University of Colorado School of Medicine
Competency-based test of inpatient geriatric management skills grading admission orders for a standardized case.
Assessment of a student or resident's clinical skills in the care of the hospitalized elderly patient requires evaluation of applied knowledge measured in discrete competencies. This assessment grades the student on admission orders based on history, physical, and laboratory assessment of a standardized patient. It is designed to evaluate actual clinical behavior in the inpatient setting. The test assesses selected competencies from the Minimum Geriatric Competencies for Internal Medicine and Family Medicine Residents. Management of geriatric syndromes in the hospital setting occurs in the milieu of inter-current medical illness, co-morbid conditions, and need to prevent iatrogenic complications. As such, this assessment also incorporates competencies of hospital medicine from The Core Competencies in Hospital Medicine.
The patient is an elderly woman with multiple predisposing factors for falls that began to have increased falls and functional limitation after toe amputation and new initiation of amitriptyline. These elements contributed to gait impairment and increase in falls over the prior month. The acute trigger for this hospitalization was increased weakness induced by systemic infection (MRSA abscess/cellulitis) beginning approximately 3 days prior to admission. This infection triggered decreased p.o. intake, dehydration, and acute on chronic renal failure. Impaired clearance of digoxin from worsening renal function led to accumulation and digoxin toxicity manifesting as nausea and visual changes. The final event which caused her to seek medical attention was a fall with inability to get back up. As with many admissions the problem is multifactoral with both chronic and acute elements.
The test taker is expected to recognize that this patient is ill, merits empiric antibiotics with coverage against MRSA (given the high and rising prevalence of caMRSA and patients history of recent hospital exposure) with renal adjustment, and requires discontinuation of medications which are causing side effects. House officers need to anticipate and mitigate hazards of hospitalization such as delirium, falls, iatrogenic urinary tract infections, hyper/hypoglycemia, venous thromboembolism and deconditioning.
Paper based exam in which the learner is graded based on their written admission orders for a standardized patient case.
The standardized case was developed to have face validity and piloted on a cohort of 10 third year medical students, 10 interns, and 8 third year residents who had completed an inpatient geriatric rotation. To evaluate external validity, the standardized case was then reviewed by 20 expert educators in geriatrics and hospital medicine at 6 academic medical centers nationally (eight geriatricians, eight hospitalists, and four geriatric-hospitalists). The scoring system was developed using a relative weight for each competency using average judgment of the 20 experts and multiplying the importance of the competency by the importance of acting on this competency for the patient in the standardized case.
Test performance in the pilot cohort was:
- Third year medical student average score 49.4 (range 11-80)
- First year resident average score 61.7% (range 36-91)
- Third year resident average score 85.5% (range 78-100%)