.S. elders will require moving past prior assumptions and into an era of collaboration on training the next generation of IM residents.