The Institute of Medicine’s 2008 report Retooling for an Aging America: Building the Health Care Workforce states plainly, “Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.”1 The shortage in the number of physicians in the United States who are qualified to care for a growing elderly U.S. population is attributable, at least in part, to deficiencies in medical education. Although the recent publication of specific competencies in geriatrics for graduating medical students and postgraduate trainees represents significant progress,2,3 many medical schools and training programs still lack the structured curricula and qualified educators needed to teach the basic principles of geriatric medicine.4-6 Program surveys reveal that a substantial number of U.S. medical schools (29 of 99 respondents) have no required experiences in geriatrics and that residents completing training in internal medicine and family medicine graduate with limited experience in caring for older patients.4-6 These curricular deficiencies stem, in part, from a shortage of available faculty with expertise in geriatrics education.6
Over the last decade, recruitment of new trainees and faculty into geriatrics has slowed.7 In 2009, only 273 of 489 first-year fellowship positions in geriatric medicine were filled.8 Moreover, that same year, only 23 fellows nationwide chose to pursue a second year of training in geriatric education or research in preparation for academic careers.8 As a result, the pool of talent from which to develop the next generation of leaders in geriatrics is quite small,9 and faculty who have not completed geriatric fellowships are being asked to teach geriatrics. Few of these nongeriatrician faculty would be willing to matriculate into yearlong fellowships; thus, short courses with intensive exposure to geriatrics content and educational approaches present a more feasible option.10 Such a model for faculty development may be effective in increasing geriatrics education by both geriatrician and nongeriatrician teachers in medical schools and training programs.
The Donald W. Reynolds Foundation has provided critical support and resources for educators in geriatrics. In 1996, the foundation made a strategic decision to support innovative educational programs that target physicians-in-training at all levels. Beginning in 2001, the foundation provided four-year, $2 million grants to four cohorts of 10 medical schools with sufficient geriatrics infrastructure to implement major curricular programs.11 Although this effort has improved training at the respective schools, most of the nation’s remaining medical degree (MD)-granting and osteopathic medical schools and training programs still lack the critical mass of expertise in geriatrics necessary to create and maintain meaningful educational programs.1,6,8
To more broadly address the needs of medical schools without direct Reynolds support, the foundation launched the Consortium for Faculty Development to Advance Geriatrics Education (FD~AGE) in 2004. Leaders in geriatrics programs at four leading medical schools—Duke University School of Medicine (Durham, North Carolina), Johns Hopkins University School of Medicine (Baltimore, Maryland), Mt. Sinai School of Medicine (New York, New York), and the David Geffen School of Medicine at University of California, Los Angeles (Los Angeles, California; UCLA)—developed a plan for establishing a consortium aimed at disseminating expertise in geriatrics education to clinician–educators across the country. The program leaders took on the challenge of spreading know-how and resources from four different locations to a large audience of individuals and institutions in a variety of programs nationwide. The result has been a faculty development model, combining individualized training for faculty members and customized consultation for institutions, that constitutes an innovative approach to meeting the challenges articulated in the Institute of Medicine’s report. This report describes the design and implementation of the program and provides an assessment of its effects to this point.
The goal of the FD~AGE consortium is to promote, through the development and mentoring of clinician–educators, geriatrics medical education at U.S. medical schools and training programs that do not have prior Reynolds grants. The program aims to extend geriatrics expertise in teaching and curriculum design from the four consortium schools to current and future clinician–educators through a combination of internal and external programs. The target audience includes both geriatricians without prior formal educational training and nongeriatricians. Working together, program leaders, faculty, and administrators at the consortium schools have developed a three-pronged approach for the program:
- Increasing the number of geriatrician clinician–educators through advanced fellowships based at the four consortium schools.
- Training clinician–educator faculty from other institutions (with a priority for nongeriatricians) by offering mini-fellowships and intensive geriatrics courses at the four consortium schools.
- Supporting the effectiveness of clinician–educator faculty at their home institutions through on-site consultations with peers and institutional leaders.
Specifically, for all three “prongs,” the program targets four key domains of faculty development, including (1) improvement in teaching skills using experiential, interactive strategies, (2) demonstration of and access to model teaching programs and resources both in person and online, (3) instruction in curriculum design and assessment, and (4) fostering of mentoring relationships to promote academic growth and achievement.12 Within this framework, each of the four consortium member institutions has developed its own specific approach to the implementation of the program based on local expertise and infrastructure. Consortium sites differ in the types of support offered for fellows and faculty, in the specific clinical and educational themes for mini-fellowship programs, and in the timing, targets, and goals for consultations (Table 1). Principal investigators, faculty, and program coordinators from the four schools confer regularly and meet at least twice a year for detailed review and further planning.
All four schools have expanded their capacity to provide advanced training in geriatrics education for fellows through practical teaching experiences, project work, and mentoring. This expansion has occurred as a second year of fellowship for a physician who has already completed one year of required clinical training. Fellowship curricula at all four schools offer instruction in education theory, in interactive teaching methods, in topic- and venue-specific teaching skills, in curriculum design and evaluation, and in education research and scholarship. All participating fellows are expected first to complete individual projects by the end of their fellowship year and then to present their work in local and national venues. Fellows receive mentoring from consortium faculty on planning for a career as a clinician–educator. Mentoring includes help with preparing a curriculum vitae, developing an education portfolio, and preparing for interviews. To meet the goal of increasing the number of teachers of geriatric medicine at other academic health centers, the four consortium schools work to place graduating FD~AGE fellows in teaching positions in academic programs across the nation.
Mini-fellowships and intensive geriatrics courses
Consortium schools offer faculty development workshops, called mini-fellowships, to clinician–educators from other schools and programs. The mini-fellowships provide visiting educators with the opportunity to work with faculty and staff at a consortium site in order to develop their knowledge and skills in teaching geriatric medicine. Mini-fellowships offer participants (called “scholars”) an intensive three- to five-day training experience. Scholars gain knowledge and experience in curriculum development, teaching strategies, leadership and presentation skills, and educational issues related to specific core topics or settings (hospital medicine, long-term care, palliative care, undergraduate and graduate medical education, surgical specialties, etc.; Table 1). Among the four schools, the structure of the mini-fellowships varies according to the number of participants and the topic emphasized, but the overall goal of improving teaching skills in geriatrics remains central to all programs. Scholars attend workshops on didactic and clinical teaching strategies, participate in small groups, role play, and observe and critique real teaching sessions. Scholars are also introduced to a variety of model curricula and resources to help them in developing their own programs. These hands-on sessions help them become familiar with different online resources and repositories, including the Portal for Geriatrics Online Education (POGOe), where they can review teaching materials, curricular plans, and assessment tools. In the course of the program, scholars also have the opportunity to meet individually with consortium faculty to review their educational projects and career plans.
At the end of each mini-fellowship, participants identify targeted tasks (or action items) to do within a few days or weeks of returning to their home institution so that they may maintain the creative momentum developed during the mini-fellowship. Over the subsequent year, consortium faculty communicate regularly with participants by phone, e-mail, face-to-face meetings, and progress reports to help with curriculum implementation, problem solving, career development, and/or research and scholarship.
Three of the four consortium schools offer scholarships to allow clinician–educators to attend intensive courses in geriatrics and related topics, some of which include a special “Train the Trainer” track for those who will teach geriatrics.
To meet the needs of programs and institutions, consortium faculty also perform on-site consultations lasting from one to two days. These visits provide guidance for institutions and their faculty on how to improve local teaching and evaluation in geriatrics education. Before the visits, consortium members ask host faculty to perform an internal review using a SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis of their current programs and to list specific goals. They also ask the participants to provide information about their institution, including descriptions of key locations and personnel (e.g., lists of geriatrics faculty, of division and departmental leaders, of recent accreditation submissions for training programs). This information guides creation of the agenda for the visit.
Whereas FD~AGE consortium members individualize each site visit according to the institution’s needs, certain common activities occur. Consortium faculty offer teaching sessions (e.g., grand rounds or morning report) on specific topics in geriatrics, as requested by faculty and learners. In addition, consortium faculty provide development sessions on teaching skills, learner assessment, and educational resources. FD~AGE faculty are also available to observe host faculty teaching and then provide feedback. In the course of the visit, consortium faculty talk with learners, key faculty, and the institution’s leaders. They provide specific recommendations for improving geriatrics education programs, direct local faculty and leaders to educational resources (e.g., such as those available through POGOe), and meet with institutional leaders to advocate training and resources for geriatric-medicine educators. After the visits, consortium members generate written reports with detailed assessments and specific recommendations, which are forwarded to key personnel at the institution.
In an effort to evaluate FD~AGE and its reach, each consortium school tracked, with the support and oversight of an evaluation team based at the University of Cincinnati (UC) College of Medicine (Ohio), the number of participants involved and the number of site visits completed. Each consortium member also gathered qualitative information from scholars and institutions on successes and challenges in implementing educational programs. The UC team used a multimethod approach to evaluate the effectiveness and reach of FD~AGE. First, the team reviewed annual progress reports generated by each of the four consortium schools. Team members independently abstracted key information, including program descriptions, the number of individuals and institutions participating, and the number and type of educational programs and products created.
Secondly, representatives of the UC team and the Donald W. Reynolds Foundation conducted site visits at each consortium-member institution at years 2, 4, and 6 of the project (i.e., 2006, 2008, and 2010) to assess progress and program fidelity. Thirdly, the team interviewed a sample of mini-fellowship participants and of leaders from schools that had participated in on-site consultations. Participants, randomly selected from a list of those who had agreed to be contacted by UC, were interviewed using a structured set of questions (see Supplemental Digital Appendix 1, available at http://links.lww.com/ACADMED/A84). All interviews were taped and transcribed. Members of the UC team combined responses for analysis. They analyzed the interviews using a grounded theory approach, looking for recurring themes and key comments.
Finally, at the end of the initial grant period (2010), the four schools conducted a brief online survey of mini-fellowship alumni inquiring about their continued educational activities and the number of learners they had taught and/or the number of other faculty they had involved in geriatrics education. Survey questions inquired about (1) the type and number of target learners, (2) the number of sessions taught and the instructional strategies used, (3) the intent to continue to teach geriatrics (yes / no), and (4) the degree to which mini-fellowships facilitated geriatrics education (not really / somewhat / to a great extent).
We have reported responses as percentages for dichotomous or categorical items and as means for continuous variables. Evaluators at UC combined and analyzed data from the surveys using PASW Statistics (version 18.0.0 SPSS, Inc., 2009, Chicago, Illinois).
Institutional review boards at all four consortium schools and at UC reviewed the program, including evaluation, and granted exemption. The program evaluation results described below combine quantitative estimates of participation and productivity and qualitative information from individual consortium members, from the UC reports and interviews, and from the follow-up survey.
In six years, the Reynolds FD~AGE consortium has provided training in geriatrics education to a total of 981 program participants, including 82 advanced fellows, 200 intensive program attendees, and 699 mini-fellowship scholars. FD-AGE consortium members provided 65 on-site consultations. Faculty and institutions participating in FD~AGE programs represented 48 states. Many institutions sent multiple scholars to mini-fellowships, and multiple institutions within some states received on-site consults (Figure 1). By the end of the initial grant period, the program had involved at least one participant through fellowships, mini-fellowships, and/or consultations from 108 (70%) of 155 different MD-granting and osteopathic medical schools in the United States, including Puerto Rico.
The 82 graduates of clinician–educator fellowships assumed a variety of professional roles, including 57 (70% of 82) in academic positions (full-time or affiliated) at 21 different institutions or hospitals in 14 different states. A review of their professional experiences as reported in interviews highlights three key fellowship components as particularly important contributors to their success: (1) instruction in teaching and curriculum development, which allowed graduates to begin contributing to medical education in geriatrics immediately, (2) practical experiences in program administration and collaboration, which provided trainees with the skills necessary to assume leadership roles, and (3) advanced skills in evaluation and education research that afforded them the opportunity to secure funding, access resources, and disseminate products. To illustrate, one FD~AGE fellow noted in the follow-up survey, “I feel I have benefited most from the mentoring I received and [from] the hands-on experience of teaching and curriculum design.” A geriatrics division head who hired an FD~AGE clinician–educator fellow also commented on the added value of the program:
His work has led to a profound transformation in our programs…. He is a perfect example of what programs such as the FD~AGE are supposed to achieve … that is, to train promising clinical educators and encourage them to move on to strengthen programs elsewhere.
Although program graduates evaluated the fellowships positively, some have anecdotally reported encountering significant challenges in securing protected time to perform their educational and administrative duties and have suggested that the program provide more instruction on negotiation and time management.
Of the 699 faculty trained in mini-fellowships, 430 came from 105 different MD-granting and osteopathic medical schools; the number of participants from each institution ranged from 1 to 27. The remaining 269 participants came from 161 different community-based hospitals and training programs; the number of participants from community-based institutions ranged from 1 to 19. Per program objectives, 608 of the 699 scholars (87%) were nongeriatricians. The scholars represented a broad range of disciplines and specialties; the most common was general internal medicine (246 scholars; 35% of 699), followed by family medicine (148; 21%). Fewer scholars represented hospital medicine (45; 6%), palliative medicine (37; 5%) and emergency medicine (31; 4%). The scholars held a wide range of appointments and positions, including department chairs, division chiefs, program directors, clerkship directors, and chief residents.
Of the 699 mini-fellowship alumni, 174 (25%) responded to the online survey at the end of the program. Of these, 162 respondents (93%) reported teaching geriatric medicine topics to health care trainees or practitioners since their mini-fellowship experience. And of those 162, 104 (64%) had taught medical students, 118 (73%) had taught residents, 53 (33%) had taught fellows, and 71 (44%) had taught other faculty. Importantly, 75 (46%) also reported teaching providers from other professions (see Table 2). With respect to instructional methods, 111 respondents (69%) reported developing one or more new geriatrics-focused lectures, and 43 (27%) designed new modules for existing geriatrics courses. Many also reported taking on the task of designing new courses (27; 17%), organizing new clinical experiences (69; 43%), and/or developing entire curricula (45; 28%). When asked to what extent the mini-fellowship facilitated their teaching of geriatrics, 50 (31%) reported “somewhat” and 103 (64%) reported “to a great extent.”
The case of one scholar illustrates these points. Dr. J was a newly appointed associate program director in a family medicine residency training program charged with improving residents’ clinical experiences in nursing home care. To help with this task, he attended the mini-fellowship in long-term care education at Duke University. Using materials and methods acquired during the mini-fellowship, Dr. J designed and implemented an introductory curriculum that includes information on different levels of care, funding mechanisms, and interprofessional teams. He restructured the clinical experience to facilitate greater continuity and ownership of a small panel of patients. The curriculum resulted in not only improvements in residents’ attitudes, knowledge, and skills in long-term care but also the establishment of a required rotation in geriatrics.
In follow-up surveys and interviews, scholars like Dr. J identified as the most valuable aspects of the program the following: enhanced knowledge and skills in geriatrics, improved teaching and curriculum-development skills, professional development, and peer support. One scholar noted,
The mini-fellowship provided the foundation to create new and innovative modules. The content is more inclusive, without being overdone, the modules are more interactive and have been geared more specifically to the audience: training hospitalists.
I am teaching differently because one of the portions of the program was to take a look at your teaching style and see if you could be a little more versatile and more flexible in your presentations, and to recognize that the delivery of the information does make a difference on how students are engaged.
One participant’s comment specifically noted the peer support provided by the FD~AGE mini-fellowships:
It is not just the didactics that are great, it’s the peer support. You’re with a whole lot of other people who are out there in the real world practicing, and they’re not fresh out of residency. They’re dealing with the real things that I see.
Scholars also reported using specific teaching tools shared at the mini-fellowship (often from other Reynolds programs), as well as POGOe. Further, they cited the close mentoring and follow-up from consortium faculty as critical to their success. One scholar stated,
The most effective aspect of the mini-fellowship was the mentoring I received from faculty on my project over the past year…. The mentoring gave me the confidence to propose a major curriculum revision.
Similar to FD~AGE fellows, the major challenge that some scholars described was difficulty implementing educational programs after returning home, particularly as a result of insufficient time, resources, and collegial support. One participant speculated,
When I came back [from mini-fellowship training] I had a lot of skills I thought I could use, but maybe the biggest reason it hasn’t happened … is because it’s one person trying to change the culture of the whole place.
Consortium faculty performed 65 on-site consultations in 31 different states (Figure 1). Individuals and institutions requesting consultations identified a variety of specific goals for these visits, including the following:
validating geriatrics education programs with leaders,
providing external review of and specific recommendations for programs,
extending programs’ reach and influence,
developing curricula evaluation metrics for residency programs and/or medical schools,
developing a geriatrics fellowship, and
promoting faculty development and securing faculty “buy-in.”
The on-site consultations have proved, according to leaders at recipient institutions, most useful in helping participating institutions assess needs, gain buy-in from key institutional leaders, and establish groups for collaborating on geriatrics-teaching across settings, disciplines, and professions. A major challenge was applying recommendations to individual institutions. One faculty member commented, after an on-site consultation: “Our institution is very, very different from others. So from that perspective the recommendations in the report were not at all tailored to our individual environment.”
In many instances, a single institution participated in different aspects of the FD~AGE program by, for example, sending multiple faculty members to attend mini-fellowships and hosting an on-site consultation. The following case illustrates the cumulative effect of this type of multitiered involvement.
The medical director from the acute care of the elderly unit at a teaching hospital attended a mini-fellowship at UCLA. While there, he focused on the redesign of the geriatrics curriculum for learners rotating on the unit, and he created a faculty teaching guide. Three hospitalist faculty colleagues subsequently attended mini-fellowships at UCLA, and each of them further developed an aspect of the curriculum—specifically, a new palliative care rotation, a revision of slide sets and test questions, and enhanced communication training using videotaping. A follow-up, on-site consultation focused on the work of the hospitalist group and connected them to other geriatricians as well as to local and national curricular resources. Members of the group subsequently presented at a regional meeting and have published educational products on POGOe.13 One of these scholars stated,
Your program has been a huge inspiration, role model, and mentor as we have created our own service to better care for the hospitalized elderly and [have] develop[ed] a curriculum designed to help graduate the next generation of hospitalists with better skills and attitudes about the care of the growing vulnerable geriatric population.
This case illustrates the cumulative effects of combining individual mentoring and development with an institutional consultation. Mini-fellowships offered an opportunity for multiple faculty from this medical center to gain knowledge and skills in teaching about care of the hospitalized elderly and to develop their own specific projects. The on-site consultation not only provided further support for these scholars but also helped to coordinate their efforts, disseminate resources, and maximize impact.
Through a combination of training individual faculty members and providing consultations for academic programs, the FD~AGE consortium has significantly increased the number of faculty prepared to teach geriatrics across the United States. Nearly 1,000 individuals from 266 different schools, hospitals, health facilities, and training programs have participated in at least one aspect of the FD~AGE program. As a result, clinician–educator fellows with technical training and practical experience in geriatrics education have assumed leadership roles at academic and community-based programs. Faculty, as individuals and groups, have used knowledge, skills, and resources gained from mini-fellowships to introduce new educational experiences to an ever-growing number of students, residents, and colleagues at their schools and programs. Through on-site consultations, institutions have undertaken improvements in their geriatrics education programs at a variety of levels. In some cases, the combination of an on-site consultation and the participation of multiple faculty members in mini-fellowships has further enhanced the effect of the program.
Published reports of faculty development programs in geriatrics and, more broadly, medical education have focused on the intensive development of individuals’ knowledge and skills. Premier national programs on faculty development in clinical teaching offer models for intensive individual training, followed by monitoring the trainee, and then evaluating the effects of the training upon his or her return home.14,15 Additional training models include those focused on oncology16 or palliative care medicine,17 or those aimed at chief residents.18 Still others have targeted single institutions, providing training for multiple faculty members to effect curricular change at the local level.19 The FD~AGE program employed a combination of these strategies— including individual training and institutional development as well as short-term and yearlong programs—to introduce change and improvement in geriatrics education.
Another important distinction was the deliberate choice to target a variety of types of faculty in offering many different tracks (Table 1) through our mini-fellowship programs. Publications and reports have emphasized the urgency of increasing the competency of physicians in all fields in the care of their older patients.20,21 Whereas many prior programs have targeted development to single specialties, FD~AGE aimed to include both geriatricians and nongeriatricians from a broad array of disciplines, including medical subspecialists and surgeons, to enhance the overall impact on geriatrics education.
Despite its success, the program has several important limitations. First, a more robust evaluation would provide a better understanding of the mechanism and magnitude of its effect. Indeed, individual consortium schools used different measures to demonstrate scholar satisfaction and increases in self-efficacy after mini-fellowships.22–24 Our reports of the effects of the program would be greatly enhanced by measuring changes in both teacher and learner performance at participating institutions in a more rigorous and uniform manner.
Further, the Donald W. Reynolds Foundation has provided generous funding and other support for this ambitious faculty development program, raising questions about its financial and logistical sustainability and its ease of replication for other disciplines. Specifically, the foundation provides funding to support the effort of program leaders, faculty, and administrators at the four consortium schools. The grant supports the time, tuition, travel expenses, and project expenses of the clinician–educator fellows. For the mini-fellowships and CME programs, the grant provides support for tuition, materials, and faculty time; the four consortium sites vary in how much each supports the travel and lodging expenses of scholars and participants. Finally, the foundation covers the travel and lodging expenses for consortium faculty performing on-site consultations. In several instances, faculty who were not eligible for support under the grant (e.g., non-U.S. or nonphysician applicants) attended the program at their own expense, including tuition, suggesting that the program would be sustainable if more costs were born by participants. FD~AGE faculty are developing and testing less costly and more convenient options (e.g., online participation).
In addition, most participants attended FD~AGE one time and as the only representative from their institution. We believe that both expanding the program to include more longitudinal involvement and targeting multiple faculty or teams at participating sites will result in improved geriatrics education at those institutions. To this end, in May 2011, the foundation announced a renewal of the program through 2015 with a particular focus on the longitudinal development of geriatrician and nongeriatrician clinician–educators. The hope is for each participant to attend multiple mini-fellowships, host on-site consultations, and present at national meetings.
Finally, given that alumni routinely encountered barriers related to lack of time and resources, the consortium will also continue to consider methods to help participants secure the necessary support to complete projects upon returning to their home institutions.
The FD~AGE program offers an effective model for disseminating faculty development for clinician–educators in a specific field that may be applied in other disciplines and professions. The effort proved to be remarkably efficient in reaching large numbers of trainees at any level at the home institutions of program participants. Future directions for the consortium include continued efforts to reach regions and institutions that have not yet participated, to find means of bringing the program to more institutions and more participants at those institutions, and to replicate the program in other fields of medical education.
Acknowledgments: The authors wish to thank Rani Snyder, MPA, senior program officer at the Donald W. Reynolds Foundation, for her invaluable advice and advocacy throughout this project. They would also like to thank the faculty and program coordinators at the four schools for their hard work, enthusiasm, and creativity in making this program happen.
Funding/Support: This work was funded by a grant from the Donald W. Reynolds Foundation.
Other disclosures: None.
Ethical approval: The institutional review boards at each of the four consortium schools—Duke University School of Medicine, Johns Hopkins University School of Medicine, Mt. Sinai School of Medicine, and David Geffen School of Medicine at University of California, Los Angeles—and at the University of Cincinnati College of Medicine reviewed the program and provided exemption.
Previous presentations: Park E, Christmas C, Schmaltz H, Durso SC. The perceived change of diverse clinician–educators through an intensive course on teaching geriatrics. Int J Self-Directed Learn. 2006;3:36–51; Pinheiro SO, Heflin MT, White H, et al. Assessing the impact of a faculty development program to advance geriatrics education: Toward a mixed-method evaluation approach. J Am Geriatr Soc. 2008;56:S10 (Oral paper presentation at the 2008 Annual Meeting of the American Geriatrics Society in Washington, DC); Christmas C, Park E, Schmaltz H, Gozu A, Durso SC. A model intensive course in geriatric teaching for non-geriatrician educators. J Gen Intern Med. 2008;23:1048–1052.