This article describes the iterative process of consensus development used to identify the essential knowledge and skills residents need, in addition to core EM training, to give competent care to elders in the ED. The results of this inductive, qualitative consensus process highlight the issues that EM education and geriatric experts believe EM residents should have the ability to recognize, anticipate, and act on to assure the quality and safety of care received by elders in the emergency setting. With clear guidelines, experts identified eight domains and 26 competencies.
The domains reflect three types of content. The first are core geriatrics concepts such as the atypical presentation of disease, recognition and treatment of cognitive and behavioral disorders, and the complexities of medication management. Elders simply present differently from younger adults. Myocardial infarctions often present with dyspnea or dizziness, not chest pain; a perforated viscous presents without abdominal tenderness; subdural hematomas without acute neurologic changes; and injury with occult shock.35–37
However, these subtle presentations are not really atypical for elders, they are just different from what is typical for younger adults. EM residents need to learn the typical presentations for the countless elders they will see in their practices.
The second content area includes core EM concerns such as trauma and emergent interventions. Trauma is a key part of the EM curriculum, and falls are the most prevalent type of geriatric trauma.35
Yet understanding how to care for elders who have fallen, and how to prevent future falls, is not a standard part of residents’ training. Emergent intervention modifications include adapting treatments and monitoring to maximize benefit and minimize harm in elders. Modifications include recognizing that, in general, age alone should not be the deciding factor on whether to treat, and that for older adults, the need for care like bladder catheterization or spinal immobilization needs to be regularly reevaluated because the benefit may decrease while the likelihood of harm increases.38
The third content area involves adapting fundamental principles within geriatrics to the specifics of the emergency patient. These include concerns about transitions of care (the tradeoff in care and safety between going home and hospitalization), pain management and palliative care (the tradeoff between the ED need for rapid pain management and the geriatric mantra of “start low, go slow” for medications), and anticipating the effect of comorbid conditions on the patient’s episode of illness. EPs must recognize that many elders are physiologically frail and that stress on one system can soon lead to deterioration in another. For example, an elder who comes to the ED with a gastrointestinal hemorrhage is at risk for myocardial ischemia. Residents need to anticipate what other organ systems are at risk and take appropriate preventive measures.
The Model of the Clinical Practice of Emergency Medicine is designed as the core foundation document for future medical school and residency curricula.39
The geriatric competencies are meant to complement the Model, taking those broad overarching principles and identifying the specific behaviors that assure quality care for geriatric patients. The competencies are intended to inform the curriculum and assessments needed for residents to gain the knowledge and skills to demonstrate these behaviors.
Defining the geriatric EM competencies is just a first step toward achieving desired norms of practice for older adults seen in the ED. Despite the “calls to action” from ACEP and the IOM, the interest of CORD leadership, and the ACGME mandate to move to competency-based education, there are multiple barriers to actually achieving this goal. One is that most faculty did not receive training in geriatric EM, making it less likely that they will be comfortable teaching the competencies to their residents. At the request of CORD, an educational “tool box” is being developed to provide curricular materials that residency programs can use to facilitate implementing geriatric EM teaching and assessment. The tool box of teaching and assessment resources for the geriatric EM competencies, being developed by members of the expert panel and others, will serve as a content repository for educational material that supports the teaching of each competency and for faculty development. These educational materials will be organized under the eight domains and include relevant articles, PowerPoint presentations, Web-based interactive clinical cases, pocket cards, and suggested assessment tools. The tool box will also include resources that can be used for asynchronous learning outside of the conference setting. Assessment tools are being developed, including written tests, case simulations, interactive Web-based cases, and other materials to facilitate the measurement of residents’ performance of the competencies. The tool box also provides links between each geriatric competency and the corresponding ACGME core competency it demonstrates. In this way the geriatric competencies can be used to demonstrate active compliance with ACGME and RRC mandates. An example of such a tool box exists in the Portal of Geriatric Online Education (http://www.pogoe.org
), sponsored by the Donald W. Reynolds Foundation, where the AAMC medical student geriatric competencies are being linked to teaching and assessment products accessible on the Web site.
Implementing effective models of education in an overcrowded residency curriculum is a challenge to all programs. According to several theoretical models of education, such as Miller’s Triangle,40
and the six steps identified by Davis et al.,41
learners must progress through specific stages to achieve competence. Each step is necessary for the next, and the steps build on one another toward the final goal of consistently improved patient outcomes. Receptive attitudes are necessary to allow suitable intake of knowledge, knowledge must be used to develop skills, skills must be used to result in appropriate actions, actions must achieve desired outcomes, and all of these must be taken up in norms of practice for overall improvement to result. Definition of minimum competency targets is a necessary prerequisite for implementing any of these steps well. There are several ways that viable implementation can be achieved using these models. Currently a pilot is under way at five EM residency programs to evaluate one method for teaching the geriatric EM competencies. Attitudes toward the care of older adults, knowledge, and skill acquisition in EM residents will be measured as outcomes using a written knowledge assessment as well as chart review. Impact on norms of practice will not be measured, but can be expected, and progress will be further aided as additional residency programs adopt these competencies.
The geriatric EM competencies herald a new era for EM residency programs. With this tool we have identified critical topic areas with its own set of minimum behaviorally measurable performance standards. With such tools, resident educators can seize new opportunities to drive specialty content. The competencies can serve as evidence of a program’s advancement in step with the ACGME Outcomes Project, because each competency ties to several of the core competences. The geriatric EM competencies can serve as a report card for mastery and eventually assure the public that our residents are prepared for the predictable challenges of caring for the upcoming tidal wave of older adults.