Kanter, Steven L. MD
Each time I walk through a nursing home to visit a family member or friend, the same questions strike me. First, why don’t I see residents and medical students at nursing home residents’ bedsides taking histories, performing physical examinations, learning clinical skills, and contributing to the care of these individuals? * After all, unlike hospital inpatients—who, these days, most often are not to be found in their rooms because they are off getting CAT scans, bone scans, MRI scans, and a myriad of other medical tests—most nursing home residents tend to be available most of the day. Many have a number of clinically important findings and would be glad—even grateful—to accept a learner who needs to spend time to listen to a heart murmur again and again, to hear the different sounds a lung makes over time as a pneumonia clears, or to see how a wound—packed open—changes from day to day.
Second, why don’t I see residents and medical students in the nursing home learning as members of interprofessional teams? The nursing home environment presents an ideal setting for learners from medicine, nursing, pharmacy, dentistry, social work, and other health professions to work together in essential ways to take care of nursing home residents, to learn better ways to function as a team, and to explore cross-cutting issues of ethics and professionalism, among others.
Finally, why don’t I see groups of faculty, residents, and medical students rounding on nursing home residents the same way an inpatient team rounds on patients in a teaching hospital? A rounding team is a time-tested method of patient care that fosters high-quality communication and education. And, based on both my professional and personal experiences with nursing home residents, I know that they have challenging medical problems, that they can benefit from a more thorough and comprehensive approach to their health care, and that they almost always welcome attention from residents and medical students.
Of course, a fundamental query that underlies these questions is, Should nursing homes be part of mainstream medical education? In other words, in addition to being important sites to learn the basics of geriatrics and the principles of long-term care, 1 should nursing homes be sites for residents and medical students to learn core clinical, communication, and team skills? Should nursing homes be among the standard sites used for education during residency rotations and medical student clerkships?
My answer is, Yes. The nursing home would make an excellent core teaching site for residents and medical students. And this is the right time for those of us who are responsible for medical education programs to develop “teaching nursing homes” as such sites. 2
It is the right time for several reasons.
The capacity is there. For example, in the United States, the National Center for Health Statistics 3 reports that in 2010, there were 1,396,473 nursing home residents in 15,690 nursing homes. One half of the states in the United States have an overall bed occupancy rate of about 85% or more, and none of the states has an overall bed occupancy rate less than 60%.
The need is there. For example, residency program directors and medical school clerkship directors work hard to find clinical sites at which residents and medical students can have high-quality learning experiences. A teaching nursing home would help fulfill this need. In addition, rounding teams, including interprofessional groups, have great potential to lead to better and safer health care for nursing home residents, thus fulfilling a need for the nursing home. 4,5
And the opportunity is there. Nursing homes are rich environments in which medical students can use their stethoscopes, otoscopes, and reflex hammers again and again until they begin to develop competence. They are ideal sites for residents to do bedside teaching with medical students. They are ideal sites for interprofessional education. And they are ideal sites to engage with families, to learn how to deal with complex family issues, and to study the most effective ways to work with families.
In addition, the nursing home is an opportune venue in which to learn about, practice, and study patient safety, quality improvement, and points of transition in care (e.g., between hospital and nursing home or nursing home and hospice). The nursing home is an excellent place to learn fundamental principles of public health, such as managing infection risk in a defined population. And the nursing home can serve as a point of departure for studying financial, regulatory, and legal aspects of the health care system.
As yet another potential benefit, I wonder whether more residents and medical students would be motivated to pursue careers in geriatrics if they had at least one of their core learning experiences in a nursing home. These experiences would show learners first-hand that those who live in nursing homes are human beings with rich and varied backgrounds, interests, and accomplishments. Learners would gain a deeper sense of the complexity of these individuals’ medical problems and how they interact, and would appreciate that such medical problems have relevant and challenging biological, psychological, social, and physical dimensions.
And finally, the more time that academic faculty spend in nursing homes, the more likely they will be to develop improved ways of caring for those in need of skilled long-term care. So, if nursing homes were to become a core part of mainstream medical education, that could benefit not only the learners but also those who work, and especially those who live, in nursing homes.
It is important to note that the idea of a teaching nursing home is not new. In fact, 30 years ago, in this journal, Pawlson 6 concluded that “[c]linical experience in a nursing home should be an integral part of medical education” both to “impart general and unique skills to future physicians” and “to improve the medical care provided to … nursing home residents.” The discussion of teaching nursing homes continued in the 1980s and 1990s, 7-9 including an article by Wiener and Shamaskin10 in this journal. They compared student experiences in a teaching hospital and nursing home and concluded that “the nursing home is an appropriate alternate site for teaching the medical interview and physical diagnosis.”
In this issue of the journal, Heflin et al 11 describe an innovative program designed to increase the number of clinician – educators with expertise in geriatrics education to amplify our ability to educate future physicians in this area. I wonder if those individuals could be prepared also to oversee core educational experiences at nursing home sites, lead rounding teams in nursing homes, and contribute to better care for nursing home patients.
So, yes, in addition to learning in a teaching hospital, residents and medical students should routinely learn basic knowledge and skills in a teaching nursing home. A nursing home is as good a site for students to learn basic history-taking and physical examination skills as any other clinical site. And it is as good a site as any other for residents to hone diagnostic acumen, refine skills to manage patients with multiple medical problems, and further develop knowledge of therapeutic options.
I call on every medical school and teaching hospital to develop collaborations with nursing homes, to study ways to make such collaborations effective and beneficial for all stakeholders, and to cultivate relationships that will improve clinical education, research, and, of course, the care of nursing home patients.
Steven L. Kanter, MD
* I will use resident to refer to an individual who is pursuing graduate medical education (be it internal medicine, family medicine, psychiatry, or another discipline) and nursing home resident to refer to an individual living in a nursing home. Cited Here...
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