Education in long-term care for family medicine residents

Abstract

Problem addressed

Family medicine residents require more exposure to all aspects of care of the elderly in the community, including care in long-term care (LTC) homes.

Objective of program

To provide a framework for the development of integrated LTC rotations in family medicine programs.

Program description

Clear objectives for residents and clinical preceptors provided the foundation for the program. Rotations of 4 half days per year in LTC homes were integrated into core family medicine blocks. Residents worked with family physician preceptors providing LTC in the community. Teaching was case based and aligned with the core competencies set out in the CanMEDS (Canadian Medical Directives for Specialists) framework for medical education. The program was strongly supported by the university’s administration, clinical preceptors in the community, and LTC homes.

Conclusion

All the residents rated their LTC rotations as useful or extremely useful in preparing them to provide LTC in their future practices. Long-term care homes realized that investing in training medical residents in LTC could help improve care of the elderly in the community.

In 2007, the College of Family Physicians of Canada’s Health Care of the Elderly Committee released a position statement outlining priorities for education and delivery of service to elderly patients. Among the recommendations was the suggestion that family medicine residency programs should expose residents to all aspects of care of the elderly in the community, including care in long-term care (LTC) homes.¹

Although every postgraduate family medicine program in Canada has a mandatory geriatrics rotation or some equivalent experience in care of the elderly in the curriculum, it is rare to find a program that offers formal training in LTC settings. Given the immense complexity of caring effectively for patients in LTC homes, it seemed high time that family medicine training programs across the country put greater emphasis on placing family medicine residents in these settings. A recent national survey of medical students in the United States indicated that although students said they were relatively comfortable with geriatric medicine in acute-care settings and among well elderly people, they were much less comfortable in LTC settings.² Improvements in skills, knowledge, and attitudes toward elderly patients were noted among internal medicine residents after regular placement in nursing homes.³ It is hoped that with increased exposure to LTC homes during their residency training, family medicine residents in Canada will broaden their clinical capabilities and increase their awareness of the important role they can play in LTC settings in their future practices.

Background

Teaching nursing homes have existed in some form in the United States since 1963; they gained in both popularity and funding throughout the 1970s and 1980s. These teaching nursing homes still exist today in many areas. Some have affiliations with medical schools and some with nursing schools.⁴ Traditionally, the emphasis in many of these homes has been on medical management of patients rather than on the LTC settings themselves or on how care can best be provided.⁵ A successful LTC curriculum for family medicine residents should extend beyond simply teaching how to manage complex elderly patients medically. An approach to and a philosophy of care should also be taught, as both are very different from those appropriate for acute care settings. As Hall et al pointed out, medical students often struggle with the philosophical shift from “curing patients” as seen in acute care medicine to “caring for patients” as is generally the focus in LTC.⁶

Canada’s National Physician Survey reported in 2007 that 22.1% of family physicians in the country worked in nursing homes on a regular basis.⁷ Family doctors who practise in LTC settings are well aware that working in these settings is far different from any other working experience that residents are exposed to during their training. The medical and social problems faced by seniors living in LTC homes are extremely complex. Dementia, falls, incontinence, osteoporosis, and the later stages and complications of chronic diseases, such as diabetes, chronic obstructive pulmonary disease, and Parkinson disease, are examples of conditions that family medicine residents will face in LTC homes upon graduation, but might not have had adequate exposure to during their training. The interprofessional, team-based approach to providing care to patients with these conditions must be an essential part of the clinical experience in any educational program in LTC.

During the planning stage of our own LTC academic program at McMaster University in Hamilton, Ont, a survey of family medicine programs across Canada was sent out to 15 postgraduate program directors. It asked about the education in LTC offered in their programs. Ten programs returned completed surveys (response rate 67%), and 2 of the schools (Queen’s University and the University of Ottawa) stated that they already had a mandatory LTC experience for their family medicine residents. All respondents reported that they thought that training in LTC would benefit their residents, and all but 2 stated that they thought such training should be a mandatory component of family medicine training programs.

The purpose of this descriptive article is to provide a framework for the development of an integrated LTC rotation in family medicine programs. We suggest that exposing our family medicine residents to LTC is just as important as exposing them to palliative care, low-risk obstetrics, or internal medicine. Skills learned during these rotations are essential to practising independently after graduation, and it is accepted that training programs should offer residents opportunities to acquire skills in these areas. Long-term care is no different. Communities expect and need family doctors to care for their patients in LTC homes, but at this time there is no formal expectation in place that postgraduate family medicine training programs will get them ready for this task.

Program description

Our first step in creating an educational program in LTC was to outline clear objectives for our residents and clinical preceptors. These objectives provided an essential foundation for planning all subsequent aspects of the clinical experience in LTC. The 5 core objectives are

• to introduce family medicine residents to the unique set of clinical, ethical, and organizational challenges faced by family physicians working in LTC homes;

• to provide a longitudinal clinical experience in LTC for residents during their 2-year residency program;

• to educate family medicine residents about some of the practical aspects of LTC work, such as on-call commitments, administrative responsibilities, and effects on their weekly clinical schedule;

• to foster partnerships between the Department of Family Medicine at McMaster University and community-based LTC homes in order to establish high quality training sites in LTC; and

• to present LTC work as an attractive career option and an integral part of the comprehensive scope of family medicine.

In Hamilton, at the time this paper was written, 8 family medicine preceptors at 6 different LTC homes were teaching family medicine residents on their weekly clinical rounds.

In this program, residents are scheduled for 4 half-days per year in LTC homes for a total of 8 half-days during their residency. These half-days are integrated into core family medicine blocks, so that they will resemble the scheduling patterns of family physicians in the community who work in LTC. In June, the schedules for the entire academic year, which begins in July, are prepared by dedicated administrative assistants in each of the 3 teaching units at McMaster. Residents’ expectations of their rotations are circulated electronically before they start their LTC rotations, and residents are sent evaluation forms to fill out at the completion of their clinical experience. Learning objectives are individualized for each resident and are agreed upon with their clinical preceptors on the first day of the rotation.

The content of the on-site teaching is case based, and the core curriculum provides for the essential competencies set out in the CanMEDS (Canadian Medical Directives for Specialists) framework for medical education (Table 1).⁸ On site, each resident receives information from the nursing staff on patients who have active issues and need to be seen that day, as well as on periodic physical examinations, medication reviews, or family conferences that need to be completed. Residents see their assigned patients, then meet with attending physicians to review diagnostic or treatment challenges. The case-review model offers opportunities for preceptors to teach clinical skills bedside and to offer practical management advice on commonly encountered problems in LTC.

Table 1.

The CanMEDS competencies and the educational program in LTC

CanMEDS COMPETENCY	DESCRIPTION OF HOW COMPETENCY IS BEING MET
Medical expert	On-site, case-based clinical exposure to topics such as polypharmacy, assessments of capacity, care of dementia, and prevention of falls helps to fill important gaps in the content of family medicine training programs
Communicator	Residents learn how to gather information from families, interprofessional staff, and patients with complex medical and social histories and to lead discussions during family care conferences
Collaborator	Residents are trained to work collaboratively with interprofessional teams that include nurse practitioners, registered nurses, personal support workers, dieticians, physical and occupational therapists, and recreation therapists Emphasis is placed on fostering better understanding of the knowledge and skills that each of these core disciplines brings to the management of LTC patients
Manager	Residents learn to conduct family meetings and interprofessional care conferences during which broader organizational issues, such as the responsibilities of a medical director in an LTC setting or how to organize a combined call schedule for a community of LTC providers, are discussed
Health advocate	A key focus of the LTC program is to teach residents the importance of meeting both the health needs of individual patients and the needs of the community they serve; in many communities, this includes taking on a substantial role in LTC
Scholar	Journal articles are regularly assigned to be read during LTC rotations to highlight key evidence-based guidelines or approaches to specific cases under review in nursing homes
Professional	Resident physicians are held to the highest standards of ethical practice and professional behaviour Challenging residents with ethical scenarios has been identified as a useful teaching strategy, eg, asking “How would you respond if you witnessed misuse of restraints in a nursing home?”

CanMEDS—Canadian Medical Directives for specialists, LTC—long-term care.

Box 1 shows the most common topics covered in the case-review teaching model. These topics are discussed with students in the context of real clinical cases in nursing homes, often with collaborative input from interprofessional team members, such as registered nurses, physiotherapists, nurse practitioners, occupational therapists, and recreation therapists. Evidence-based review articles are often assigned for additional reading, depending on residents’ needs and personal objectives for the rotation.

Box 1. Core topics covered in long-term care family medicine rotations.

The training program aims to develop competency in the following areas:

• An approach to behavioural disturbances in dementia

• An approach to delirium

• Assessing consent and capacity

• End-of-life planning (advanced directives, powers of attorney)

• Failure to thrive in the elderly

• Strategies for prevention of falls

• Infection control

• Infectious disease management

• Polypharmacy

• Principles of interprofessional collaboration in health care

• Use and misuse of restraints

• Managing symptoms at the end of life

This program was pilot-tested in 2 teaching units for 6 months starting in January 2006, and spread to a third teaching unit and LTC sites in Kitchener-Waterloo, Ont, and Brampton, Ont, during the next 2 academic years. A total of 150 residents have been exposed to LTC clinical training and have had more than 1000 half-days of experience since the program began. These numbers are over and above whatever sporadic LTC experience residents might have had before we integrated this mandatory rotation into our curriculum.

Family medicine residents are surveyed about the quality and content of their experience in the LTC program. With more than 100 evaluation forms completed to date, feedback has been overwhelmingly positive. All the residents surveyed rated their LTC clinical rotations as “extremely useful” (54%) or “useful” (46%). In written comments, many residents stated that even more half-days in LTC would be valuable, citing the range of unique clinical problems encountered and the high quality of teaching as the most common reasons for positive scores on the evaluation forms.

Perspective

To date, our experience with the LTC education program at McMaster University has been positive for 3 main reasons. First, we have had constant support from the Department Chair and Postgraduate Program Director from the beginning. This has come in the form of a small annual budget for stipends for our teachers and for administrative support for the program, both of which are essential for sustainability. Second, we have been able to recruit enthusiastic clinical teachers in LTC who have a passion for both LTC and for residency education. Finally, we have forged effective partnerships with several LTC homes that have been extremely supportive of this initiative, with an understanding that investing in family medicine residents is like investing in the care of their own LTC patients.

Our goals for the future are to promote high-quality teaching through continuing medical education events directed at clinical teachers in LTC and to continue to promote this program’s sustainability in all teaching units across our LTC sites. Beginning in July 2010, all residents will also have a 2-hour interactive teaching session exploring clinical challenges in LTC, such as prevention of falls, use of restraints, and managing the behavioural and psychological disturbances of dementia.

We hope that publishing this program description will also open a long-overdue national dialogue on the ways in which family medicine residents can be prepared to work and take on leadership roles in LTC. It is an essential sector of our health care system.

EDITOR’S KEY POINTS

• McMaster University in Hamilton, Ont, developed and implemented a long-term care (LTC) rotation into their family medicine residency program.

• Residents worked 4 half-days per year with community family physicians in LTC facilities. The half-days were integrated into core family medicine blocks so that they would resemble the scheduling patterns of community physicians who worked in LTC.

• All the residents found the rotations useful for learning the intricacies of LTC of elderly patients, and LTC homes realized the benefits of training residents in this complex and specialized area of family medicine.

• The program had strong support from the Department Chair and Postgraduate Program Director at McMaster University, clinical preceptors in the community, and LTC homes.

POINTS DE REPÈRE DU RÉDACTEUR

• L’université McMaster d’Hamilton, Ontario, a mis au point un stage sur les soins de longue durée (SLD) et l’a implanté dans son programme de résidence en médecine familiale.

• Ce programme consiste en 4 demi-journées par année de travail dans des centres de SLD avec des médecins de famille communautaires. Les demi-journées ont été intégrées dans les blocs principaux de médecine familiale de façon à s’ajuster aux horaires des médecins communautaires prodiguant des SLD.

• Tous les résidents ont trouvé que les stages étaient utiles pour apprendre les subtilités des SLD aux patients âgés, et les centres de SLD ont constaté les avantages de former les résidents dans ce domaine complexe et spécialisé de la médecine familiale.

• Le programme a reçu un excellent support du directeur du département et directeur du programme des études graduées de l’Université McMaster, des précepteurs cliniques dans la communauté et les centres de SLD.