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POGOe Editor's Choice Archives
Distinguishing Delirium, Dementia, and Depression
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In clinical practice, differentiating among the “three Ds” - Delirium, Dementia, and Depression - can be difficult because these disorders may co-exist in the same patient. Clinical pearls are needed in an educational session to assist learners with this clinical challenge. “Distinguishing Delirium, Dementia, and Depression” module, part of the GeriaFlix series, from the Carver College of Medicine at the University of Iowa, has been designed to address that and can be used “anytime, anywhere” by a wide spectrum of learners, from clinical students to practicing clinicians. The educational goals are to improve the learner’s ability to screen, diagnose, treat and increase their appreciation for the co-occurrence of the 3 D’s in the elderly patient.
The educational product is a streaming digital video format with synchronized PowerPoint presentation slides lasting approximately one hour. The lecture presentation, delivered by Dr. Gerald Jogerst, Professor of Family Medicine at the Carver College of Medicine at the University of Iowa, is divided up into three sections (one for each “D”). Each section includes a clinical case report as well as an image of a typical patient with the disorder. Dr. Jogerst is a skilled teacher and has a witty and engaging delivery. He does an excellent job of explaining concepts at a level appropriate to a broad spectrum of learners. He also makes it clear what is evidence-based and what is anecdotal in his recommendations. His presentation slides include a variety of figures, tables, and multiple-choice questions. Simple screening tools are also described that could be easily implemented immediately after watching the presentation. These screening tools are available for download on the University of Iowa website. In addition, the initial pharmacologic and non-pharmacologic therapeutic interventions of the delirious patient are reviewed.
Overall, the material is well-organized and easy to follow. Its ease of use and broad scope of information has allowed it to be embedded within curricula of multiple training programs at the University of Iowa Geriatric Education Center. Data provided by the authors at University of Iowa showed that, 96% of learners felt confident that they have achieved the four learning objectives. Many also commented that it provided materials and tools that they would use as teaching tools for their own professional/academic endeavors.
However, it would be helpful if a learner viewing the presentation could go directly to specific parts of the video presentation rather than an ordered approach. Another limitation is that the dementia section draws heavily on Alzheimer’s disease without distinguishing among other diagnostic possibilities such as vascular, frontal lobe or Lewy body. Some materials are also not adequately referenced so learners could not refer to the primary source for additional information. Most importantly, watching a digitized presentation can be a passive learning experience so the product should be an adjunct to a planned blended learning educational session.
This month’s Editor’s Choice, “Distinguishing Delirium, Dementia and Depression,” will help learners recognize and diagnose these conditions as they occur and co-exist in the geriatric patient population. Practical clinical tools for assessment are given and appear easy to employ. And this product is available here – for FREE - on POGOe.
Guest Reviewers: Andrew B. Rosenzweig, MD, Clinical Assistant Professor of Medicine and Margot I. Boigon, MD, Clinical Associate Professor of Medicine, Drexel University College of Medicine and Abington Memorial Hospital.
The educational product is a streaming digital video format with synchronized PowerPoint presentation slides lasting approximately one hour. The lecture presentation, delivered by Dr. Gerald Jogerst, Professor of Family Medicine at the Carver College of Medicine at the University of Iowa, is divided up into three sections (one for each “D”). Each section includes a clinical case report as well as an image of a typical patient with the disorder. Dr. Jogerst is a skilled teacher and has a witty and engaging delivery. He does an excellent job of explaining concepts at a level appropriate to a broad spectrum of learners. He also makes it clear what is evidence-based and what is anecdotal in his recommendations. His presentation slides include a variety of figures, tables, and multiple-choice questions. Simple screening tools are also described that could be easily implemented immediately after watching the presentation. These screening tools are available for download on the University of Iowa website. In addition, the initial pharmacologic and non-pharmacologic therapeutic interventions of the delirious patient are reviewed.
Overall, the material is well-organized and easy to follow. Its ease of use and broad scope of information has allowed it to be embedded within curricula of multiple training programs at the University of Iowa Geriatric Education Center. Data provided by the authors at University of Iowa showed that, 96% of learners felt confident that they have achieved the four learning objectives. Many also commented that it provided materials and tools that they would use as teaching tools for their own professional/academic endeavors.
However, it would be helpful if a learner viewing the presentation could go directly to specific parts of the video presentation rather than an ordered approach. Another limitation is that the dementia section draws heavily on Alzheimer’s disease without distinguishing among other diagnostic possibilities such as vascular, frontal lobe or Lewy body. Some materials are also not adequately referenced so learners could not refer to the primary source for additional information. Most importantly, watching a digitized presentation can be a passive learning experience so the product should be an adjunct to a planned blended learning educational session.
This month’s Editor’s Choice, “Distinguishing Delirium, Dementia and Depression,” will help learners recognize and diagnose these conditions as they occur and co-exist in the geriatric patient population. Practical clinical tools for assessment are given and appear easy to employ. And this product is available here – for FREE - on POGOe.
Guest Reviewers: Andrew B. Rosenzweig, MD, Clinical Assistant Professor of Medicine and Margot I. Boigon, MD, Clinical Associate Professor of Medicine, Drexel University College of Medicine and Abington Memorial Hospital.
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Numb and Number:A Practical Approach to Periperhal Neuropathy: Product of the Year at the 2011 Reynolds Grantees Meeting (1st Place)
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Peripheral neuropathy is a common complication of systemic diseases such as diabetes mellitus. Although the exact cause remains unknown, peripheral neuropathy can cause significant health concerns and decrease the quality of life for those with this condition. Although a prevalent problem in the clinical setting, instruction in this debilitating process is quite poor or even lacking. Drs. Vivyenne Roche, Mike Singer and Lindsay Oksenberg from The University of Texas Southwestern Medical Center have certainly filled a curricular gap with their POGOe product: Numb and Number: A Practical Approach to Peripheral Neuropathy. Attendees of the Reynolds Grantees’ Meeting with over 40 medical schools represented have acknowledged this and have rightly chosen it as the 2011 Product of the Year.
Numb and Number: A Practical Approach to Peripheral Neuropathy is a self-directed interactive instructional web-based module, which comprehensively reviews the approach to peripheral nerve disorders. As described by its authors, it will tune up your anatomy skills (including the brachial plexus and lumbosacral plexus) and is presented within a clinical framework. It includes key aspects of history-taking, a step-wise clinical exam, etiologies, evaluation, management, a quiz, references and even the Texas Plexus Game to test your new skills.
The flash-based module is divided into sections: 1) an instructional module focusing on data gathering (history and physical exam), a detailed review of the upper and lower limb plexuses, common etiologies and management utilizing both non-pharmacologic and pharmacologic approaches; 2) a 5-item multiple choice type pre- and post-test; 3) a game/quiz (Texas Plexus Game) that tests one’s knowledge of the brachial and lumbosacral plexuses and their associated dysfunctions by rolling over their diagrammatic representations; 4) a summary pocket card; 5) further readings and references.
Highlights include a brief tutorial at the start of the module that introduces the user to specific navigation tools. The flash-animation and illustrations are of high quality. The navigation buttons allow you to control the instructional pace of the module giving the user the ability to advance or review materials. The post-test allows the users to review their submitted answers and see what they got correct. However, it does not give the rationale for the incorrect choices. One other limitation is the audio quality, which can sound muffled and difficult to understand. This improves with increasing the volume or using headphones. However, if one sets the volume while listening, it seems to reset to default volume setting as soon as you hit ‘Continue’ thus forcing the user to readjust the volume control each time. The pocket card would be more useful if it also included the important nerve distributions emphasized thoroughly in the module.
These are definitely minor quibbles on this well-designed and conceived POGOe product. Try this 2011 Product of the Year at POGOe.org! It’s FREE!
Numb and Number: A Practical Approach to Peripheral Neuropathy is a self-directed interactive instructional web-based module, which comprehensively reviews the approach to peripheral nerve disorders. As described by its authors, it will tune up your anatomy skills (including the brachial plexus and lumbosacral plexus) and is presented within a clinical framework. It includes key aspects of history-taking, a step-wise clinical exam, etiologies, evaluation, management, a quiz, references and even the Texas Plexus Game to test your new skills.
The flash-based module is divided into sections: 1) an instructional module focusing on data gathering (history and physical exam), a detailed review of the upper and lower limb plexuses, common etiologies and management utilizing both non-pharmacologic and pharmacologic approaches; 2) a 5-item multiple choice type pre- and post-test; 3) a game/quiz (Texas Plexus Game) that tests one’s knowledge of the brachial and lumbosacral plexuses and their associated dysfunctions by rolling over their diagrammatic representations; 4) a summary pocket card; 5) further readings and references.
Highlights include a brief tutorial at the start of the module that introduces the user to specific navigation tools. The flash-animation and illustrations are of high quality. The navigation buttons allow you to control the instructional pace of the module giving the user the ability to advance or review materials. The post-test allows the users to review their submitted answers and see what they got correct. However, it does not give the rationale for the incorrect choices. One other limitation is the audio quality, which can sound muffled and difficult to understand. This improves with increasing the volume or using headphones. However, if one sets the volume while listening, it seems to reset to default volume setting as soon as you hit ‘Continue’ thus forcing the user to readjust the volume control each time. The pocket card would be more useful if it also included the important nerve distributions emphasized thoroughly in the module.
These are definitely minor quibbles on this well-designed and conceived POGOe product. Try this 2011 Product of the Year at POGOe.org! It’s FREE!
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Mini Clinical Evaluation Exercise (Mini-CEX)
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Primarily utilized to monitor learning progress during patient encounters, the Mini Clinical Evaluation Exercise (Mini-CEX) is a formative assessment method that simultaneously assesses clinical skills and offers feedback to the learner. It has been extensively evaluated in the context of internal medicine and found to be a reliable assessment tool of workplace performance for medical housestaff. A 2009 systematic review by Kogan et al in JAMA found that medical student programs have extensively utilized this assessment tool for various skills domains. This may partially be in response to the Liaison Committee on Medical Education (LCME) standard which requires that medical education programs include ongoing assessment activities that ensure that medical students have acquired, and can demonstrate on direct observation, the core clinical skills, behaviors, and attitudes that have been specified in the program's educational objectives.
This month’s Editor’s Choice highlights three mini-CEXs in our product library. They are the Health Care Proxy (HCP) Mini-CEX and Mini-Cog Mini-CEX from Albert Einstein College of Medicine and the MMSE CEX from UCSF. Commonalities include the delineation of the specific tasks the learner should perform, summary assessments of competency in both performing the task and the relevant ACGME competency, sections for comments, satisfaction questions for both student and faculty, and faculty guides. Although each is designated as appropriate for learners from medical students to fellows, only the MMSE Mini-CEX gives suggestions for the level at which these tasks should be mastered by each.
The HCP Mini-CEX (click here) developed by Drs. Amy Ehrlich and Hannah Lipman assesses 5 specific steps important in setting the stage and discussing HCPs with patients. Examiners are asked to judge whether the learner has completed each step. The Mini-Cog Mini-CEX (click here) by Drs. Ehrlich and Kim Freeman similarly assesses 12 steps when conducting the Mini-Cog, however it does not require the student to interpret the test results. Both tools ask the examiner to judge overall competency in Interpersonal and Communication skills using a 9 point scale. This scale is similar to that used in ABIM evaluations, however the scale’s anchors differ- with a score of 2 considered passable (compared with 4 on the ABIM).
The MMSE Mini-CEX (click here) by Dr. C. Bree Johnston from UCSF assesses both the performance and the scoring of each of 11 items. Interpretation of the score, humanistic qualities, counseling performance, and a summary score are evaluated using the ABIM 9-point scale with 4 as the lowest satisfactory rating. Examiners are also asked to note things that were done particularly well. The faculty guide is comprehensive, providing examples of what is considered incorrect for certain items.
In this day where we are being asked to document not just that learners were exposed to, but that they actually achieved competency in specific areas, it is important that we have a shared mental model of what that competency looks like. These 3 Mini-CEXs provide examples of this that you may wish to use ‘off-the-shelf’ or modify for your learners. They allow you to provide feedback based on direct observation, improving your skills in observation and increasing the likelihood that all learners will learn the same key points in how to perform these tasks.
So try out these Mini-CEXs today! They are available for free in POGOe.org! (You can find all of them under the following link or by searching for "mini-CEX")
This month’s Editor’s Choice highlights three mini-CEXs in our product library. They are the Health Care Proxy (HCP) Mini-CEX and Mini-Cog Mini-CEX from Albert Einstein College of Medicine and the MMSE CEX from UCSF. Commonalities include the delineation of the specific tasks the learner should perform, summary assessments of competency in both performing the task and the relevant ACGME competency, sections for comments, satisfaction questions for both student and faculty, and faculty guides. Although each is designated as appropriate for learners from medical students to fellows, only the MMSE Mini-CEX gives suggestions for the level at which these tasks should be mastered by each.
The HCP Mini-CEX (click here) developed by Drs. Amy Ehrlich and Hannah Lipman assesses 5 specific steps important in setting the stage and discussing HCPs with patients. Examiners are asked to judge whether the learner has completed each step. The Mini-Cog Mini-CEX (click here) by Drs. Ehrlich and Kim Freeman similarly assesses 12 steps when conducting the Mini-Cog, however it does not require the student to interpret the test results. Both tools ask the examiner to judge overall competency in Interpersonal and Communication skills using a 9 point scale. This scale is similar to that used in ABIM evaluations, however the scale’s anchors differ- with a score of 2 considered passable (compared with 4 on the ABIM).
The MMSE Mini-CEX (click here) by Dr. C. Bree Johnston from UCSF assesses both the performance and the scoring of each of 11 items. Interpretation of the score, humanistic qualities, counseling performance, and a summary score are evaluated using the ABIM 9-point scale with 4 as the lowest satisfactory rating. Examiners are also asked to note things that were done particularly well. The faculty guide is comprehensive, providing examples of what is considered incorrect for certain items.
In this day where we are being asked to document not just that learners were exposed to, but that they actually achieved competency in specific areas, it is important that we have a shared mental model of what that competency looks like. These 3 Mini-CEXs provide examples of this that you may wish to use ‘off-the-shelf’ or modify for your learners. They allow you to provide feedback based on direct observation, improving your skills in observation and increasing the likelihood that all learners will learn the same key points in how to perform these tasks.
So try out these Mini-CEXs today! They are available for free in POGOe.org! (You can find all of them under the following link or by searching for "mini-CEX")
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Communicating with Geriatric Patients
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Doc.com, a repository of 41 learning modules that cover various topics in healthcare, has offered a free demo of their geriatric module product called Module 23: Communicating with Geriatric Patients. Authored by Dr. Brent C. Williams from the University of Michigan Geriatrics Center and Institute of Gerontology and Dr. James T. Pacala from the University of Minnesota Department of Family Medicine and Community Health, this module introduces the learner to the basic skills in communicating with older patients and their caregivers in order to optimize patients’ functioning, management of their medical conditions, and long-term health outcomes. This web module allows the learner to observe the physician’s interaction with different patients so that by the end of the module, the learner will have a better idea of how to communicate effectively with an older patient.
Highlights include annotated videos, including a patient presentation, a clinic encounter and a panel discussion with the clinical team. It is also interesting to see videos of the same clinical problem from both the patient’s view and the physician’s view. There is a menu on the side panel of the screen for easy navigation as well as highlighting key points for the learner. Text and video explain the material and the learner clicks through it. There are several cases presented and Dr. Williams explains his communication process as he goes along. Limitations include a very linear module format, and there is no assessment section to ensure that the learner has grasped the material (see below).
In summary, this web module provides the learner with a self paced tutorial on how to communicate with older patients. Doc.com also offers access to two other modules free of charge. They are the complete modules from the doc.com series - with just one limitation: the assessment feature is not available, which is an important part of the full doc.com version. The Communicating with Geriatric Patients module is accessible online here at POGOe right now!
Highlights include annotated videos, including a patient presentation, a clinic encounter and a panel discussion with the clinical team. It is also interesting to see videos of the same clinical problem from both the patient’s view and the physician’s view. There is a menu on the side panel of the screen for easy navigation as well as highlighting key points for the learner. Text and video explain the material and the learner clicks through it. There are several cases presented and Dr. Williams explains his communication process as he goes along. Limitations include a very linear module format, and there is no assessment section to ensure that the learner has grasped the material (see below).
In summary, this web module provides the learner with a self paced tutorial on how to communicate with older patients. Doc.com also offers access to two other modules free of charge. They are the complete modules from the doc.com series - with just one limitation: the assessment feature is not available, which is an important part of the full doc.com version. The Communicating with Geriatric Patients module is accessible online here at POGOe right now!
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OSCE geriatric patient with fall and cognitive impairment: Margaret Donovan
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The statement “assessment drives learning” emphasizes the critical place of assessment in a learner’s education. Attributed to the educator George Miller, this statement is of particular importance in medical education nowadays given the focus on clinical competency assessment. Miller proposed in 1990 a schematic hierarchical representation (pyramid) of clinical competence: factual knowledge (knows), concept building and understanding (knows how), competence to perform (shows how) and ability to carry out a task competently in real life situations (does). The context-specific nature of medical education requires educators to rely on multiple assessment methods in multiple levels in this competence pyramid to reliably gauge a medical learner’s skills. As one moves up the levels, performance approaches professional authenticity or expertise.
A fine example of an outcome focused (summative) assessment product in the POGOe Library is the OSCE Geriatric Patient with Fall and Cognitive Impairment: Margaret Donovan from Dr. Lisa Strano-Paul at SUNY Stony Brook School of Medicine. Designed as a 20-minute station in a multi-station OSCE, it assesses clinical students’ or residents’ performance of functional and cognitive assessments. The standardized patient (SP) case scenario is of an older adult person in whom the spouse notices progressive memory loss. Set in an outpatient clinic, the station requires the learner to evaluate the patient's and the spouse’s chief concerns; assess the patient's functional status through history including ADLs, IADLs and social support; perform the Get Up and Go Test, a Mini Mental status exam, and clock drawing and make recommendations to improve the patient’s functional status.
The product consists of SP instructions and facilitator guide, a presenting case scenario, a multi-domain skills checklist including communication and interpersonal skills and a critical action sheet. Highlights include the straightforward case scenario, minimal SP requirement, and detailed instructions that provide examples of what to look for when observing the learner’s performance. However the presence of multiple items in a single checklist may make it difficult for the observer to provide an accurate assessment of the learner’s performance. It also would be helpful to have specific descriptions of poor or borderline performance to anchor observations and increase inter-rater reliability.
The use of OSCEs to make judgments about the attainment of competence requires that sufficient evidence is collected. Studies have shown that OSCEs with more stations of shorter duration have better reliability and validity of performance assessment than those with fewer and longer stations. This is a 20-minute encounter followed by a 10-minute rest; if the other stations follow a similar pattern, a 2-hour OSCE would just consist of 4-6 stations at most. Shorter stations with fewer more specific skills performance may improve the overall multi-station OSCE performance.
This OSCE provides an easy to use assessment of a student’s ability to evaluate and begin management for geriatric Patients with falls and cognitive impairment. Try this month’s POGOe Editor’s Choice now, and browse through the POGOe Library which currently contains 58 other learner assessments that address multiple levels in Miller’s clinical competence pyramid.
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