Tag Archives: clinical exposure

Perspective on teaching Aged Care

Teaching Aged Care for general practice – getting perspective

How do we appropriately prepare doctors for care of the ageing, particularly in general practice? What is the relevant curricular content (what do GPs see or what do they need) and how is it best taught?

Let’s start with the caveats. Not all practices are the same and not all doctors are the same.  Despite statistical observations about average patient populations there are some doctors who see scores of nursing home patients and some who see none.  There are GPs who focus on kids or women’s health or travel medicine.  Some sub-specialise in palliative care, sports medicine or skin procedures.  The list goes on and, certainly, newly Fellowshipped doctors are more likely to see (on average) a younger patient load in their early years.

A lot of the fuss about aged care is because it often seems complex but it is also at the forefront of discussion because it is high on the government agenda. Policy makers of course are concerned about anything that is a significant cost to the health system and this includes hospital admissions and residential care, in which areas older patients are well represented.

Demographics and “Aged Care”

Our population is undeniably ageing, chronic disease is increasing, the cost of dementia and residential aged care is increasing and the cost of the final year of life is disproportionately high. These are the issues that make headlines and influence policy and funding.  Unsurprisingly, therefore, I have noticed that when Aged Care is mentioned these days it often refers only to those in Residential Aged Care Facilities (RACF) as if this were the most important area of caring for the ageing patient.  In fact, the proportion of those over 65 in residential care has actually declined over recent decades.  However, given the increasing proportion of older people overall, the absolute numbers are still increasing.  Of the 85 + age group a quarter are in RACF whereas in the 65-74 years age group it is only 2%.

The median length of stay in RACF is five months (the average is higher owing to some with very long lengths of stay) and half die within 6 months of nursing home admission. Today, over half of people die in hospitals and around thirty percent in residential care.

Care for those in RACF is becoming rather separated from usual GP care, partly because there is often a change of doctor as patients are obliged to move to a different geographical area. Instead of following a patient’s care to the nursing home a GP often takes on multiple patients in one location, which is a different style of practice.  Residents are also older and sicker than they were decades ago.  Recruiting doctors to work in RACF is problematic (for many reasons) but we also know that those who care for nursing home patients as a registrar are subsequently more likely to do this once fellowed so, despite the low numbers, it would seem to be useful to address this area in teaching.

What is not celebrated

Along with the decreased proportion of older patients living in RACF, it should be noted that not only are Australians living longer but most of those additional years are free of disability.  Nevertheless, there are often years at the end of life where multiple services are required.  Despite a tendency toward greater use of health services with age, someone over 85 with no chronic diseases is less likely to need services than someone under 85 with several chronic diseases. The problem is not just age.

The implications for general practice

The average GP has 20 patients die each year in GP practice in the UK (with higher patient loads) and if we can extrapolate to Australian practice, a full time GP might have between one and two per cent of their regular patients die each year – which leaves some hundreds of older patients requiring other sorts of care.

Topics taught in aged care courses generally include diseases such as Parkinson’s, dementia, stroke and so forth and yet these are a minority of the problems presented by older patients in primary care. Nevertheless, if you are looking after nursing home patients the proportion with these conditions is very much higher.

In terms of population proportions, the 15-64 year old age group has remained stable whereas the under 15s have decreased and those over 65 have increased, with the over 85s growing at a faster rate than other segments of the population. But they are still only at 2%.  Over 65s are a similar  proportion to under 15s. This will be reflected in general practice but, as older people tend to have more conditions, more medications and more illness, the GP will be seeing them much more often.

The “average” (but with incredible variation) GP probably only has a couple more nursing home patients than they might have had in the 1990s. For every 1000 patients in a practice there may now be 20 who are over 85 of which 5 might be in RACF but there will be 15 in the community – with all that this implies about complex care needs.  There might also now be 130 between 65 and 84 – the age group where chronic diseases are increasing but where appropriate preventive activities may still make a substantive difference.   Basically, this is where the changes are most apparent in general practice and this indicates the skills that are needed.

The majority of GP patients are not in nursing homes, nor in the final year of their lives or requiring palliative care. In addition we are not dealing just with patients who have been judged to have entered the geriatric paradigm although it is useful to be aware of the concepts of geriatric syndromes and functional status etc.  However, GPs care for patients transitioning through some of these stages.

GPs, in the community, hopefully see patients over a period of time – continuity of care. We manage their acute illnesses (despite the spin being that these days GPs see only chronic disease) as well as their injuries.  We listen to their problems and we try to implement appropriate preventive interventions.   Somewhere along this journey they likely acquire some chronic diseases and the ongoing management becomes a little more complex.  Crucially we need to recognise impending frailty or acute deterioration. All this constitutes caring for ageing patients.

So what should we be teaching GPs?

First, we should still start (and finish) with being patient/person-centred and we need to convey this in a system which is becoming more of a challenge to continuity and patient-centredness. The doctor/patient relationship still matters. We often need to be advocates for elderly patients in an increasingly impersonal system.  Second, the skill of clinical judgment is more important than ever.  GPs need to identify when it is appropriate to apply differing paradigms for management (such as prevention, geriatric principles, palliative care approach, teamwork etc).   In addition to all this, of course, are the skills of prescribing, managing polypharmacy and multimorbidity which are most appropriately utilised in the general practice context.  For the majority of ageing patients the GP is crucial in terms of delaying progression of disease and functional decline.  It is a challenge to enthuse learners about prevention when outcomes are hard to measure and not obvious.

This still misses a couple of things. One is the necessity of knowledge about other services and the requirement for teamwork.  This is quite a challenge in our fragmented system and mentors, role models and supervisors are invaluable.  The practice placement makes such a difference.  The next crucial factor to consider is the carer.  People are staying in the community and being cared for by others often with their own health needs.  This adds an extra dimension to the health care and moves appropriately into the ethical, professional, legal and organisational domains of curricula.

So, if we are keen to teach what is relevant in terms of GP clinical exposure and workload we need to keep the realities of practice in mind. Certainly teach about palliative care and focus on the specific skills for the increasingly differentiated processes of care in RACF (there are some useful AFP articles such as http://www.racgp.org.au/afp/2015/april/models-of-general-practitioner-services-in-residential-aged-care-facilities/ ) and ensure experience in this area.  However, the useful long term outcome is to have fewer patients requiring this sort of care so don’t forget about the continuum of ageing care and the large number of relatively healthy, ageing patients and what can be done for them – which may then influence the development of dependence and frailty and quality of life at the end of life.

In terms of how it is done, the suggestions would be similar to those in the post on Multimorbidity. Although lectures can be useful for becoming acquainted with important concepts (frailty, functional status, geriatric syndromes, recognising delirium), case studies and case discussion give learners the opportunity to practice the complexity of diagnosis and management in this group of patients. However, many of these skills are honed in practice as one’s patients age.  It is a very relevant topic for ongoing CPD.

 

Some interesting references with figures on the population, ageing, chronic disease and service use etc if interested

The Training Environment – micro and macro

Education and training does not just depend on the teacher / learner dyad in isolation. They are just part of a bigger training environment.  We are probably well aware of the micro environment of the practice or clinical setting which includes attitudes and involvement of the non-supervisor medical staff, the busyness of the service (in either direction), the variety of clinical cases, the supportiveness of non-medical staff and so forth.   These can be even more variable in community settings (compared to hospital) and can be harder to control.  However, they may often need to be accounted for.  If a particular practice has a patient load that is largely acute presentations, repeat scripts and medical certificates with little continuity of care (not uncommon in some settings) then educators should be aware of this and able to direct the registrar to a different type of experience in a later term  It can be more subtle within a practice where “female problems” are directed to a female registrar who then gains less experience in other areas.  A registrar may feed back that a supervisor is not very helpful  but yet the environment is conducive to learning because office staff are supportive and other medical staff are knowledgeable and involved.  The one thing you can say is that the issues are complex and a training system needs to take account of this.

There are a few points made in the following article (about education in residency training) regarding the importance of the “intangibles of the learning environment”.  The author claims that “At its best, the residency experience must be conducted as professional education, not as vocational training.” It goes further than mere training or credentialling and should focus on things that are obvious to many good supervisors : the assumption of responsibility, reflective learning, primacy of education and continuity of care.  http://www.jgme.org/userimages/ContentEditor/1481138241158/06_jgme-09-01-01_Ludmerer.pdf However, I do not agree with the negative interpretation of the limiting of work hours and suspect the principle of continuity should be addressed in other ways. A positive training environment can certainly encourage the learners to be curious about the outcomes of patients they see in the context of good handovers and teamwork.

He suggests there is a need to prepare “residents to adapt to the future, not merely learn for the here and now…excellency in residency training is not a matter of curricula, lectures, conferences, or books and journals…. Nor is it a matter of compliance with rules and regulations. Excellence depends on the intangibles of the learning environment: the skill and dedication of the faculty, the ability and aspirations of trainees, the opportunity to assume responsibility, the freedom to pursue intellectual interests, and the presence of high standards and high expectations.” You can sense his frustration at the increasing bureaucratisation in learning environments.  I am aware of many great supervisors in general practice who do all of this almost intuitively and we rely on their skills and commitment when broader systems are not adequate.

It is not so immediately obvious that the macro environments also have a significant influence on the learning culture.  These can include the ethos of a hospital, training organisation or government policy frameworks.

If the varying stakeholders (government, colleges, standard setters, accreditors, funders) emphasise outcomes and competencies, this can move the learning environment towards one that focusses on assessment and box ticking.  This may have benefits but there may be intangible losses which are not acknowledged.  If efficiencies are sought through larger institutions and faculty mergers, then the interpersonal nature of education may be lost.

Standardisation may increase the quality of training or lead to a lowest common denominator approach and the implementation of IT platforms  is extremely unpredictable in its outcomes.  At its worst, educational quality ends up at the mercy of unresponsive systems and learners and teachers feel they are part of an industrial process.  At its best, resources become more accessible to learners and reflective and self-directed learning can be enhanced.

In the clinic setting a positive learning environment is encouraged when the learner feels free to ask questions and when they observe a culture of learning in their colleagues;  where all staff acknowledge the importance of education and the learning task; where the supervisor is able to admit when she doesn’t know something and where the learner is treated with respect.  Learning is facilitated when there is sufficient challenge matched by the appropriate level of support – the concept of “flow” (another topic of its own) – which is not always easy to achieve and is a shifting dynamic.  The learning environment must also be safe for learner and patient and this often relates to the quality of supervision.

There are other learning environments which include the “workshop” setting. There is more to it than standing up in front and presenting relevant or required content to a group of learners.  The focus of evaluation is often on the presenter but a fantastic performer or an attractive collection of slides does not always ensure the most effective learning. Similarly, pre-prepared learning objectives may have limited relevance to the learning that is actually occurring. The size of the group will affect how active or passive the process is (300 is very different to 30).  Consider the members of the particular group of learners – are they at the same level, do they already know each other, do the presenters know them, have they travelled far?  What about the size of the rooms and the acoustics?  Are the small group facilitators well prepared?  Which of the educational staff takes note of (or has power to influence) these “small” but important issues.

In the bigger picture, consider the effect on the learning environment if service delivery is always prioritised over teaching or if the educational staff have minimal professional development to develop their skills. The “intangibles” of the learning environment that lead to excellence include the unintended consequences of policies and rules.   Learners are enthused to extend their knowledge and skills when they are inspired by mentors, when they can communicate with their educators and interact with their peers, when they feel supported by their supervisors and when the parameters of training include sufficient flexibility to allow for individual needs and rates of progression.

Over the last couple of decades there has been talk of both vertical and horizontal integration in teaching and learning environments. Some of this has been ideological, idealistic or pragmatic. It is affected by the size of institutions, the remoteness of training locations and the training requirements of various health professions. It has been influenced somewhat in Australia by the waxing and waning of funding for the PGPPP (pre-vocational general practice placement program) and it is no doubt also affected by practice economics, student numbers and reimbursement (or otherwise) for teaching.  The GP supervisors group has written about this from a supervisor viewpoint http://gpsupervisorsaustralia.org.au/wp-content/uploads/GPSA-Vertical-and-Horizontal-Learning-Integration-in-General-Practice-Apr2014.pdf  (before the more recent significant changes to the structure of Australian GP training) and there are some notable examples of practices who make a conscious effort to create a learning environment.

Consider the learning environments that you are part of and the factors that are influencing its educational quality. I suggest discussing these with colleagues and considering the broader issues when you are evaluating your teaching sessions and the experience of learners.  We want learners to bloom  (not shrivel up like the pot plants on my windy and salty balcony) and for that they need the right environment!  Bear in mind that you can make assumptions about the factors that create a positive learning environment but, ideally, it would be best practice to actually try to measure this.  The validity of educational methods is very context dependent.

Educators may have limited power to influence decision making at many levels but we have a professional responsibility to inform decision makers when the learning environment can be improved and, especially, when it is under threat.

 

Teaching Multimorbidity – part two

Just an initial parenthesis about multimorbidity

If you ever wondered about the importance of multimorbidity, then wonder no more. Late yesterday (a Friday) the Australian government announced a summary of its revamp of funding policies and parameters for the “Health Care Home”.  These apply to general practice and refer to patients variously described as having chronic diseases and complex chronic illness – in short, it includes multimorbidity.  There are many really interesting articles and studies out there raising complex aspects of how to define, classify and research (and hence add to the evidence base of) multimorbidity, but from now on it will probably also be defined and counted by the Department of Health.  If you were wondering which patients we are generally talking about in referring to multimorbid patients, it is interesting to dip into a couple of articles. An interesting one in the Australian context is Brett T et al. Multimorbidity in patients attending 2 Australian primary care practices. Ann Fam Med 2013; 11(6): 535-542. http://www.annfammed.org/content/11/6/535.full In general practice, maybe a third of patients will have some sort of multimorbidity (defined as 3 or more co-morbidities) and more than half of these will not be elderly, but the clinical significance will also depend on severity and multimorbidity is more common in deprived populations. The estimated proportion of these patients will also depend on the classification system – eg whether cardiovascular is a category or individual diagnoses such as IHD or AF are listed and whether risk factors such as hyperlipidaemia are included. As Einstein said, “Not everything that can be counted counts, and not everything that counts can be counted.” Well, I guess it can but how meaningful it is may be in dispute.

pasha-bulkaGovernments have persuaded us of the impending doom to the health system and solutions are proposed. The Health Care Home (if implemented, not just piloted) will affect the way we fund (and manage) the majority of consultations in general practice, if not the majority of patients (given that these patients, unsurprisingly, attend more frequently).  This will affect the way that we teach about the management of multimorbidity in the future but it will still be important to understand the experience of the patient, the clinical issues regarding effective treatment and the challenges faced by health professionals. This is an interesting summary of the latter point: Sinnott C et al doi:  10.1136/bmjopen-2013-003610 GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research

Registrars confidence levels – 2014 snapshot

As part of routine feedback, evaluation and quality improvement in training, a survey was done in 2014 which was a snapshot of confidence levels across registrar terms and in different curriculum areas. Basically, registrars appear to increase in confidence in all areas by term 3 (over 18 months), as might be expected.  On a scale of 1-5 the average difference in confidence levels, between Term 1 and Term 3, in managing various patient groups and problems was 0.6 (from 3.3 to 3.6).  However there was quite a range – from 0.3 to 0.9.  The areas rating 4 or above in levels of confidence by Term 3 were:

  • uncomplicated older patients (also high initially)
  • young children with acute presentations
  • patients with hypertension, hyperlipidaemia, diabetes
  • women’s health problems.

Of course, this could reflect a high initial level of confidence, effective teaching or natural improvement with appropriate experiences. It would be nice to have the opportunity to tease this apart.  In our then Regional Training Provider there was a significant focus on education in cardiac risk factors and diabetes and numerous sessions on women’s health and mental health.

Interestingly, therefore, the lowest Term 3 level of confidence was with multimorbid patients (with three or more chronic diseases / morbidities). The difference in confidence between Term 1 and Term 3 in this area was relatively small and from a low base. There had been no focussed specific input except that some of the registrars may have heard a one-off lecture by a visiting international speaker.  Interestingly, also, the broadest range of confidence levels (averages don’t always tell the whole story) were in child health, women’s health and multimorbidity (2-5) so perhaps not everyone needs the same interventions in each area and learning needs to be individualised, as we know.

After the implementation of the new multimorbidity education approach in late Term 1, the confidence levels were followed in this cohort. They already demonstrated a relatively high confidence with uncomplicated older patients despite educator concerns about lack of clinical exposure.  Multimorbidity started at a low base and then increased by 0.6 which was just below the average increase in confidence over the period.  We asked a new question in the final round about confidence levels in “patients with multiple morbidities PLUS polypharmacy or psychosocial problems”.  This only achieved a level of 3.3 (the lowest in term 3).

I suspect that “complex mutimorbidity” is the new frontier.

What registrars see

Registrars felt that they were seeing sufficient multimorbid patients for learning. In end-of-term feedback on their perceptions of the variety of patients in their placements, registrars (on average) reported seeing a good proportion of children, older patients, chronic disease and multimorbidity along with only slightly less mental health and women’s health.  On the other hand many registrars had limited experience in men’s health, palliative care and nursing home visits.  However, numbers and statistics do not always reveal the full picture.

In the practice

A registrar may see more than the average number of older patients or chronic disease diagnoses and yet they may be having shorter consultations with low markers of continupaperbark-fernleighity and unexpectedly lower than average number of problems per consult. It’s good if a training program collects, utilises and feeds back this sort of data in order to close the educational loop. This type of picture may possibly be interpreted as less engagement with the complexity.  On the other hand a registrar seeing fewer such patients may be encouraged by their supervisor to gain the maximal learning from their experiences. The potential is there but there needs to be an individualised approach – the experience for each registrar in each practice can be widely different at different points in training and a supervisor can adjust their teaching in the light of this.

What is helpful – the registrars’ retrospective view

A summary of points from previous survey and focus group data

  • It is useful to experience the continuity of staying in the same practice for more than six months.
  • Initially consultations tend to be “repeat script” appointments but by Term 3 they were taking more ownership.
  • This was affected by how much supervisors “owned” their own patients.
  • It was limited also by the variability of supervisor’s expertise in the area
  • The top three useful strategies were: 1. case discussion 2. prior hospital experience (gen med, aged care, pall care and ED terms) and 3. workshop sessions.

Registrar suggestions to maximise effective learning in this area

  •  Learning needs to be patient-based in the practice and involve case review with the supervisor (with the patient if needed) plus discussion of common combinations of co-morbidities.
  • There is a preference for case-based teaching in workshops.
  • Medication review discussions should happen with supervisors.
  • Early exposure to guidelines and read up when not confident.
  • “Co-ownership” of a chronic disease patient with the supervisor.
  • Involvement in nursing home care
  • Emphasis on information re local resources

 

The curriculum walks through the door – sometimes

This was a favoured concept in the days before college curricula existed (hard to believe, I know). Certainly a gifted teacher can turn any clinical encounter into a multi-faceted learning opportunity (often done on teaching visits). Plus, the self-directed learner will fill in their perceived gaps and GPs are the sort of doctors who can turn their hand to anything (a uni colleague of mine headed out bush after a single RMO term in obstets and delivered babies for years). But those were the good old days and the assumptions were a bit idealistic. The pendulum has swung decisively in the opposite direction.

Pisa-2006- 051The question remains unanswered regarding how much clinical exposure / experience is adequate in various areas but this does not stop people making policies. There is the much repeated “ten thousand hours” to become an expert and proceduralists in the US assert that shorter working hours by trainees means that specialty training should be longer.  Well, no one is going to win that argument as regards Australian GP training as long as the government is effectively in charge of training.

In GP training clinical exposure varies greatly because of the variability of practices. A registrar might do only 18 months in general practice (or less with ACRRM) and might work in only two locations. Previously we collected end of term registrar feedback data on multiple aspects of the practice experience and could state with confidence which practices were at one end of the distribution curve of older patients or kids, for instance. Sometimes there were surprises.  Registrars may do far fewer minor procedures in a rural practice with a part-time surgeon than in a keen urban practice. Sometimes you have to dig deeper than the statistics. All this enabled evidence-based training and was useful in advising choices for subsequent placements – but only if educational priorities are as high as training location priorities.  In any case, such data is now lost in databases which are defunct due to the recent changes to training.

Growing with your patients

Still, does it really matter in the long term?  Currently, in the climate of doom saying about population demographics and health system “sustainability”, there is a lot of angst around about how registrars see fewer older patients than established GPs.  Is anyone surprised?  Even BEACH figures showed that younger (Fellowed) GPs see fewer older patients – and someone still needs to see the kids!  My second GP job was in an inner city practice whilst still working weekends in ED for two years.  I was happy with acute presentations, became something of an expert in STIs and contraception (and some later occupational health) and augmented this by doing the FPA course in my holidays.  I left there to move to the suburbs and a group practice to do more “family medicine” in a practice with two GP obstetricians.  Northumb-2006- 059The years passed and I did some extra dermatology and paeds, a women’s health course  and some research into menopause.  I didn’t do a lot of extra mental health because I had trained as a social worker and worked as a counsellor. If we had moved to the country I would have upskilled again in emergency medicine. I then did a geriatrics course followed by a PhD on frailty.  You can see where this is heading. Some years later, for curiosity, I looked at the demographics of “my patients” – those who generally only saw me (no mean feat given I am part time in clinical practice).  Their mean age was 60 – which, fortuitously, was my age!

Let’s face it, aged care will require a whole new set of knowledge and skills in twenty years and GPs will be up-dating most of what they learnt as registrars.  Oh dear, all that wasted time learning about how to bill GP Management Plans!

Recognising the curriculum knocking on the door – relevant up-sEdinburgh-2006- 154killing

I have taught aged care for twenty years (and I will talk about teaching aged care in a later post) and am keen on it but that doesn’t mean I think all registrars need to see a lot of it or be as enthused as I am.  General practice is dynamic across a lifetime and we need to encourage registrars to recognise community needs and do something about their gaps.  They need to know the basics and take responsibility for the patients they see.  “Just a script” should be the chance to reflect on polypharmacy, rational prescribing and de-prescribing.  Multimorbidity is not limited to older patients so experience can be gained with younger age groups.  of course, exams need to be passed.

Registrars all have different back stories and maybe the ex-geriatric registrar actually needs to see more kids and sports injuries. Maybe the ex-orthopaedic registrar needs to do more mental health.  Maybe they can be directed to useful extra curricular courses and CPD to set a pattern for lifelong learning.  There is nothing like a bit of extra knowledge to open our eyes and help us to see patient problems we overlooked before and to address them more effectively.

As educators and supervisors we have the opportunity to (hopefully) individualise the vast resources that are the curricula and to go a bit beyond the mandatory syllabuses that need to be ticked off.

Given the brevity of GP training, and the breadth and dynamism of general practice, a disposition to ongoing professional development is the crucial priority.