Lesley Charles , BSc, MBChB, CCFP, COE (Dip) , Jean A.C. Triscott , BSc, BED/AD, MD, CCFP, FAAFP, FCFP , Bonnie M. Dobbs , BA, PhD , Rhianne McKay , BA, MA
Division of Care of the Elderly, Department of Family Medicine, University of Alberta, Edmonton, AB.DOI: http://dx.doi.org/10.5770/cgj.17.95
Background
There is a growing mandate for Family Medicine residency programs to directly assess residents’ clinical competence in Care of the Elderly (COE). The objectives of this paper are to describe the development and implementation of incremental core competencies for Postgraduate Year (PGY)-I Integrated Geriatrics Family Medicine, PGY-II Geriatrics Rotation Family Medicine, and PGY-III Enhanced Skills COE for COE Diploma residents at a Canadian University.
Methods
Iterative expert panel process for the development of the core competencies, with a pre-defined process for implementation of the core competencies.
Results
Eighty-five core competencies were selected overall by the Working Group, with 57 core competencies selected for the PGY-I/II Family Medicine residents and an additional 28 selected for the PGY-III COE residents. The core competencies follow the CanMEDS Family Medicine roles. Both sets of core competencies are based on consensus.
Conclusions
Due to demographic changes, it is essential that Family Physicians have the required skills and knowledge to care for the frail elderly. The core competencies described were developed for PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE, with a focus on the development of geriatric expertise for those patients that would most benefit.
Key words: core competencies , core competency development , core competency assessment , care of the elderly residents , family medicine residents , enhanced skills
Over the past 50 years, the age of Canada’s population has changed dramatically, with the number of seniors increasing from 8% of the population in 1971 to 14.8% in 2012.(1,2) It is projected that this segment of the Canadian population will increase to 27.2% by 2056.(3) The increase in the number of seniors in the Canadian population has important implications for health-care delivery. One of those implications is the current transformation of health-care delivery from an approach focused on acute illness to one that recognizes the prevalence of chronic and complex disease.(4,5) As noted by MacAdam, “… integrated care for the elderly has become a major theme in health reform because of well-documented issues surrounding the poor quality of care being delivered to those with chronic conditions”.(6) It also has been noted that the strongest programs of integrated care include active involvement of physicians.(6) By 2020, family physicians can anticipate that at least 30% of their outpatients, 60% of their inpatients, and 95% of their continuing care patients will be aged 65 and older.(7,8)
In Canada, physicians who specialize in caring for the older adult include specialists in geriatric medicine, geriatric psychiatrists, and family physicians who have taken additional training in ‘Care of the Elderly’ (COE). In 2009, there were 228 geriatricians in Canada, but an estimated need for 500.(9) Significantly, 20% of Canadian geriatricians are nearing retirement age and few physicians are electing to train in this area.(10) In 2009, there were approximately 130 physicians who had completed COE training.(11) The United States is experiencing a similar geriatrician shortage.(11,12) All of these considerations underscore the importance of the need for, and the important role that, COE physicians play in the delivery of health services to seniors with complex health needs.
COE academic programs are sanctioned by the College of Family Physicians of Canada (CFPC) and were officially established in Canada in 1989. These 15 programs represent “elective, supplementary training in care of the elderly for 6 or 12 month’s duration, available after the two-year core Family Medicine residency”.(13) Core program requirements include experience in geriatric inpatient, geriatric psychiatry, ambulatory, continuing care, and outreach settings, as well as regular time in a longitudinal clinic. There also is a formal research project requirement. A full description of the COE Diploma requirements are published in the Standards for Accreditation of Residency Training Programs.(14)
In order to provide the resident with the requisite medical knowledge, clinical assessment skills, and attitudes (communication, responsibility, respectfulness, ethical consideration) in this area, COE residents completing an Enhanced Skills Diploma need clearly defined educational objectives.(15) Clearly defined educational objectives also are central to COE diploma program administrators in that they can serve as a guide in the development and/or refinement of the curriculum for the Enhanced Skills program and can serve as the foundation for evaluation of residents completing the program.
Our impetus for the development of core competencies for the COE was two-fold: 1) our recognition of the growing mandate for Family Medicine residency programs to directly assess residents’ clinical competence, and 2) the potential to use the core competencies to demonstrate the added benefit of Enhanced Skills COE Diploma training.
From the beginning, it seemed fundamental that the core competencies should be built on the learning objectives that were previously developed for COE residency training in Canada.(15) Those learning objectives relate closely to a specific lesson, and provide residents with requisite medical knowledge and clinical assessment skills. The core competencies, on the other hand, are more general, and relate to skills, behaviours, and knowledge that should be gained through a course or series of courses. The core competencies also differ from learning objectives in that the core competencies explicitly define expected levels of overall competence for practice. As such, core competencies allow for competency-based assessment of postgraduate medical education learners, which is a significant model change from past assessment practices.(16) Specifically, this switch to competence-based assessment determines whether learners “do the right thing at the right time in the right way in complex situations, by using and integrating the right internal and external resources, in accordance to professional roles and responsibilities” (slide 10).(17) An added benefit of standardized core competencies is that they also can be used to standardize expected learning outcomes, and provide direction to curriculum developers and content experts in terms of instructional strategies, feedback on relevancy of context, and the determination of the most relevant and up-to-date medical content.
The objectives of this paper are to describe the development of incremental core competencies for Postgraduate Year-I and Year-II Integrated Geriatrics/Geriatrics Rotation (PGY-I/II) Family Medicine and PGY-III Enhanced Skills Care of the Elderly for COE Diploma residents and the implementation of these core competencies into our program.
The development of the core competencies for the PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE residents at the University of Alberta followed an iterative process. That process involved three primary steps.
Selection of committee members
A COE Core Competency Working Group was established using interested and experienced members of the University of Alberta’s COE Residency Program Committee. Members were selected based on roles at the local and national level (e.g., Program Director, Divisional Director, experience on national committees). Members of our working group had sat on the national Canadian Geriatric Society’s Core Competency Committee for medical students, the CFPC’s Health Care of the Elderly Committee that worked on Core Competencies at the PGYI/II Family Medicine resident level and/or on the current CFPC’s Working Group on Assessment of Competence in Care of the Elderly. A list of members, based on components of the COE Competency Working Group, is provided in Table 1.
Identification of potential core competencies
Potential core competencies were identified through a focused review of the pertinent literature using PubMed and MEDLINE, as well as a review of guidelines published by other national societies, such as the American Geriatrics Society and the Canadian Geriatrics Society.(4,18–25) The 20 core competencies for medical students, developed by the Medical Education Committee of the Canadian Geriatrics Society, were selected by the COE Core Competency Working Group as a baseline.(24) An additional seven competencies were received from the national Health Care of the Elderly (HCOE) Committee on Core Competencies at the PGY-I/II level for Family Medicine residents.(26) Each COE Core Competency Working Group member then worked on competencies in a number of domains, developing core competencies expected at the PGY-I/II Family Medicine and PGY-III COE level of training.
Selection of core competencies
The draft list of core competencies for the two groups (PGY-I/II Family Medicine and PGY-III COE) were then circulated to each individual member of the Working Group who was asked to independently review the core competencies and indicate those that were appropriate, and if appropriate, for which level (PGY-I/II/III). Individual members then anonymously submitted this information to the Chair of the Working Group. Consensus statements that all members of the Working Group agreed to as being appropriate were retained, and those that were inappropriate were discarded. Statements that did not reach consensus were identified and discussed formally with all members of the Working Group. Those statements were revised until there was consensus or discarded because there was lack of agreement.
TABLE 1.
Roles of the Care of the Elderly Core Competency Working Group
Fifty-seven core competencies were selected by the COE Core Competencies Working Group for the PGY-I/II Family Medicine residents, and an additional 28 (for a total of 85) core competencies were selected for the PGY-III COE residents (see Appendix A, Table A.1). Both sets of core competencies are consensus competencies that would be expected at the Family Medicine/COE level of training. They cover 12 primary domains which include cognition, function, mobility, medication, biology of aging, adverse events, incontinence, transitions of care, health-care planning, professionalism, communication, and research. Importantly, they follow the CanMEDS-Family Medicine Roles.(27) A description of CanMEDS-Family Medicine roles can be found in Appendix A, Table A.2.
Implementation of the core competencies followed a pre-defined process, including methodologies to ensure opportunities to familiarize residents and preceptors with them before incorporating them into evaluation (rotation evaluations, exit examinations, etc.). The core competencies described above have been implemented into our program and serve as the foundation for the COE rotations at the University of Alberta. They also are utilized in the rotation evaluations/Academic Half-Day curriculum at the PGY-I/II/III resident level through clinical observation and Program Evaluation/Exit Examination at the PGY-III resident level. Each of these evaluations has been mapped to cover the respective core competencies.
The core competencies that were developed for PGY-I/II Family Medicine residents and PGY-III Enhanced Skills COE residents include behavioural competence, as well as performance competence, with a focus on enhancing learner performance and what we want them to achieve. They build on the competencies developed for medical students for better coordination of teaching and clinical experiences. They also define competence that would be expected of a Family Physician receiving integrated geriatrics or the more traditional geriatric’s rotation. Notably, a recent national survey of Family Medicine Residency education in Geriatric Medicine found that, between 2001 and 2004, the percentage of programs requiring geriatric clinical experience for all residents rose from 92% to 96%.(28) As such, core competencies are similarly important to Family Medicine residents who will increasingly be caring for older patients. An added advantage of having clearly defined competencies at the Family Medicine level is that they will help to ensure equivalent experiences for residents, irrespective of whether they are in an integrated or vertical one-month block.
Finally, the core competencies incrementally define the competence that would be expected of a Family Physician with Enhanced Skills in COE. There is much research outlining that geriatric expertise should be targeted to those patients who would most benefit (e.g., those aged 85 and older, or those who have complex medical problems, frailty or other geriatric conditions, disability, or dementia).(29–32) The consequences of not achieving these competencies are increased costs of care, poor coordination of services, multimorbidity, and polypharmacy.(5)
Due to demographic changes, the majority of health professionals today regularly care for elderly patients. It is thus crucial that Family Physicians and those with Enhanced Skills in COE have the required skills and knowledge to care for this segment of the population. Core competency requirements can be used to develop curriculum that will prepare future physicians to competently care for older people. The 57 core competencies for PGY-I/II Family Medicine residents are included as curriculum objectives on the University of Alberta Department of Family Medicine website and on the formal evaluation of their geriatrics rotation. The 85 core competencies were introduced into the PGY-III COE program in 2010 and overarch all components of the program. They define the rotation evaluations, the overall evaluation, Academic Half Day curriculum, and the Exit Examination. Currently we are researching the effects of these core competencies at the PGY-III Enhanced Skills COE level by retrospectively examining resident evaluations pre- and post-implementation of core competencies. Finally, it is hoped that the core competencies can be integrated into PGY-I/II geriatric rotations and PGY-III Enhanced Skills COE training nationally, with that work being done through the national HCOE Committee. One of the authors also sits on the CFPC Working Group on Assessment of Competence in Care of the Elderly. The experience gained in the development of the University of Alberta’s core competencies will be of benefit, and can be used to guide national efforts in this area.
The authors declare that no conflicts of interest exist.
1. Statistics Canada. Seniors in Canada. Catalogue No.: 85F0033MIE.Ottawa, ON: Author; 2001. Available from: http://publications.gc.ca/Collection/Statcan/85F0033M/85F0033MIE2001008
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27. The Royal College of Physicians and Surgeons of Canada. The CanMEDS 2005 Physician Competency Framework: better standards, better physicians, better care. Ottawa, ON: Author; 2005.
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TABLE A.1.
PGY-I Integrated Geriatrics, PGY-II Geriatric Rotation, and PGY-III Core Competencies (with the 57 PGY-I/II core competencies bolded and the additional 28 PGY-III italicized)
TABLE A.2.
CanMEDS-Family Medicine Roles(20)
Canadian Geriatrics Journal , Vol. 17 , No. 2 , June 2014