Evaluation of an Elderly Faller by Medical Students and Rehabilitation Residents

Authors


Address correspondence to Lydia Rolita, 462 First Avenue, C&D Bldg., Room 627, New York, NY 10016. E-mail: rolitl01@nyumc.org

Abstract

As part of the development of a curriculum for medical students and rehabilitation residents at New York University School of Medicine, an Objective Structured Clinical Examination (OSCE) station was developed for formative evaluation. The goal was to determine the existing knowledge and competence of medical students and rehabilitation residents in the analysis and treatment of a geriatric patient with a history of falls. This OSCE station was designed to focus on three specific clinical skills needed in assessing the elderly faller. The OSCE station was a standardized patient (SP) encounter with a 75-year-old man presenting with falls. Seventy-five medical students and 41 rehabilitation medicine residents participated in the study. There was high agreement between the SP and a geriatric physician used to assess performance on gait (Cronbach alpha=0.918) and orthostatic blood pressure (Cronbach alpha=0.887) assessment. Of the medical students, 43.5% did not check orthostatic blood pressure, 56.8% did not evaluate gait, and 92.0% did not consider assistive device prescription. Only 20.0% checked both orthostatic blood pressure and gait. Likewise, 73.8% of residents did not check orthostatic blood pressure, 38.1% did not evaluate gait and 92.9% did not consider assistive device prescription. Only 19.0% checked both orthostatic blood pressure and gait. The results of this examination are alarming and suggest that education regarding the approach to an elderly person who falls is inadequate, leaving students and residents poorly prepared to take care of the “silver tsunami.”

The U.S. population aged 65 and older is in desperate need of trained geriatricians to implement effective care.1 The current estimated need of geriatricians is 30,000; the 9,000 geriatricians who are certified today falls short.2 Conservative estimates are that the number of those aged 85 and older will increase from 4 million to 18.2 million by 2050.1 Given these demographic changes in society, it becomes imperative that programs equip nongeriatrician medical providers with the knowledge and skills that will enhance the lives of this aging population and help them to maintain independence, autonomy, and quality of life as long as possible. Too often the focus of medical education is on learning to develop a quick differential diagnosis and apply learned principles to confirm and treat the most likely diagnosis. This technique is likely to fail when a geriatric patient presents with a geriatric syndrome such as frequent falling. A geriatric syndrome is defined as an accumulation of impairments in multiple systems that produce a phenotypic decline in function or independence.3 This concept that multiple etiologies may be contributing to the chief complaint of a patient is not consistent with current medical education. Residents must learn to shift their focus from diagnosis and treatment to maintenance of function and quality of life when they encounter a geriatric patient.

To address these educational needs, a geriatric curriculum is being developed for medical students and rehabilitation residents at New York University (NYU) School of Medicine and the Rusk Institute for Rehabilitation Medicine. In addition, a geriatric Objective Structured Clinical Examination (OSCE) was designed to determine existing knowledge and competence in the analysis and treatment of a geriatric patient with a history of falls. OSCEs have been used for the evaluation and teaching of geriatric clinical and communication skills, but they have focused on broadly covering all or most geriatric curriculum components4–6 or on specific diseases and syndromes other than falls.7 A four-station OSCE that included a station on an elderly faller was studied,8 but this station was conducted with the scenario of a telephone call and therefore did not examine physical examination skills. Moreover, this study also had the drawback of being conducted on only 10 residents.

The OSCE station designed for the current study focused on three important clinical skills needed in assessing elderly fallers. Falls assessment was chosen as the area of focus, because it is a frequently encountered clinical scenario for a physician specializing in rehabilitation medicine. Falls are common in elderly people and are a leading cause of morbidity and mortality. Widespread adoption of fall-prevention measures has not taken place, and too few eligible patients receive recommended care in this critical domain.9 The three clinical skills focused on were evaluation of gait and orthostatic blood pressure and prescription of an assistive device. The purpose for focusing on these skills is that the Association of American Medical Colleges and the John A. Hartford Foundation believe that the minimum geriatric competencies require that medical students ask all patients aged 65 and older or their caregivers about fall incidents in the last year, watch patients rise from a chair and walk (or transfer), and assess for balance and gait disorders. If an elderly patient has fallen, they recommend constructing a differential diagnosis and evaluation plan that addresses the multiple etiologies identified by history, physical examination, and functional assessment.10 Moreover, studies have found10–12 that evaluation of gait, orthostatic blood pressure, consideration for assistive devices, balance. and strength evaluation in vulnerable elderly people were quality indicators for falls and mobility problems. As a result, this study focused on observing these particular skills for the OSCE as necessary to be conducted during a clinical encounter in fall prevention efforts.10–12

A Geriatric Attitude Survey13 was also administered to the rehabilitation residents to determine their attitudes toward geriatric care and how their attitudes would correlate with their performance on the OSCE station.

METHODS

Participants

Seventy-five medical students at the end of their third year and 41 rehabilitation residents across all 3 years of training participated in this OSCE station. Approval was obtained from the NYU School of Medicine institutional review board, and informed consent was obtained from each medical student and rehabilitation resident.

Design

A single OSCE station was scripted. The case of an elderly man with a history of multiple falls was chosen because it is a common geriatric syndrome, has guidelines for its evaluation and management, and involves the performance of physical examination skills that could be readily assessed using a standardized patient (SP).12

Case

The scripted SP was a 75-year-old man with the chief complaint of falling. He had a history of falls twice within the previous month—both times associated with getting up from a seated or lying position. Before entering the room with the SP, students and residents were told that the encounter was an outpatient visit with a 75-year-old man named Joshua Baker who was complaining of a fall in his home. They were instructed to obtain vital signs, take a focused history, perform a problem-focused examination, and discuss with the patient differential diagnosis(es) and initial evaluation. When the student or resident asked the SP to tell him or her about the problem or why the SP was visiting the clinic, the SP responded: “Well, I wanted to speak to my doctor about my fall yesterday. It's the second one this month.” The SP was instructed not to elaborate about the fall and that the student or resident must ask additional questions to obtain more in-depth information. The SP was instructed not to bring up the second fall or the circumstances surrounding it unless prompted. Upon prompting, the SP revealed that he had a history of hypertension that was being treated with a diuretic—hydrochlorothiazide. The SP was instructed to attempt to show a slight overcompensation in attention—indicating that he was still alert, awake, and attentive and attempting to show that his capacity was not diminished—if slipping up, exclaiming, “Oh, I was just about to say that” or “of course” or “I'm sorry, I'll pay better attention next time.” As the interview progressed and the student or resident delved more into current life situation, the SP was instructed to become more anxious about potential threats to independence and to become slightly more withdrawn. The SP was instructed during the physical examination portion to use the bed or wall for support to help hoist himself up off the bed, to be incapable of rising without using his arms for support, and to have a broad, wide-based gait.

Three SPs were trained. All were elderly professional actors. The station was scripted such that it would stratify students and residents who were above average and those who were below average by increasing scores for students or residents who asked specific social history questions, inquired about activities of daily living and instrumental activities of daily living or performed a mental status examination.

The station was designed to test the medical student's or resident's ability to take a focused history for a geriatric patient after a fall, perform a problem-focused physical examination, and establish and discuss with the patient differential diagnosis(es) and initial evaluation. Each student and resident was given 15 minutes with the SP, with a 5-minute warning knock. Immediately after the encounter, students and residents were given 10 minutes to complete their write-up. Also during this time, the SP rated the medical students and residents using the OSCE checklist. The rehabilitation residents' encounter with the SP was videotaped.

Measurements

OSCE Checklist

The SP rated each student and resident using an OSCE evaluation checklist consisting of 41 items grouped into sections on communication, information gathering, and physical examination. The SP rated each item on a 3-point scale of not done (resident or medical student did not perform this task at all), partially done (the resident or medical student attempted to perform the task but did not do it correctly), and well done (the resident or medical student performed the task and did it correctly). SPs also rated whether they would recommend this doctor to a patient on a 4-point scale (1=not recommend, 4=highly recommend). There was also a section for additional comments by the SP. After the encounter, the student or resident wrote a patient note consisting of the history with pertinent positives and negatives, past medical history, review of system(s), social history and family history, pertinent physical examination findings, and differential diagnosis with management plan. For research purposes, only the assessment of gait, orthostatic blood pressure, and prescription of an assistive device were focused on. The assessment of gait and orthostatic blood pressure information was gathered from the physical examination section of the OSCE evaluation checklist rated by the SP. The prescription of assistive devices was gathered from the management plan of the patient note, which a faculty member reading the note rated as being present or absent.

Survey

Rehabilitation residents answered a Geriatrics Attitude Survey and an experience form. The Geriatrics Attitude Survey consists of 14 statements rated on a 5-point Likert scale. Residents rated each statement on the degree to which they strongly disagreed (1) or strongly agreed (5). This scale has previously demonstrated high reliability on known-groups and construct validity.12 The experience form consisted of questions regarding how well they thought they had done, whether they had previously seen a case such as this, challenges of the case, and take-home points they may have learned.

Videotape

Only the rehabilitation residents' encounters were videotaped. Each resident reviewed his or her videotape with a geriatrician, who focused on four things: attitude toward the patient, gait, orthostatic blood pressure, and assistive device prescription. The geriatrician rated the four items on a 2-point scale of not done (the resident did not perform the task) or done (the resident performed the task, regardless of whether it was done well).

The NYU institutional review board approved this study.

RESULTS

Demographics

Demographic data were analyzed using chi-square and independent t-tests. No statistically significant differences were found across sex, postgraduate year, and the subject' own OSCE performance perceptions within residents or medical students.

OSCE Station Assessment

The SP ratings of medical students and residents of partially done and well done on gait and orthostatic blood pressure were collapsed to make an equivalent category to compare with the geriatrician category of done. Figures 1 and 2 display the overall frequencies of not done and done for the three items of assessment. Of the medical students (n=75), 43.5% did not check orthostatic blood pressure, 56.8% did not evaluate gait, and 92.0% did not consider assistive device prescriptions. Similarly, of the residents (n=42) 73.8% did not check orthostatic blood pressure, 38.1% did not evaluate gait, and 92.9% did not consider prescribing an assistive device. Only 20.0% of medical students and 19.0% of residents checked both orthostatic blood pressure and gait. For the evaluation of the residents, there was high agreement between the SP and geriatrician on gait (Cronbach alpha=0.918) and orthostatic blood pressure (Cronbach alpha=0.887) assessment.

Figure 1.

 Percentage of residents who performed the geriatric tasks, n=42.

Figure 2.

 Percentage of medical students who performed the geriatric tasks, n=75.

Attitude Survey

An independent t-test was conducted on the overall mean geriatric attitude score between those who self-reported previously observing a similar geriatrics case and those who did not. A significant difference was found (P=.001). Those who reported previously encountering a similar case had a greater positive attitude toward elderly patients on the Geriatric Attitude Scale. No statistical significance was found between geriatric attitude score and overall communication, history gathering, or physical examinations scores on the OSCE.

DISCUSSION

The purpose of this study was to examine whether residents and students were able to perform key physical examination skills such as orthostatic blood pressure. To prepare for the aging of our patients, it is imperative that physicians be trained and prepared with the proper tools to assess and treat elderly patients, especially their most common problems. The results of this OSCE station examination are alarming and suggest that education regarding the approach to an elderly person who falls is inadequate, leaving students and residents unprepared. This is a cause for concern, because it seems to be a persistent problem that lasts beyond residency training. Liaison Committee on Medical Education and Accreditation Council for Graduate Medical Education requirements for medical school and residency training programs are becoming more and more complex. The list of core competencies extends from the ability to counsel and educate patients and their families to performance of procedures.14 Residents and students must show proficiency in all these areas. That being said, the concept of geriatric syndromes is foreign to most nongeriatricians, yet competencies that would be best performed with a good understanding of the concept of geriatric syndromes are appearing in medical student and residency lists of competencies. Based on the literature and the minimum geriatric competencies developed by the Association of American Medical Colleges and the John A. Hartford Foundation, medical students should be able to evaluate gait and orthostatic blood pressure and consider assistive devices for routine fall assessments in vulnerable and at-risk elderly people. These OSCE station results show that we are far from preparing medical students and even residents to perform these minimum competencies and quality indicators.

The OSCE station also demonstrated the sufficiency of using a SP to evaluate the residents, because there was high reliability between the attending physician grader and the SP. This makes OSCEs more appealing as an evaluation method, because it is not necessary to have the attending physician involved in the evaluation and is therefore cost-effective and practical in real-life practice settings when attending physicians are not easily available. Also, the patient note written by the residents and students at the end of the station did not add much to the evaluation—oftentimes not including things conducted during the examination or incorrectly adding things not done. This is another component of the OSCE station that needs to be improved upon, because residents and students are not using it as it was intended. However, this is an ongoing struggle most institutions are addressing, because there is little or no consensus as to what components should be included in a high-quality patient note; as a result, the reliability of the patient notes tends to be low.

Residents who reported encountering a similar geriatrics case in the past had a higher positive attitude toward the working with, treating, and interacting with elderly patients. This suggests that exposing medical students or residents to cases involving elderly patients may improve their attitudes toward them. One hypothesis is that, if this exposure could be accomplished using a geriatric OSCE early in training, it not only can serve as a baseline evaluation of skills, but also potentially creates an opportunity to improve attitudes toward interacting with and treating patients from the geriatric population. Future studies will examine this hypothesis further.

The reliability of using a single OSCE station to assess performance is limited and reduces the generalizability of results to other cases. Nevertheless, given the financial and personnel resources required to conduct a multistation OSCE, this OSCE was designed to obtain a snapshot of baseline abilities of the medical students and residents and to provide a method for formative feedback for the rehabilitation residents through review of their videotaped performance. The checklist also served the purpose of providing richer formative feedback to the students on their performance.

This study found that rehabilitation residents and medical students at NYU College of Medicine are not prepared to appropriately assess and manage elderly patients with a history of falling. This is a serious deficiency that calls for explicit training during medical school and residency for individuals involved in primary care of the elderly population. These skills are also important for all residents regardless of their future subspecialty because they are important when caring for hospitalized elderly patients. This OSCE station can be used not only as a clinical assessment tool, but also as an opportunity for faculty members to provide residents with guided standardized feedback on geriatric care. Geriatric care requires a unique subset of skills and needs to be a supplement to medical and residency training. Usng an OSCE station may provide an innovative instructional tool to implement this.

ACKNOWLEDGMENTS

The authors wish to thank the following faculty for their assistance in the development and implementation of our OSCE station: Michael Freedman, MD (Department of General Internal Medicine, Geriatrics Section), Adina Kalet, MD (Department of General Internal Medicine), Regina Richter (Department of General Internal Medicine), Judith Glaser, MD (Department of Physical Medicine and Rehabilitation).

This study was partially funded by a grant from the American Geriatrics Society/Hartford Foundation Geriatrics Education for Specialty Residents program. Portions of this study were presented at the American Geriatrics Society May 2008 meeting in Washington, DC, in poster format.

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this manuscript.

Author Contributions: Lydia Rolita: acquisition of subjects, administration and grading of examination, data analysis, and preparation of manuscript. Tavinder Ark: data analysis, interpretation of data, and preparation of manuscript. Alex Moroz and Valery Lanyi: study concept, acquisition of subjects, and administration and grading of examination. Julianne Southwell: study concept, acquisition of subjects, administration and grading of examination, and preparation of manuscript. David Sutin: design of OSCE examination, study concept, acquisition of subjects, grading of examination, and preparation of manuscript.

Sponsor's Role: Neither of the funding agencies played any role in the design, methods, subject recruitment, data collection, analysis, or preparation of the manuscript.

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