herding cats: leverage points for geriatric medical education in 2011 rosanne m. leipzig, md, phd...

Herding Cats:Herding Cats:Leverage Points for Geriatric Leverage Points for Geriatric Medical Education in 2011 Medical Education in 2011

Rosanne M. Leipzig, MD, PhDRosanne M. Leipzig, MD, PhD

Brookdale Department of Geriatrics Brookdale Department of Geriatrics

and Palliative Medicineand Palliative Medicine

Mount Sinai School of MedicineMount Sinai School of Medicine

Table of Organization

Medical Education Table of Disorganization

Professional Certification

School Program

Accreditation

Professional Licensing

LCME NBME

ABMS

ABMS

FSMB

FSMB

Medical Students

Residents + Fellows

Practicing Physicians

ACGME

ACCME

Getting Change in Medical Education is Like Herding Cats

Medical Education

Geriatricizing Medical Geriatricizing Medical EducationEducation

• Leverage PointsLeverage Points

– Make it easier to teach Make it easier to teach – Make it easier to assessMake it easier to assess– Faculty developmentFaculty development– Geriatrics in High Stakes ExaminationsGeriatrics in High Stakes Examinations– Geriatrics requirements for Geriatrics requirements for

accreditationaccreditation– Advocacy Advocacy

That Was the Year That Was2010

Leveraging Geriatrics Medical Education

Making it Easier to TeachMaking it Easier to Teach

Leverage PointLeverage Point

Geriatric Competencies by Learner

MedicalStudents

Practicing MDs

Sub-Specialty Fellows

Emergency Medicine

AnesthENTOb-Gyn

Residents

Surgical Specialty Residents

Geriatric Fellows

Internal MedicineFamily MedicineSurgery

Falls Competencies

Med Student:Ask about falls, watch the patient rise from a chair and walk, record

and interpret In a faller, construct a differential diagnosis and evaluation plan to

address the multiple etiologies identified.

IM/FM Resident:Yearly screen all ambulatory elders for falls or fear of falling. If

positive, assess gait and balance, evaluate for potentially precipitating causes, and implement interventions

In hospitalized medical and surgical patients, evaluate at admission and regularly for fall risk……and institute appropriate corrective measures

Falls competencies

Geriatric Fellow:• Recognize abnormal gaits associated with specific

conditions, and perform and interpret common gait and balance assessments.

• Conduct an appropriate evaluation of patients who fall, implement strategies to reduce future falls, fear of falling, injuries, and fractures, and followup on referrals.

• Implement strategies to reduce falls in patients in all health care settings.

Partnership for Health in Aging (PHA) Competencies

• Dentistry• Medicine• Nursing• Nutrition• Occupational

Therapy

• Pharmacy• Physical Therapy• Physician

Assistants• Psychology• Social Work

Still Need to Get Teaching Materials

NO TIME!!End-of-Life Care

GeriatricsQI projects

EBM

Cultural CompetencyACGME Competencies

Genetics/Genomics

Blended Learning

• LEARNERS: acquire knowledge prior to face time with faculty

• FACULTY: with student on knowledge application– Direct observation and modeling– Formative feedback on performance– Iterative performance till competency

achieved

Sponsored by the Association of Directors of Geriatric Academic Programs through a grant from the Donald W. Reynolds Foundation, managed by the Mount Sinai School of Medicine

The Portal of Geriatric Online EducationThe Portal of Geriatric Online Education

www.POGOe.orgwww.POGOe.org

““One-Stop Shopping” for One-Stop Shopping” for Geriatric Education MaterialsGeriatric Education Materials

POGOe Products

597 POGOe Products

52Assessment

Products

545Instructional

products

POGOe Collaborations

• Hartford Geriatrics Nursing Initiative (HGNI) – formalized 2010– 11 products posted, more to come (113 potential)

• Geriatrics-for-Specialists Initiative (GSI)– began 2003– 7 posted products thus far

G-Wiz (Geriatric Wizard)

• Identifies the best POGOe products for each medical student competency

G-Wiz (Geriatrics Teaching Wizard)

POGOe Product Reviews

• JAGS e-learning section– Examples:

• New Mexico's Health Care Decision Making • Harvard’s Web-Based Module to Train and

Assess Competency in Systems-Based Practice

• Arizona’s Elder Care Provider Fact Sheets

• Editor’s Choice on POGOe and in monthly newsletter

Video Library

POGOe Works in Progress

Virtual Clerkship

• Medical student curriculum that students can use independently

• Clerkship Directors will be able to:• Customize or use as pre-packaged curriculum (plug

and play)• Track student usage• View statistics page capturing student activity

• Pilot funded to develop 1 domain

Updated Search

At This Meeting

• Town Halls– Geriatric Fellows Competencies– POGOe Users Group

• Feedback on POGOe: help make it suit your needs

• Input on virtual clerkship and other features

• POGOe booth: (Beta) Test drive new search engine and get a chocolate treat!

Making it Easier to AssessMaking it Easier to Assess

Leverage Point:Leverage Point:

The Reynolds Trans-The Reynolds Trans-Institutional Evaluation Group Institutional Evaluation Group

(R-TIEG)(R-TIEG)• Anne Fabiny (Harvard) Anne Fabiny (Harvard)

• Jim Powell (Vanderbilt)Jim Powell (Vanderbilt)

• Donna Rosenstiel (Vanderbilt)Donna Rosenstiel (Vanderbilt)

• Renee PorierRenee Porier (Vanderbilt) (Vanderbilt)

• Gail Sullivan (U Conn)Gail Sullivan (U Conn)

• Brent Williams (Michigan)Brent Williams (Michigan)

R-TIEG: R-TIEG: ‘Best’ ways to assess ‘Best’ ways to assess each student competency each student competency

• Spearheaded by U Cal consortiumSpearheaded by U Cal consortium– Knowledge: shelf-like exam.Knowledge: shelf-like exam.– Performance in practicePerformance in practice

• Direct observation: mini-clinical exam (Cex) Direct observation: mini-clinical exam (Cex) checklists.checklists.

– Clinical skillsClinical skills• Objective Structured Clinical Exams Objective Structured Clinical Exams

(OSCEs), standardized patients, (OSCEs), standardized patients, simulations, etc.simulations, etc.

TIREG: Assessment Tool TIREG: Assessment Tool RatingRating

• Developed an assessment rating Developed an assessment rating instrumentinstrument

• Beta tested the instrumentBeta tested the instrument• Now- Using the instrument to evaluate Now- Using the instrument to evaluate

existing assessment tools (Looking for existing assessment tools (Looking for volunteers)volunteers)

• Next steps: Map tools to competenciesNext steps: Map tools to competencies• Will be available (and searchable) on Will be available (and searchable) on

POGOe (estimated date: AGS 2011)POGOe (estimated date: AGS 2011)

POGOe Assessment ToolsPOGOe Assessment Tools

• Mostly Knows, Knows How, Shows

• Policy for securing and releasing assessment materials

• Some materials not directly accessible on POGOe

• “Human Firewall” • released upon request and • verification of requester’s faculty status

Learner Assessments

ACGME MilestonesACGME Milestones

• ACGME mandateACGME mandate

• Develop milestones of competencyDevelop milestones of competency– Help to interpret the ACGME core Help to interpret the ACGME core

competencies for each specialtycompetencies for each specialty– Assist with the assessment of competencyAssist with the assessment of competency– Provide specific feedback to learners Provide specific feedback to learners

regarding progression towards regarding progression towards competence.competence.

IM MilestonesIM Milestones• ACGME CompetencyACGME Competency

– Patient ManagementPatient Management• Developmental milestoneDevelopmental milestone

– Provide appropriate preventive care and teach Provide appropriate preventive care and teach patient regarding self-care patient regarding self-care

• Approximate timeframe by which this should be Approximate timeframe by which this should be achievedachieved– 6 months6 months

• General Evaluation StrategiesGeneral Evaluation Strategies– Chart reviewChart review

IM/FM Competencies / IM/FM Competencies / Milestones RelationshipMilestones Relationship

Brent Williams workBrent Williams work• 11 competencies are 11 competencies are specific instancesspecific instances of one or of one or

more Milestonesmore Milestones• 11 competencies not directly addressed11 competencies not directly addressed

– identify identify unrecognized problemsunrecognized problems that are NOT a complaint that are NOT a complaint or presenting problem, in or presenting problem, in individual encountersindividual encounters with with patients at patients at high riskhigh risk..

– case-findingcase-finding and and targeted risk assessment for targeted risk assessment for syndromessyndromes are rarely addressed in the milestones are rarely addressed in the milestones

IM/FM Competency / IM/FM Competency / Milestones RelationshipMilestones Relationship

4 competencies are 4 competencies are not reflectednot reflected in Milestones. in Milestones.– Advance care planning.Advance care planning.– Determining decision-making capacity. Determining decision-making capacity. – Actively identifying and addressing patient-Actively identifying and addressing patient-

specific barriers to communication.specific barriers to communication.

– Identifying with the patient, family and care Identifying with the patient, family and care team when goals of care and management team when goals of care and management

should transition to primarily comfort care.should transition to primarily comfort care.

How does the milestone crosswalk make it easier to teach and assess

geriatrics?

ABIM interested in having ABIM interested in having residency programs pilot this as residency programs pilot this as

competency-based learningcompetency-based learning

Internship OSCEs: Internship OSCEs: Geriatric StationsGeriatric Stations

• University of MichiganUniversity of Michigan• 15- minute encounter of a patient about to 15- minute encounter of a patient about to

be discharged from the hospital focusing be discharged from the hospital focusing on two dimensions:on two dimensions:

• Geriatric Assessment (ADLs, IADLs, Mini-Geriatric Assessment (ADLs, IADLs, Mini-cog, depression screen, continence, falls) cog, depression screen, continence, falls) ANDAND

• Communication skills (separate rating, verbal Communication skills (separate rating, verbal and non-verbal communication skills, getting and non-verbal communication skills, getting glasses on, etc.)glasses on, etc.)

• Evaluator’s Toolbox Evaluator’s Toolbox working groupworking group

• Assessment FairAssessment Fair• NBME workshopsNBME workshops• Clinical Skills sessionsClinical Skills sessions

• Learner Assessments 101Learner Assessments 101• 360 assessments360 assessments• DDx of Delirium: training DDx of Delirium: training

to competenceto competence

At This Meeting

Speak with Anne Fabiny or Brent Williams if interested in reviewingAssessment tools with the new rating instrument

Faculty DevelopmentFaculty Development


GACAs 2010GACAs 2010

• 105 eligible applications received105 eligible applications received– 80 new; 25 renewals80 new; 25 renewals

• 68 funded68 funded– 66 MDs, 1 psychology, 1 physical therapy. 66 MDs, 1 psychology, 1 physical therapy. – 56 new; 12 renewals 56 new; 12 renewals

• Assuming level funding, the next round Assuming level funding, the next round of GACAs will be in 2015.of GACAs will be in 2015.

Faculty Development Possibility

• Adapting ABIM Faculty Development course in assessment to geriatric competencies

Geriatrics in Geriatrics in High-Stakes ExaminationsHigh-Stakes Examinations


Changes to ABIM Internal Changes to ABIM Internal Medicine ExaminationMedicine Examination

• Blueprint changedBlueprint changed– Previously 10% cross content geriatrics, 0% Previously 10% cross content geriatrics, 0%

primary geriatricsprimary geriatrics

• Now geriatrics is a primary content area.Now geriatrics is a primary content area.– 4% of the test4% of the test

• Will test geriatric syndromes and the care of geriatric Will test geriatric syndromes and the care of geriatric patients, rather than just diseases in older adults.patients, rather than just diseases in older adults.

– 8% of the test will be cross content geriatrics8% of the test will be cross content geriatrics

2010 Exams Reviewed2010 Exams Reviewed

• NBME subject (shelf) examsNBME subject (shelf) exams

• USMLEUSMLE– Step 1Step 1– Step 2 Clinical KnowledgeStep 2 Clinical Knowledge– Step 2 Clinical SkillsStep 2 Clinical Skills– Step 3Step 3– Computer-based simulation casesComputer-based simulation cases

• ABIMABIM– ‘‘Geriatric’ pool (cross-content items)Geriatric’ pool (cross-content items)

2010: Exam Reviewers2010: Exam Reviewers

• Christine ArensonChristine Arenson• Lynn BickleyLynn Bickley• Jan Busby-WhiteheadJan Busby-Whitehead• Danelle CayeaDanelle Cayea• Anne FabinyAnne Fabiny• Lisa GranvilleLisa Granville

• Bree JohnstonBree Johnston• Reena KaraniReena Karani• Rosanne LeipzigRosanne Leipzig• Sharon LevineSharon Levine• Joanne SchwartzbergJoanne Schwartzberg• Amit ShahAmit Shah• Gail SullivanGail Sullivan

Funded by AMA

A A GeriatricGeriatric Question Question 1.1. involves one of the 26 geriatricsinvolves one of the 26 geriatrics competencies competencies, ,

and/orand/or

2.2. involves one of ABIM’s 16 geriatricinvolves one of ABIM’s 16 geriatric syndromes syndromes and/orand/or

3.3. involves a “geriatric” involves a “geriatric” disease/conditiondisease/condition: : (a)(a) not covered by a competency, not covered by a competency,

(b)(b) predominantly affects 65+,predominantly affects 65+,

(c)(c) testing what is typically seen in an older adult, testing what is typically seen in an older adult,

(d)(d) if the examinee gets it wrong – could hurt an older if the examinee gets it wrong – could hurt an older adultadult

(a)(a) Eg, differential diagnosis of abdominal pain in an older adult Eg, differential diagnosis of abdominal pain in an older adult

ABIM Geriatric Syndromes ABIM Geriatric Syndromes • Constipation and fecal incontinenceConstipation and fecal incontinence• DeliriumDelirium• DementiaDementia• DepressionDepression• Dizziness / lightheadednessDizziness / lightheadedness• Falls and gait disordersFalls and gait disorders• FrailtyFrailty• Hearing lossHearing loss• ImmobilityImmobility• MalnutritionMalnutrition• PainPain• Pressure ulcersPressure ulcers• Sleep disordersSleep disorders• Urinary incontinenceUrinary incontinence• Vision impairment Vision impairment • Failure to thriveFailure to thrive

•From ABIM Geriatric Medicine Maintenance of Certification Examination Blueprint, http://www.abim.org/pdf/blueprint/geri_moc.pdf accessed 8/10/2010, with modifications to include content from the Blueprint Geriatric Psychiatry and Functional Assessment and Rehab categories

http://www.abim.org/pdf/blueprint/geri_moc.pdf%20accessed%208/10/2010



Geriatric DiseasesGeriatric Diseases

• PMR/TAPMR/TA

• Osteoporosis (OP)Osteoporosis (OP)

• BPH BPH

• Examples of others being consideredExamples of others being considered– Mesenteric ischemiaMesenteric ischemia– AAAAAA– VolvulusVolvulus– Myasthenia GravisMyasthenia Gravis– Multiple MyelomaMultiple Myeloma

NBME Subject Exams Reviewed

• Family Medicine• Psychiatry• Internal Medicine• ObGyn• Surgery• Clinical Neurology• Medicine Sub Internship• Ambulatory

N = 8

GQ Letter to Committee April 2...


NBME Subject Exams

• 100 questions per exam

• 800 questions reviewed

• 147 (18.4%) involved people 65 or older

• 48 (32.7%) of these were ‘true geriatric.’

• Numbers of ‘true geriatric’ per exam: – Median 6.5, range of 1-12.

– Far lower than representation of this population either in the discipline workload or in the national adult population.



Preliminary USMLE Exam Results

0

50

100

150

200

250

300

350

Step 1 Step 2CK Step 3

# Questions

# Geriatric Qs

# non-diseaseGeriatric Q

3 forms for each Step; all >65 yo

ABIM Review Results

0

20

40

60

80

100

120

140

160

# Questions

# Geriatric Qs

Non-diseaseGeriatric Qs

Needs Identified from Exam Reviews

• MCQ Knowledge Gaps• Geriatric content in Clinical Skills exam• Ways to provide feedback to schools

– NBME• Geriatrics shelf exam• Geriatrics subscores on 2 exams given at most schools

(IM, surg, psych?)• Composite geriatric subscore from questions on several

shelf exams

– USMLE• Geriatric subscore

• NBME question writing sessions to NBME question writing sessions to begin to fill in gapsbegin to fill in gaps

• Anne Jobe session on geriatrifying Anne Jobe session on geriatrifying Step 2 clinical skills Step 2 clinical skills – Need for observational anchors in order Need for observational anchors in order

to be able to include geriatric to be able to include geriatric assessments as part of clinical skillsassessments as part of clinical skills

At This Meeting

Geriatrics Requirements in Geriatrics Requirements in AccreditationAccreditation


The curriculum of a medical education program must prepare students to enter any field of graduate medical education and include content and clinical experiences related to each phase of the human life cycle

LCME Revised Standard ED-15

It is expected that the curriculum will be guided by the contemporary content from and the clinical experiences associated with, among others, the disciplines and related subspecialties that have traditionally been titled family medicine, internal medicine, obstetrics and gynecology, pediatrics, preventive medicine, psychiatry, and surgery.

REFUSED request to add geriatrics to this list!

LCME Revised Standard ED-15Commentary

AAMC Graduation Questionnaire (GQ)

• 2001-2009: specific geriatrics questions

• 2010: Geriatrics questions eliminated

• Currently lobbying for reinstatement in 2011

Residency Review Residency Review Committees Committees

• Dr. George Drach has appeared Dr. George Drach has appeared before the RRC Chairs committee before the RRC Chairs committee and discussed the need for geriatric and discussed the need for geriatric competency. competency.

• Each RRC is reviewing their geriatric Each RRC is reviewing their geriatric requirements requirements

• Next steps unclearNext steps unclear

Internal Medicine RRC

• Removed requirement for 1 month geriatric rotation

• New languageFaculty with credentials appropriate to the care

setting must supervise all clinical experiences. These experiences must include:

– exposure to each of the internal medicine subspecialties and neurology;

– an assignment in geriatric medicine

Why the Change to Fewer Requirements

• Medical education moving to outcomes, getting away from process

• Carnegie Pillar 1:– Standardization of learning outcomes– Individualization of the learning process

• No longer telling schools/programs HOW to teach.

• Increases influence of the Certification and Licensing bodies

Encouraging SignsEncouraging Signs

MedPAC 2009 concerns

• Communication

• Care Coordination

• Multidisciplinary Teamwork

• Patient Safety

• Judicious Resource Use

• Nonhospital Experiences

• (Basic geriatric instruction)

Congress and $$$

• $9 billion to GME from CMS

• June, 2009 MedPAC report to Congress– Concern that our health professionals

are not learning certain skills necessary to work optimally in delivery systems that focus on care coordination, quality, or judicious resource use

June 2010 MedPAC Report to Congress

Gaps in medical education, including physician prep to care for older adults, be addressed by:

(1) Making a significant portion of Medicare’s GME payments contingent on reaching desired educational outcomes and standards, and

(2) Making information about Medicare’s payments & teaching costs available to the public - also fosters greater accountability for educational activities within the GME community

June 2010 MedPAC Report to Congress

An educational goal that is particularly pertinent to Medicare is the growing need for basic geriatric competency among almost all our physicians, as called for by many experts, clinicians, and researchers (Boult et al. 2010, Institute of Medicine 2008, Leipzig et al. 2009).

While many specialties require some form of geriatric instruction for ACGME accreditation, and several organizations have collaborated to develop a set of geriatric competencies for all medical students and residents, Medicare’s GME financing does not place any requirements on geriatric skills and experience.

Encouraging basic knowledge in geriatric care amonggraduating residents would have important benefits forelderly Medicare beneficiaries.

AMA: House of Delegates Resolution AMA: House of Delegates Resolution sponsored by AGSsponsored by AGS

• Co-sponsored by:Co-sponsored by:– American Academy of Child and Adolescent PsychiatryAmerican Academy of Child and Adolescent Psychiatry– American Academy of Family PhysiciansAmerican Academy of Family Physicians– American Academy of Hospice and Palliative MedicineAmerican Academy of Hospice and Palliative Medicine– American Academy of Physical Medicine and American Academy of Physical Medicine and

RehabilitationRehabilitation– American Academy of Psychiatry and the LawAmerican Academy of Psychiatry and the Law– American College of PhysiciansAmerican College of Physicians– American Medical Directors AssociationAmerican Medical Directors Association– American Psychiatric AssociationAmerican Psychiatric Association

Ensuring Physician Competence Ensuring Physician Competence in the Care of Older Adultsin the Care of Older Adults

• RESOLVED, That Our AMA recognize the critical RESOLVED, That Our AMA recognize the critical need to ensure that all physicians who care for need to ensure that all physicians who care for older adults, across all specialties, are competent older adults, across all specialties, are competent in geriatric care, and encourage all appropriate in geriatric care, and encourage all appropriate specialty societies to identify and implement the specialty societies to identify and implement the most expedient and effective means to ensure most expedient and effective means to ensure adequate education in geriatrics at the medical adequate education in geriatrics at the medical school, graduate, and continuing medical school, graduate, and continuing medical education levels for all relevant specialties education levels for all relevant specialties

• Directive to Take Action.Directive to Take Action.

Other Encouraging ActionsOther Encouraging Actions

• JAMA series on geriatric careJAMA series on geriatric care• Elder Workforce Alliance (EWA): Health Elder Workforce Alliance (EWA): Health

reformreform– Geriatrics recognized as Primary CareGeriatrics recognized as Primary Care

• Our field’s strengths are the new ‘buzz’ Our field’s strengths are the new ‘buzz’ words for health carewords for health care– Systems of careSystems of care– TransitionsTransitions

– Interprofessional Interprofessional care….care….

2011: What’s Next?

Geriatricizing Medical Geriatricizing Medical EducationEducation

• Consensus on what to teach and how to Consensus on what to teach and how to assess assess

• Develop and rate assessment toolsDevelop and rate assessment tools• Faculty developmentFaculty development• Geriatrics in High Stakes ExaminationsGeriatrics in High Stakes Examinations• Geriatrics requirements for accreditationGeriatrics requirements for accreditation• Public PolicyPublic Policy

Continue work as a Geriatrics Learning Continue work as a Geriatrics Learning Community Community

Opportunities

• NBME– Geriatrics subscore?

• USMLE– MCQ question writers– Geriatrics subscore?– Clinical Skills exam

• ABIM– New blueprint for certification exam

Advocate for:Advocate for:

• Increasing numbers of GACAs and decreasing time interval Increasing numbers of GACAs and decreasing time interval between RFAsbetween RFAs

• Geriatrics to be seen as primary care by the PCMH & HRSAGeriatrics to be seen as primary care by the PCMH & HRSA

• Hospital recognition (systems, transitions, medical errors)Hospital recognition (systems, transitions, medical errors)

• Continued collaboration with EWA to increase and raise the bar Continued collaboration with EWA to increase and raise the bar for the workforce involved in geriatric carefor the workforce involved in geriatric care

• CMS dollars for nursing homes to cover residents and CMS dollars for nursing homes to cover residents and attending’s timeattending’s time

• CMS requiring geriatric competence for GME payments.CMS requiring geriatric competence for GME payments.

• Developing a matrix for Medicare Physician Quality Reporting Developing a matrix for Medicare Physician Quality Reporting Initiative (PQRI)Initiative (PQRI)

Why do we doing this?Why do we doing this?

• So older patients will So older patients will get safer, better careget safer, better care

• Remember—Remember—

– Don’t Kill Granny!Don’t Kill Granny!

Clinical Skills Session

Assessment Gaps:

• NEEDED: Consensus on markers for direct observation

– What tool to use?• Gait and balance assessment

– Get Up and Go?

– POMA?

– Tandem Stance?

– Checklist of critical behaviors – Faculty Development to use checklists to get

consistent ratings of competency (inter-rater reliability)

Direct Observation: Faculty Ratings: ABIM 1-9

1 2 3 4 5 6 7 8 9

Satisfactory

SuperiorUnsatisfactory

Direct Observation: Faculty Ratings: ABIM 1-9 scale

4 5 6 7 8 9

Satisfactory Superior

Direct Observation: Faculty Ratings: ABIM 1-9

1 2 3 4 5 6 7 8 9

Satisfactory

SuperiorUnsatisfactory

Direct Observation: Faculty Ratings: ABIM 1-9 scale

4 5 6 7 8 9


TUAG Direct Observation: Faculty Ratings: ABIM 1-9 scale

4 5 6 7 8 9


Timed Up and Go: Standards for Evaluation

Skill Specific Features

Communication Introduce oneself.

Explain the reason for the test.

Provide explicit instructions:

Rise without using arms of chair

If using assistive device, use if for test.

How far to walk; when to turn/return.

Performing the Task

Use chair without arms or wheels.

Guard the patient if safety is a concern.

Accurately time the test.

Reporting and Interpretation

Describe observations (use of arms to rise, stance, balance, step length, path deviation, turning, arm movement).

Report ‘score’ (time elapsed) (Cut-offs: ?8, 11, 15)

Accurately interpret the score in light of the gait and balance observed.

TUAG Direct Observation: Faculty Ratings: ABIM 1-9 scale

4 5

How Do We Get There?

herding cats: leverage points for geriatric medical education in 2011 rosanne m. leipzig, md, phd...

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