ORIGINAL CONTRIBUTION
geriatrics
Geriatric Trainingin EmergencyMedicine ResidencyPrograms From the Emergency Medicine Residency Program, Butterworth
Jeffrey S Jones, MD, FACEP* Elaine W Rousseau, PhDt
Hospital, Grand Rapids, Michigan;* Arizona Long-Term
Arthur B Sanders, MD, FACEP•
Care Gerontology Center,t and Section of Emergency Medicine, University of Arizona College of Medicine, Tucson;¢ and Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force, Lansing, Michigan.§ Receivedfor publication February 28, 1992. Acceptedfor publication March 12, 1992. This study was supported in part by a grant from the John A Hartford Foundation, New York.
Mary Ann Schropp s
Study objectives: The health care needs of the elderly population are significantly different from those of younger patients and require special knowledge and skills on the part of emergency physicians. The purpose of this study was to identify the nature and extent of geriatric training currently provided to emergency medicine residents. Design: Self-administered survey distributed to residency directors of the 85 accredited emergency medicine residency programs in the United States. Interventions: The survey consisted of 17 questions focusing on residency directors' views about teaching and research of geriatric emergency care. Results: Survey information was obtained from 85 (100%) emergency medicine residency programs. Forty percent (34 of 85) of respondents believed the teaching of geriatric emergency care was inadequate; 44 programs (52%) plan to increase the number of didactic hours devoted to geriatrics (mean increase of 5.9 hours). The five geriatric topics most frequently taught included acute dementia, atypical presentation of illness, common complaints in the elderly, geriatric trauma, and ethical issues. Sixty-five percent believed ongoing national research efforts regarding geriatric emergency medicine were insufficient; 21 programs (25%) had faculty involved in geriatric studies. Most respondents reported that growing numbers of elderly will have a major impact on all areas of patient care in the near future. Conclusion: Although geriatric emergency care is becoming an integral part of the emergency medicine residency program, there may be a need for better focused and more intensive training. [Jones JS, Rousseau EW, Schropp MA, Sanders AB: Geriatric training in emergency medicine residency programs. Ann EmergMedJuly 1992;21:825-829.]
74/825
I
ANNALS OF EMER[3ENCY MEDICINE 21:7 JULY 1992
GERIATRIC TRAINING Jones et al
INTRODUCTION
The p a r a d o x of aging is that having e n d u r e d decades of biological and environmental hazards and the muhifaetorial stresses of modern life, the elderly become more susceptible to the effects of bacterial infection, t r a u m a , and adverse reactions to pharmacologic therapy. They also merit special consideration in the application of psychiatric and social sciences and present unique ethical challenges to the physician. 1 Recent studies have pointed to many demographic and soeiologic factors that will lead to an increase in the use of emergency medical care by the elderly population. 2-4 Bettertrained professional and support personnel will be needed to provide this medical care effectively and economically. The American Medical Association, the American Geriatrics Society, and the Association of American Medical Colleges have recommended that actions be taken for p r e p a r a t i o n of future practitioners to r e n d e r health care to the growing elderly population.5, 6 In an effort to define more clearly the role its members should 15lay, the Society for Academic Emergency Medicine formed the Geriatric Emergency Medicine Task Force in the summer of 1990. The aim of this task force was to assess the present and future service, research, and educational needs of geriatric emergency medicine. The task force, in collaboration with the Arizona Center on Aging, has collected survey information from emergency practitioners, educators, and consumers. This report summarizes the results of a survey of emergency medicine residency directors assessing the nature and extent of geriatric training currently provided to emergency medicine residents. MATERIALS
AND
METHODS
The survey used in this study was p r e p a r e d by emergency physicians, gerontologists, and professional surveyors comprising the SAEM Geriatric Emergency Medicine Task Table I. Number of didactic hours dedicated to geriatric topics during the past year
Topic Acute dementia/confusion Atypical presentation of illness Common complaints in the elderly Geriatric trauma Ethical issues in geriatrics Abuse and neglect in the aged Psychiatric emergencies in elderly Clinical pharmacology of the elderly Social problems/community services Acute rheumatic diseases in elderly Physiology of aging Functional assessment of elderly Effects of age on diagnostic testing Dermatoses in the elderly Geriatric gynecology Geriatric ophthalmology
JULY 1992
21:7
Mean Hours
SD
No. (%)
2.0 1.3 1.2 1.0 1.0 0.8 0.8 0,7 0,7 0,6 0,4 0,4 0.4 0,4 0.1 0.1
2.5 1.7 1.8 1.6 0.9 0.8 0.9 0.9 1.0 1.5 0.6 0.6 0.9 0.7 0.2 0.3
71 (84) 65 (77) 67 (79) 61 (72) 65 (77) 68 (80) 64 (75) 61 (72) 63 (74) 82 (73) 65 (77) 61 (72) ~0 (71) 60 (71) 57 (67) B2 (73)
ANNALS OF EMER6ENCY MEDICINE
Force. Questionnaires were mailed to the training directors of the 85 accredited emergency medicine residency programs in the United States. Stamped r e t u r n envelopes were provided to maximize return. Follow-up telephone calls were made to nonrespondents by SAEM staff members until a 100% response rate was achieved. The survey consisted of 17 questions focusing on residency directors' views about teaching and research of geriatric emergency care. Respondents were then asked to provide specific information on the exposure of their emergency medicine residents to a variety of didactic topics, using a modification of the recommended geriatrics curriculum for emergency medicine training programs. 7 The r e m a i n d e r of the questions were related to demographic aspects concerning the major hospital serving their residency program. Data from the questionnaire were entered into a microcomputer. Frequency distributions and s t a n d a r d deviations were determined for each question. Because of the descriptive nature of the r e p o r t and the inclusion of all residency programs, tests for statistical significance were not required. RESULTS
The questionnaire was completed by all 85 accredited emergency medicine residency programs in the United States. The m a j o r teaching hospital in 37 residency programs (44%) was university based, 22 (26%) were community based, 21 (25%) were city or county based, four (5%) were military or veterans based, and one (1%) listed the p r i m a r y hospital as other. Most of these hospitals (96%) h a d more than 300 patient beds and were located in u r b a n areas (88%). Thirty-four respondents (40%) r e p o r t e d more than 60,000 emergency department visits per year, 28 (33%) had 45,000 to 60,000 Table 2. Rank order o f geriatric emergency care issues* Mean
Medical Issues Altered disease presentation in elderly 5.3 Multiple dedications and drug interactions 5.0 Altered physiologic response of the elderly 5.0 Inability to assess functional activities 4.1 Social Issues Cost to society of caring for the elderly 4.4 Elder abuse/neglect 4.4 Inadequate access to care 4.3 Lack of primary care providers 4.2 Ability to pay for care 4,0 Resources in the ED Social support for the elderly 4,6 Information transfer problems 4.5 Nursing support for the elderly 4,3 Emergency medical services 4.1 Ancillary services 33 Ethical Issues Uncertainty regarding withholding care 4.9 Resuscitation issues 4.9 Adequate assessment of mental capacity 4.6 *Issues are rankorderedwithin categories(6,very important;,1,very unimportant).
SD
0.9 1.0 1.0 1.0 1.3 1.0 1.2 1.2 1.4 1.0 1.1 1.1 1.3 1.1 1.2 1.1 1.0
826175 I
GERIATRIC T R A I N I N G Jones et al
ED visits, 19 (22%) had 30,000 to 45,000 ED visits, and four (5%) had less than 30,000 ED visits per year. Geriatric Curriculum Forty-six respondents (54%) believed that the teaching of geriatric emergency medicine to residents was adequate, 34 (40%) viewed teaching efforts as insufficient, one (1%) reported teaching efforts as too much, and four respondents (5%) had no opinion. Forty-four of the residency programs (52%) plan to increase the number of didactic hours in the residency program devoted to geriatric emergency care. This planned increase averaged 5.9 additional hours (SD, + 3.6 hours). The number of hours spent in didactic teaching to residents on 16 geriatric topics is shown in hierarchical order (Table 1) with the most frequently reported topics listed first. Marginal comments from 13 respondents indicated that some of these didactic topics were integrated into the general curriculum without separately identifying geriatrics as a unique topic. R e s e a r c h Fifty-five of the emergency medicine program directors (65%) believed that ongoing national research efforts regarding geriatric emergency care were insufficient, 14 (17%) described research efforts as adequate, one (1%) perceived research efforts as too much, and 15 directors (18%) had no opinion. Twenty-one respondents (25%) indicated that faculty members in their program were involved in research projects dealing with geriatric emergency care issues. Examples of ongoing research efforts include advance directives, prehospital patterns of use, elder abuse, geriatric trauma, nursing home transfers, and specific diseases (eg, pneumonia, stroke). Geriatric I s s u e s Respondents were given a list of 17 issues involving emergency care of the geriatric patient and asked to indicate the level of importance of each issue using a six-point scale. Possible responses ranged from 1 (very unimportant) to 6 (very important). The four major categories were medical issues, social issues, ethical issues, and availability of resources in the ED. Residency directors tended to perceive medical issues as the most important area of concern (Table 2). E I d e r I y i n t h e E D This portion of the survey examined issues related to obtaining information on elderly patients, the comparative difficulty of managing seven specific medical complaints, and the impact of the increased number of older persons on several areas of patient Care. The residency directors were asked to indicate problems they Table 3. Level of difficulty in obtaining information regarding elderly patients from selected sources Level of Difficulty
No. (%) Source
No
Little
Moderate
Frequent
Patient Transferring nursing home Patient's primary care physician
2 (2) 5 (6) 5 (6)
8 (10) 20 (24) 30 (37)
41 (49) 35 (42) 30 (37)
33 (39) 23 (28) 17 (21)
76/827 I
had in obtaining medical information from various sources (Table 3). Most indicated that the patient was the most frequent source of problems. Program directors were then asked to indicate whether they had less, equal, or more difficulty in managing specific medical complaints for patients aged 65 years or older as compared with younger patients aged 21 to 64 years (Table 4). More than half of the respondents reported that older patients were more difficult to manage on four of seven medical complaints. The greatest difficulty was in managing abdominal pain. Respondents indicated that the growing number of elderly will have a significant impact on all three areas of patient care identified on the questionnaire (Table 5). The availability of intensive care beds was the greatest concern. Elder Abuse P r o t o c o l s Respondents were queried regarding the availability of written protocols for domestic violence. Seventy-nine programs (93%) had existing protocols for child abuse in their primary teaching hospital. In contrast, 36 programs (42%) reported availability of written protocols for suspected elder abuse. DISCUSSION This survey assessed the nature and extent of geriatric emergency care training currently provided to resident physicians. In general, it appears that there is a growing recognition among residency directors that the special needs of the elderly should be an integral part of the emergency medicine training program. However, many residency programs have not yet implemented complete training programs in geriatric emergency medicine. Fifty-two percent of the emergency medicine residency programs plan to increase the number of didactic hours in the training program devoted to geriatrics. Resident conferences and grand rounds currently include four to eight hours per year on geriatric topics (Table 1). However, by comparison, this is significantly less than the 38 hours of pediatric conference time suggested by the Task Force on Length of Training in Emergency Medicine. a One interesting finding of this survey was the disparity between the program directors' level of satisfaction with geriatric teaching and the practicing emergency physicians' Table 4. Comparative level of difficulty in managing medical complaints between younger and older adult patients Level of Difficulty
No. (%) Medical Complaint
Less
Equal
More
Abdominal pain Dizziness/vertigo Multisystem trauma Altered mental state Fever without a source Headache Chest pain
1 (1) 1 (1) 2 (2) 3 (4) 10 (12) 2 (2) 12 (15)
13 (16) 25 (31) 24 (29) 31 (38) 33 (41)' 53 (65) 45 (55)
68 (83) 56 (68) 56 (68) 48 (59) 38 (47) 27 (33) 25 (31)
ANNALS OF EMER6ENCY MEDICfNE
21:7
JULY 1992
GERIATRIC TRAINING Jones et al
perception that they have not been well trained in the special care needs of the elderly as r e p o r t e d elsewhere. 9 Although 40% of residency directors believed that training in geriatric emergency medicine was inadequate, 53% of residencytrained practicing physicians r e p o r t e d that the amount of time spent on geriatric emergency medicine during their residency was insufficient. 9 We considered the list of didactic topics surveyed to be a minimal s t a n d a r d of subjects to be covered. Relatively few programs complied with this standard. Although topics such as physiology of aging and functional assessment are not centered a r o u n d specific disease states, they are important to the b r o a d b a c k g r o u n d that is necessary for treating elderly patients. 7 Program directors tended to perceive medical and ethical issues as the most i m p o r t a n t areas of concern in geriatric emergency care. However, the resident physician should also expect to see more psychosocial and a d a p t a t i o n a l problems in elderly patients and learn efficient use of available social services. F o r example, elder abuse is estimated to occur in approximately 10% of Americans who are more than 65 years old; about 4% may be victims of moderate to severe abuse. 5 It is essential that emergency physicians be able to identify elder abuse, be informed about where to refer abused elders, and be aware of a p p r o p r i a t e assessment tools. Most of the directors surveyed did not have written protocols for suspected elder abuse in their p r i m a r y teaching hospital, although 93% h a d existing protocols for child abuse. Table 5. Degree of impact caused by increasing numbers of elderly patients on selected areas within the hospital
Degree of Impact No. (%) Availability of intensive care beds Patient flow in ED Availability of ward beds
None
Minor
Major
O 1 (1) 0
16(20) 26 (32) 35 (43)
66(81) 55 (67) 47 (57)
The similarities between responses from residency directors and practicing emergency physicians are shown (Figure). Both groups acknowledge the clinical difficulties and special problems in the emergency care of the elderly. Problems with medical and ethical issues, lack of historical medical information, and the difficulty managing specific medical complaints were emphasized. Most respondents r e p o r t e d that growing numbers of elderly will have a major impact on three areas of patient care in the near future: availability of intensive care beds, ED patient flow, and the availability of ward beds. Physicians in both surveys believed that ongoing national research efforts regarding geriatric emergency care were insufficient. Several issues of m a j o r importance to emergency physicians must be addressed if we are to become better at providing acute and urgent care to the elderly. To date, little is known about clinical presentation, functional disability, and ED use by the elderly. 3 The role of geriatric health care workers in the EI) also must be defined. These health care workers can help with functional assessment and attend to the personal and social needs of the elderly patient. And finally, outcome criteria for geriatric emergency medicine must be identified to facilitate future research. These projects will require a m u h i d i s c i p h n a r y effort involving emergency physicians, geriatricians, prehospital personnel, social workers, nurses, and home/institutional caregivers. CONCLUSION
We surveyed all emergency medicine residency programs concerning the nature and extent of geriatric training provided to resident physicians. It appears that a need exists for better focused and more intensive training in the medical, ethical, and social aspects of emergency care for older patients. To fulfill this need, more research must be devoted to geriatric emergency medicine, and a geriatric educational core content should be developed and integrated into residency training. The SAEM Geriatric Emergency Medicine Task Force acknowledges the assistance
Figure. Similarities between surveyed residency directors and practicing emergency physicians9 Both groups considered medical and ethical issues to be of great importance in the emergency care of the geriatric patient. Most physicians reported that the growing elderly population will have a major impact on several patient care areas. Respondents in both surveys believed that ongoing national research efforts regarding geriatric emergency care were insufficient. Surveyed physicians reported that older patients were more difficult to manage on four of seven specific medical complaints (ie, abdominal pain, trauma, altered mental state, and dizziness). The elderly patient was believed by most physicians to be the most frequent source of problems in obtaining medical information. Written protocols for suspected child abuse are more prevalent than written protocols for suspected elder abuse in both primary care hospitals and teach-
of staff members at the Arizona Center on Aging, Long-Term Care Program, Tucson, Arizona.
REFERENCES 1. Rose C (ed): Emergency care of the elderly. Emerg Med Clin NorthAm 1990;8:183-466. 2. AMA Council on Scientific Affairs: Societal effects and other factors affecting health care for the elderly. Arch Intern Med 1990;150:1184-1189. 3. Eliastam M: Elderly patients in the emergency department. Ann Emerg Meal 1989;18:1222-1229. 4. Lewenstein SR, Crescenzi CA, Kern DC, et al: Care of the elderly in the emergency department. Ann Emerg Med 1986;15:528-535. 5. AMA Council on Scientific Affairs: American Medical Association white paper on elderly health. Arch Intern Med 1990;150:2459-2472. 6. Panneton PE, Mortisugu KP, Miller AM: Training health professionals in the care of
JULY 1992
21:7
ANNALS OF EMERGENCY MEDICINE
828/77
I
GERIATRIC T R A I N I N G Jones et al
the elderly, JAm GeriatrSoc1982;30:144-149.
Address for reprints: Jeffrey S Jones, MD, FACEP,Department of Emergency
7. Jones J, DoughertyJ, Cannon L, et al: A geriatrics curriculum for emergency medicine training programs.Ann EmergMed 1986;15:1275-1281.
Medicine, Butterwerth Hospital, 100 Michigan NE, Grand Rapids, Michigan 49503.
8. AschSM, WeigandJV: A pediatric curriculum for emergencymedicine training programs. Ann EmergMed 1986;15:19-27, 9. McNamara RM, RousseauEW, SandersAB: Geriatric emergencymedicine: A survey of practicing emergency physicians.Ann EmergMed 1992;21:796-801.
78/829
ANNALS OF EMERGENCYMEDICINE 21:7 JULY1992
geriatrics
Geriatric Trainingin EmergencyMedicine ResidencyPrograms From the Emergency Medicine Residency Program, Butterworth
Jeffrey S Jones, MD, FACEP* Elaine W Rousseau, PhDt
Hospital, Grand Rapids, Michigan;* Arizona Long-Term
Arthur B Sanders, MD, FACEP•
Care Gerontology Center,t and Section of Emergency Medicine, University of Arizona College of Medicine, Tucson;¢ and Society for Academic Emergency Medicine Geriatric Emergency Medicine Task Force, Lansing, Michigan.§ Receivedfor publication February 28, 1992. Acceptedfor publication March 12, 1992. This study was supported in part by a grant from the John A Hartford Foundation, New York.
Mary Ann Schropp s
Study objectives: The health care needs of the elderly population are significantly different from those of younger patients and require special knowledge and skills on the part of emergency physicians. The purpose of this study was to identify the nature and extent of geriatric training currently provided to emergency medicine residents. Design: Self-administered survey distributed to residency directors of the 85 accredited emergency medicine residency programs in the United States. Interventions: The survey consisted of 17 questions focusing on residency directors' views about teaching and research of geriatric emergency care. Results: Survey information was obtained from 85 (100%) emergency medicine residency programs. Forty percent (34 of 85) of respondents believed the teaching of geriatric emergency care was inadequate; 44 programs (52%) plan to increase the number of didactic hours devoted to geriatrics (mean increase of 5.9 hours). The five geriatric topics most frequently taught included acute dementia, atypical presentation of illness, common complaints in the elderly, geriatric trauma, and ethical issues. Sixty-five percent believed ongoing national research efforts regarding geriatric emergency medicine were insufficient; 21 programs (25%) had faculty involved in geriatric studies. Most respondents reported that growing numbers of elderly will have a major impact on all areas of patient care in the near future. Conclusion: Although geriatric emergency care is becoming an integral part of the emergency medicine residency program, there may be a need for better focused and more intensive training. [Jones JS, Rousseau EW, Schropp MA, Sanders AB: Geriatric training in emergency medicine residency programs. Ann EmergMedJuly 1992;21:825-829.]
74/825
I
ANNALS OF EMER[3ENCY MEDICINE 21:7 JULY 1992
GERIATRIC TRAINING Jones et al
INTRODUCTION
The p a r a d o x of aging is that having e n d u r e d decades of biological and environmental hazards and the muhifaetorial stresses of modern life, the elderly become more susceptible to the effects of bacterial infection, t r a u m a , and adverse reactions to pharmacologic therapy. They also merit special consideration in the application of psychiatric and social sciences and present unique ethical challenges to the physician. 1 Recent studies have pointed to many demographic and soeiologic factors that will lead to an increase in the use of emergency medical care by the elderly population. 2-4 Bettertrained professional and support personnel will be needed to provide this medical care effectively and economically. The American Medical Association, the American Geriatrics Society, and the Association of American Medical Colleges have recommended that actions be taken for p r e p a r a t i o n of future practitioners to r e n d e r health care to the growing elderly population.5, 6 In an effort to define more clearly the role its members should 15lay, the Society for Academic Emergency Medicine formed the Geriatric Emergency Medicine Task Force in the summer of 1990. The aim of this task force was to assess the present and future service, research, and educational needs of geriatric emergency medicine. The task force, in collaboration with the Arizona Center on Aging, has collected survey information from emergency practitioners, educators, and consumers. This report summarizes the results of a survey of emergency medicine residency directors assessing the nature and extent of geriatric training currently provided to emergency medicine residents. MATERIALS
AND
METHODS
The survey used in this study was p r e p a r e d by emergency physicians, gerontologists, and professional surveyors comprising the SAEM Geriatric Emergency Medicine Task Table I. Number of didactic hours dedicated to geriatric topics during the past year
Topic Acute dementia/confusion Atypical presentation of illness Common complaints in the elderly Geriatric trauma Ethical issues in geriatrics Abuse and neglect in the aged Psychiatric emergencies in elderly Clinical pharmacology of the elderly Social problems/community services Acute rheumatic diseases in elderly Physiology of aging Functional assessment of elderly Effects of age on diagnostic testing Dermatoses in the elderly Geriatric gynecology Geriatric ophthalmology
JULY 1992
21:7
Mean Hours
SD
No. (%)
2.0 1.3 1.2 1.0 1.0 0.8 0.8 0,7 0,7 0,6 0,4 0,4 0.4 0,4 0.1 0.1
2.5 1.7 1.8 1.6 0.9 0.8 0.9 0.9 1.0 1.5 0.6 0.6 0.9 0.7 0.2 0.3
71 (84) 65 (77) 67 (79) 61 (72) 65 (77) 68 (80) 64 (75) 61 (72) 63 (74) 82 (73) 65 (77) 61 (72) ~0 (71) 60 (71) 57 (67) B2 (73)
ANNALS OF EMER6ENCY MEDICINE
Force. Questionnaires were mailed to the training directors of the 85 accredited emergency medicine residency programs in the United States. Stamped r e t u r n envelopes were provided to maximize return. Follow-up telephone calls were made to nonrespondents by SAEM staff members until a 100% response rate was achieved. The survey consisted of 17 questions focusing on residency directors' views about teaching and research of geriatric emergency care. Respondents were then asked to provide specific information on the exposure of their emergency medicine residents to a variety of didactic topics, using a modification of the recommended geriatrics curriculum for emergency medicine training programs. 7 The r e m a i n d e r of the questions were related to demographic aspects concerning the major hospital serving their residency program. Data from the questionnaire were entered into a microcomputer. Frequency distributions and s t a n d a r d deviations were determined for each question. Because of the descriptive nature of the r e p o r t and the inclusion of all residency programs, tests for statistical significance were not required. RESULTS
The questionnaire was completed by all 85 accredited emergency medicine residency programs in the United States. The m a j o r teaching hospital in 37 residency programs (44%) was university based, 22 (26%) were community based, 21 (25%) were city or county based, four (5%) were military or veterans based, and one (1%) listed the p r i m a r y hospital as other. Most of these hospitals (96%) h a d more than 300 patient beds and were located in u r b a n areas (88%). Thirty-four respondents (40%) r e p o r t e d more than 60,000 emergency department visits per year, 28 (33%) had 45,000 to 60,000 Table 2. Rank order o f geriatric emergency care issues* Mean
Medical Issues Altered disease presentation in elderly 5.3 Multiple dedications and drug interactions 5.0 Altered physiologic response of the elderly 5.0 Inability to assess functional activities 4.1 Social Issues Cost to society of caring for the elderly 4.4 Elder abuse/neglect 4.4 Inadequate access to care 4.3 Lack of primary care providers 4.2 Ability to pay for care 4,0 Resources in the ED Social support for the elderly 4,6 Information transfer problems 4.5 Nursing support for the elderly 4,3 Emergency medical services 4.1 Ancillary services 33 Ethical Issues Uncertainty regarding withholding care 4.9 Resuscitation issues 4.9 Adequate assessment of mental capacity 4.6 *Issues are rankorderedwithin categories(6,very important;,1,very unimportant).
SD
0.9 1.0 1.0 1.0 1.3 1.0 1.2 1.2 1.4 1.0 1.1 1.1 1.3 1.1 1.2 1.1 1.0
826175 I
GERIATRIC T R A I N I N G Jones et al
ED visits, 19 (22%) had 30,000 to 45,000 ED visits, and four (5%) had less than 30,000 ED visits per year. Geriatric Curriculum Forty-six respondents (54%) believed that the teaching of geriatric emergency medicine to residents was adequate, 34 (40%) viewed teaching efforts as insufficient, one (1%) reported teaching efforts as too much, and four respondents (5%) had no opinion. Forty-four of the residency programs (52%) plan to increase the number of didactic hours in the residency program devoted to geriatric emergency care. This planned increase averaged 5.9 additional hours (SD, + 3.6 hours). The number of hours spent in didactic teaching to residents on 16 geriatric topics is shown in hierarchical order (Table 1) with the most frequently reported topics listed first. Marginal comments from 13 respondents indicated that some of these didactic topics were integrated into the general curriculum without separately identifying geriatrics as a unique topic. R e s e a r c h Fifty-five of the emergency medicine program directors (65%) believed that ongoing national research efforts regarding geriatric emergency care were insufficient, 14 (17%) described research efforts as adequate, one (1%) perceived research efforts as too much, and 15 directors (18%) had no opinion. Twenty-one respondents (25%) indicated that faculty members in their program were involved in research projects dealing with geriatric emergency care issues. Examples of ongoing research efforts include advance directives, prehospital patterns of use, elder abuse, geriatric trauma, nursing home transfers, and specific diseases (eg, pneumonia, stroke). Geriatric I s s u e s Respondents were given a list of 17 issues involving emergency care of the geriatric patient and asked to indicate the level of importance of each issue using a six-point scale. Possible responses ranged from 1 (very unimportant) to 6 (very important). The four major categories were medical issues, social issues, ethical issues, and availability of resources in the ED. Residency directors tended to perceive medical issues as the most important area of concern (Table 2). E I d e r I y i n t h e E D This portion of the survey examined issues related to obtaining information on elderly patients, the comparative difficulty of managing seven specific medical complaints, and the impact of the increased number of older persons on several areas of patient Care. The residency directors were asked to indicate problems they Table 3. Level of difficulty in obtaining information regarding elderly patients from selected sources Level of Difficulty
No. (%) Source
No
Little
Moderate
Frequent
Patient Transferring nursing home Patient's primary care physician
2 (2) 5 (6) 5 (6)
8 (10) 20 (24) 30 (37)
41 (49) 35 (42) 30 (37)
33 (39) 23 (28) 17 (21)
76/827 I
had in obtaining medical information from various sources (Table 3). Most indicated that the patient was the most frequent source of problems. Program directors were then asked to indicate whether they had less, equal, or more difficulty in managing specific medical complaints for patients aged 65 years or older as compared with younger patients aged 21 to 64 years (Table 4). More than half of the respondents reported that older patients were more difficult to manage on four of seven medical complaints. The greatest difficulty was in managing abdominal pain. Respondents indicated that the growing number of elderly will have a significant impact on all three areas of patient care identified on the questionnaire (Table 5). The availability of intensive care beds was the greatest concern. Elder Abuse P r o t o c o l s Respondents were queried regarding the availability of written protocols for domestic violence. Seventy-nine programs (93%) had existing protocols for child abuse in their primary teaching hospital. In contrast, 36 programs (42%) reported availability of written protocols for suspected elder abuse. DISCUSSION This survey assessed the nature and extent of geriatric emergency care training currently provided to resident physicians. In general, it appears that there is a growing recognition among residency directors that the special needs of the elderly should be an integral part of the emergency medicine training program. However, many residency programs have not yet implemented complete training programs in geriatric emergency medicine. Fifty-two percent of the emergency medicine residency programs plan to increase the number of didactic hours in the training program devoted to geriatrics. Resident conferences and grand rounds currently include four to eight hours per year on geriatric topics (Table 1). However, by comparison, this is significantly less than the 38 hours of pediatric conference time suggested by the Task Force on Length of Training in Emergency Medicine. a One interesting finding of this survey was the disparity between the program directors' level of satisfaction with geriatric teaching and the practicing emergency physicians' Table 4. Comparative level of difficulty in managing medical complaints between younger and older adult patients Level of Difficulty
No. (%) Medical Complaint
Less
Equal
More
Abdominal pain Dizziness/vertigo Multisystem trauma Altered mental state Fever without a source Headache Chest pain
1 (1) 1 (1) 2 (2) 3 (4) 10 (12) 2 (2) 12 (15)
13 (16) 25 (31) 24 (29) 31 (38) 33 (41)' 53 (65) 45 (55)
68 (83) 56 (68) 56 (68) 48 (59) 38 (47) 27 (33) 25 (31)
ANNALS OF EMER6ENCY MEDICfNE
21:7
JULY 1992
GERIATRIC TRAINING Jones et al
perception that they have not been well trained in the special care needs of the elderly as r e p o r t e d elsewhere. 9 Although 40% of residency directors believed that training in geriatric emergency medicine was inadequate, 53% of residencytrained practicing physicians r e p o r t e d that the amount of time spent on geriatric emergency medicine during their residency was insufficient. 9 We considered the list of didactic topics surveyed to be a minimal s t a n d a r d of subjects to be covered. Relatively few programs complied with this standard. Although topics such as physiology of aging and functional assessment are not centered a r o u n d specific disease states, they are important to the b r o a d b a c k g r o u n d that is necessary for treating elderly patients. 7 Program directors tended to perceive medical and ethical issues as the most i m p o r t a n t areas of concern in geriatric emergency care. However, the resident physician should also expect to see more psychosocial and a d a p t a t i o n a l problems in elderly patients and learn efficient use of available social services. F o r example, elder abuse is estimated to occur in approximately 10% of Americans who are more than 65 years old; about 4% may be victims of moderate to severe abuse. 5 It is essential that emergency physicians be able to identify elder abuse, be informed about where to refer abused elders, and be aware of a p p r o p r i a t e assessment tools. Most of the directors surveyed did not have written protocols for suspected elder abuse in their p r i m a r y teaching hospital, although 93% h a d existing protocols for child abuse. Table 5. Degree of impact caused by increasing numbers of elderly patients on selected areas within the hospital
Degree of Impact No. (%) Availability of intensive care beds Patient flow in ED Availability of ward beds
None
Minor
Major
O 1 (1) 0
16(20) 26 (32) 35 (43)
66(81) 55 (67) 47 (57)
The similarities between responses from residency directors and practicing emergency physicians are shown (Figure). Both groups acknowledge the clinical difficulties and special problems in the emergency care of the elderly. Problems with medical and ethical issues, lack of historical medical information, and the difficulty managing specific medical complaints were emphasized. Most respondents r e p o r t e d that growing numbers of elderly will have a major impact on three areas of patient care in the near future: availability of intensive care beds, ED patient flow, and the availability of ward beds. Physicians in both surveys believed that ongoing national research efforts regarding geriatric emergency care were insufficient. Several issues of m a j o r importance to emergency physicians must be addressed if we are to become better at providing acute and urgent care to the elderly. To date, little is known about clinical presentation, functional disability, and ED use by the elderly. 3 The role of geriatric health care workers in the EI) also must be defined. These health care workers can help with functional assessment and attend to the personal and social needs of the elderly patient. And finally, outcome criteria for geriatric emergency medicine must be identified to facilitate future research. These projects will require a m u h i d i s c i p h n a r y effort involving emergency physicians, geriatricians, prehospital personnel, social workers, nurses, and home/institutional caregivers. CONCLUSION
We surveyed all emergency medicine residency programs concerning the nature and extent of geriatric training provided to resident physicians. It appears that a need exists for better focused and more intensive training in the medical, ethical, and social aspects of emergency care for older patients. To fulfill this need, more research must be devoted to geriatric emergency medicine, and a geriatric educational core content should be developed and integrated into residency training. The SAEM Geriatric Emergency Medicine Task Force acknowledges the assistance
Figure. Similarities between surveyed residency directors and practicing emergency physicians9 Both groups considered medical and ethical issues to be of great importance in the emergency care of the geriatric patient. Most physicians reported that the growing elderly population will have a major impact on several patient care areas. Respondents in both surveys believed that ongoing national research efforts regarding geriatric emergency care were insufficient. Surveyed physicians reported that older patients were more difficult to manage on four of seven specific medical complaints (ie, abdominal pain, trauma, altered mental state, and dizziness). The elderly patient was believed by most physicians to be the most frequent source of problems in obtaining medical information. Written protocols for suspected child abuse are more prevalent than written protocols for suspected elder abuse in both primary care hospitals and teach-
of staff members at the Arizona Center on Aging, Long-Term Care Program, Tucson, Arizona.
REFERENCES 1. Rose C (ed): Emergency care of the elderly. Emerg Med Clin NorthAm 1990;8:183-466. 2. AMA Council on Scientific Affairs: Societal effects and other factors affecting health care for the elderly. Arch Intern Med 1990;150:1184-1189. 3. Eliastam M: Elderly patients in the emergency department. Ann Emerg Meal 1989;18:1222-1229. 4. Lewenstein SR, Crescenzi CA, Kern DC, et al: Care of the elderly in the emergency department. Ann Emerg Med 1986;15:528-535. 5. AMA Council on Scientific Affairs: American Medical Association white paper on elderly health. Arch Intern Med 1990;150:2459-2472. 6. Panneton PE, Mortisugu KP, Miller AM: Training health professionals in the care of
JULY 1992
21:7
ANNALS OF EMERGENCY MEDICINE
828/77
I
GERIATRIC T R A I N I N G Jones et al
the elderly, JAm GeriatrSoc1982;30:144-149.
Address for reprints: Jeffrey S Jones, MD, FACEP,Department of Emergency
7. Jones J, DoughertyJ, Cannon L, et al: A geriatrics curriculum for emergency medicine training programs.Ann EmergMed 1986;15:1275-1281.
Medicine, Butterwerth Hospital, 100 Michigan NE, Grand Rapids, Michigan 49503.
8. AschSM, WeigandJV: A pediatric curriculum for emergencymedicine training programs. Ann EmergMed 1986;15:19-27, 9. McNamara RM, RousseauEW, SandersAB: Geriatric emergencymedicine: A survey of practicing emergency physicians.Ann EmergMed 1992;21:796-801.
78/829
ANNALS OF EMERGENCYMEDICINE 21:7 JULY1992
