Curriculum Development in Geriatric Medicine for Obstetrics and Gynecology Residents

To the Editor: By 2030, 20% of women cared for by obstetrician/gynecologists will be aged 65 and older. As primary care specialists, it is essential that obstetrician/gynecologists receive better training in care of elderly women.1 The introduction of requirements for mandatory geriatrics training in obstetrics/gynecology (ob/gyn) residency programs has supported this. The Geriatric Education Task Force of the Council on Resident Education in Obstetrics and Gynecology of the American College of Obstetricians and Gynecologists have defined basic geriatrics care objectives for residency training.2 Program directors across the United States disagree on whether the experience should be a 1-month block rotation or should be spread out over 4 years.3 The Geriatrics Education for Specialty Residents program found that a barrier to success was too little time available to convey the increasing content in the specialty.4 At the University of Hawaii ob/gyn residency program, various block rotations in geriatrics were previously attempted. The Veterans Affairs on clinical training site was unpopular because of few elderly women patients. At the Program of All-Inclusive Care for the Elderly clinical training site, residents felt patients were too frail and different from what they would encounter in practice. The objective of curriculum development in geriatric medicine was to develop an inpatient and outpatient experience in geriatric medicine for the ob/gyn residents with the following learning objectives. Positive attitudes toward care of elderly patients Inpatient perioperative management and rehabilitation in geriatric populations Outpatient management of common geriatric syndromes. In 2004, a needs assessment was sent to 25 ob/gyn residents using e-mail questionnaires, six responded (response rate 24%). Three questions were asked, with answers based on a Likert scale ranging from disagree strongly to agree strongly. Interviews were conducted with the program directors of the ob/gyn residency program and the geriatric medicine fellowship program. Findings of the needs assessment were as follows. How comfortable are you seeing elderly patients? The answers were equally divided between somewhat comfortable and neutral. Do you think your current residency curriculum adequately addresses geriatrics as it relates to ob/gyn? Majority disagreed somewhat. The top four requested topics for future instruction were medications in elderly patients, osteoporosis, incontinence, and physiological changes of aging (Table 1). Perceived challenges were time constraints; perceptions of ob/gyn residents about important issues were different from those of geriatricians; the residents preferred problem-based learning to didactics. Inpatient experience is provided at The Queen's Medical Center, a private, nonprofit, tertiary care facility. It is the largest private teaching hospital in Hawaii, with 526 acute and 28 subacute beds. Currently, the fourth-year residents on their 2-month gynecologic oncology rotation spend half a day per week performing a complete geriatric evaluation on one of their own patients, with guidance from a geriatrician. Residents can see immediate applicability of geriatrics to their own patients, making the process more meaningful. Areas of focus are thorough preoperative evaluation; functional, cognitive and nutritional assessment; social concerns and discharge planning; and management and prevention of postoperative complications such as delirium, infections, and falls. Kokua Kalihi Valley Community Health Center, serving low-income Asian-Pacific Islanders provided outpatient experience. It became one of the first community health center sites for the ob/gyn residents' continuity clinic in Hawaii 25 years ago. Presently, first-year residents spend half a day each week for 2 months in geriatrics, which is taught using a patient-centered, problem-based approach. Residents spend time with geriatricians, case managers, health maintenance exercise groups, and caregiver support groups. Focus areas include common geriatric syndromes, preventive health maintenance, interdisciplinary team approach, home care, and community resources. Pre- and postrotation surveys (n=5) revealed an improvement in knowledge of community resources, management of common geriatric syndromes, and greater comfort managing end-of-life care. Some comments from the residents were “Excellent rotation with great breadth and diversity of experiences” and “Great rotation, I am so thankful that it was incorporated into our residency. Especially helpful in getting me to think about community resources, end-of-life choices, and safety issues for older patients.” Ob/gyn residents did not receive the 4-week block rotation well. The structure and content of the experiences in geriatrics were changed based on results of the needs assessment and discussions with the program director. The residents have welcomed the new experience. Because of the limited number of responders, additional studies are needed to determine the validity of these findings. Future directions include integrating geriatrics into ob/gyn grand rounds and the residents' didactic sessions over 4 years. Donald W. Reynolds Foundation Comprehensive Programs to Strengthen Physicians' Training in Geriatrics Grant and John A. Hartford Foundation Center of Excellence in Geriatrics Grant. Conflict of Interest: Kamal Masaki: faculty member of University of Hawaii where ob/gyn curriculum is presented, co-principal investigator on grants from the Donald W. Reynolds and John A. Hartford Foundations, speaker's bureau for Pfizer, board member of Kuakini Health Systems, Honolulu, Hawaii. Patricia Blanchette: faculty member of University of Hawaii where ob/gyn curriculum is presented. The editor in chief has determined that the authors have no conflict of interest related to this manuscript. Author Contributions: All authors were involved in curriculum development, interpretation of data, and preparation of manuscript. Sponsor's Role: None, other than grant funding.