Through a consensus-building process based on expert panels and direct involvement of key stakeholder organizations, a set of 26 geriatrics competencies essential for mastery by the end of FM and IM residency has been defined. The competencies are designed to be context specific, performance oriented, and limited in number to promote acceptance, integration into residency curricula, and assessment. The IM/FM geriatrics competencies build on similarly developed medical student competencies in content and focus, and they comprise a critical step in the continuum of geriatrics competencies for all physicians who care for older adults.
The IM/FM geriatric competencies identify recommended essential skills and expertise needed when caring for older, rather than middle-aged, adults. They emphasize clinical areas of high morbidity and high prevalence among older patients for which current practice is often inadequate or inappropriate, as well as underemphasized in residency training—eg, identifying or avoiding adverse drug events; early recognition of delirium; and subtle presentations of common, serious disorders. Many address deficiencies in current residency training raised in the June 2009 MedPAC report, including care coordination, multidisciplinary teamwork, patient safety, interpersonal communication with special populations, and work in nonhospital settings.2
Several features of the IM/FM geriatrics competencies are worth highlighting. Although the content areas covered in the IM/FM competencies are nearly identical to the content areas in the medical student geriatrics competencies,4
the competencies themselves reflect a movement from knowledge-oriented to performance-oriented competencies. For example, under the medication management domain, although medical students are expected to “(i)dentify medications…that should be avoided or used with caution in older adults and explain the potential problems associated with each,” residents are expected to apply this knowledge “(w)hen prescribing drugs which present high risk for adverse events and interactions…”. Similarly, under the complex or chronic illness domain, although medical students are expected to “generate a differential diagnosis based on recognition of the unique presentations of common conditions in older adults…”, residents are expected to apply this knowledge “in evaluating adults with undifferentiated illness…”.
Each competency maps readily onto 1 or more of the 6 ACGME competencies. Because the IM/FM competencies focus on clinical care of individual patients, most relate directly to Patient Care, Medical Knowledge, and/or Interpersonal and Communication Skills. However, many competencies also relate to defining the professional scope of responsibilities and behaviors (Professionalism) and/or to practicing in and improving health care settings to best meet the needs of older patients (Systems-Based Practice). Implicit to the achievement of these competencies is the recognition that the optimal care of older adults requires that physicians learn to use the skills of other health professionals (Interpersonal and Communication Skills).
Many of the proposed competencies are best taught outside the hospital—in the office, nursing home, or community settings—and both FM and IM residency programs are encouraged to expose trainees to the full range of sites of care for older adults. However, as noted in the recent MedPAC report,2
the Centers for Medicare and Medicaid Services currently requires that teaching hospitals incur “all or substantially all” of the costs borne by nonhospital settings for teaching residents, including the cost of supervision. The importance of shifting incentives to increase training in nonhospital settings was emphasized in the MedPAC report.
Although the goal of this project was to develop a common set of minimum competencies for FM and IM residencies, some differences between FM and IM programs are relevant. For example, in recent surveys, 97% of FM residency programs require training in the nursing home, compared with 65% of IM residency programs, and 88% of FM programs require home visits, compared with only 33% of IM programs.7,8
Yet many of the IM reviewers felt that competencies related to providing care in nursing homes and at home could not be implemented in most current IM programs. To accommodate both disciplines within these common minimum competencies, specific requirements for using home or nursing home settings for training are not emphasized.
The IM/FM geriatrics competencies were developed in the context of a growing mandate for residency programs to directly assess residents' clinical competence. The competencies are phrased as observable behaviors that in principle can be assessed. As framed by Miller,22
the goal is to measure residents' ability to “show how” or “do” clinical care, rather than merely “know” or “know how” to care for patients. Assessment methods best able to meet this challenge include standardized direct observation, detailed review of clinical cases, or live simulations of clinical encounters, rather than written examinations or global assessments with little direct observation (the current norm). The best methods to assess the IM/FM geriatrics competencies, where “best” is an optimal mix of reliability, validity, and feasibility, need to be defined. A multi-institutional project is underway to critically review existing learner assessment tools and methods in the context of the developed competencies, and to make recommendations regarding further development and/or implementation.
By explicitly articulating the IM/FM competencies with a parallel set of geriatrics competencies for medical students, we envision better coordination of teaching content and clinical experiences related to the care of older adults among medical schools and residency programs. In the context of numerous ongoing projects to define geriatrics competencies among surgical and related specialties14
and medical subspecialties,15
there is an opportunity to identify common and related competencies for all residents who care for older adults. Most immediately, the IM/FM geriatrics competencies can be used as a basis for defining competencies for medical subspecialty fellows, including geriatrics fellows. Eventually, an articulated set of essential geriatrics competencies can be developed for all residents and practitioners who care for older adults, as envisioned at a recent meeting of representatives of nearly two dozen specialty or subspecialty societies, certifying boards, and members of Residency Review Committees.3
To this end, significant progress has been made in coordinating the IM/FM resident competencies with recently developed parallel competencies in emergency medicine.23
Work is currently underway to secure formal support for the competencies by organizations of teachers, program directors, and the certifying boards of FM and IM, and to work with those organizations to help disseminate and implement the competencies. For example, the competencies are being compared to, and integrated with, the work of the American Board of Internal Medicine Milestones project, whose purpose is to identify a comprehensive set of competencies in each of the 6 ACGME competencies for IM residents at early and interim points in residency.24
By design, the IM/FM geriatrics competencies reflect the nexus among gaps in current physician training, patient needs, and the current and near-term structure of residency education and health care. They therefore possess some inherent limitations. They are not comprehensive, and so they inevitably underrepresent some important areas in the clinical care of older adults. They are also likely time limited, inevitably growing outdated as training programs and the health care system change to meet the demands of the 21st century. For example, if residency training and health care systems change to enhance the care of patients at hospital discharge, the role and essential competencies for physicians may be redefined. However, we believe the competencies are compatible with, and able to facilitate, the most fundamental near-term health system changes, such as improved care for chronic illness through the implementation of the Chronic Care Model25
and the Patient Centered Medical Home.26,27