Incorporating Evidence into Clinical Teaching: Enhanced Geriatrics Specialty Case-Based Residency Presentations

Case-based presentations have a long tradition in medical training, linking trainees' developing knowledge to clinical practice in an interactive environment.1–4 The literature is sparse in describing use of evidence-based techniques to enhance case presentations.

The Vanderbilt University Knowledge Management/Eskind Biomedical Library developed a Clinical Informatics Consult Service in 1996 to provide literature searches for clinicians.5 All information specialists undergo Masters level training in literature searching and critical appraisal and demonstrate proficiency in their understanding of medical terminology, research design, and biostatistics. In 2004, the program was expanded to include ambulatory settings through an Outpatient Clinical Informatics Consult Service.6 The service included an electronic communication tool that allowed physicians to request a literature search for complex questions arising during patient encounters, including capturing the answers to clinical questions at the point of care.7,8 

We describe an innovative approach to case-based learning that uses a messaging tool within the electronic medical record system, coupled with the expertise of information specialists, to enhance case-based presentations delivered by geriatricians to nongeriatric specialty residents.

To effectively disseminate geriatric educational content to nongeriatric specialty residencies, we invited all adult specialty training program directors at our institution to meet individually with presenting geriatricians to assess geriatric learning needs as defined by the American Geriatric Society's Assessing Care of Vulnerable Elders9 quality indicators.

Eleven specialty program directors from emergency medicine, general surgery, neurology, neurosurgery, obstetrics/gynecology, ophthalmology, oral surgery, orthopedics, psychiatry, thoracic surgery, and urology consented to participate in the needs assessment and training initiative in 2006. Program directors were interviewed individually about curricular needs and training models related to competencies for caring for geriatric patients; they overwhelmingly identified case-based presentations as an effective and preferred mechanism for training residents in nongeriatric specialties. The 1949-8357-4-1-83-box01box lists the top educational competency needs expressed during individual interviews with the specialty program directors. In addition to the definitions in the Assessing Care of Vulnerable Elders, the case-based presentations we designed incorporated the Accreditation Council for Graduate Medical Education competencies10 and the Association of American Medical Colleges medical student11 and resident12 geriatric competencies that mapped to the identified curricular needs.

Through collaboration with the information specialists in the Outpatient Clinical Informatics Consult Service, we obtained tailored, evidence-based literature searches that informed our clinical decision making for the care of geriatric patients. They consisted of (1) a concise statement of the current state of the research literature, including all available viewpoints, conflicting study results, and limitations; (2) written or tabular summaries of the individual studies selected and reviewed for their quality, strength, or representation of the research evidence, with links to the full text articles when available; (3) information on the search strategies used to retrieve the relevant literature; and (4) additional readings that included practice guidelines or related research pertinent to the clinical question.13–14 The Knowledge Management team also created a Geriatrics Library to provide access to a collection of online information resources for geriatric education, research, and patient care, including the geriatric-related literature summaries, and granted open access to the summaries for non-Vanderbilt users through a web portal sponsored in part by the Donald W Reynolds Foundation, called the Portal of Geriatrics Online Education or POGOe (http://www.pogoe.org).

The appendix, provided as online supplemental material, shows a sample summary of a literature review and synthesis of all results developed in response to a clinical question submitted by the geriatrics consult service regarding the survival of dementia patients who receive primary nutrition via percutaneous endoscopic gastrostomy tube feeding. The final report sent to the clinicians is organized into 2 sections: (1) a summary of the current evidence on patient survival given percutaneous endoscopic gastrostomy tube feeding, and (2) a detailed table of study data filtered from each research study selected for the summary (provided online).

In preparing for the nongeriatric residency specialty training sessions, presenting geriatricians developed geriatric cases derived from actual patients (inpatient, outpatient, and emergency department) treated at the Vanderbilt Senior Care Service or the Tennessee Valley Healthcare System Geriatric Evaluation and Management Unit. The content targeted the educational competency needs identified by nongeriatric residency specialty program directors and included concise case descriptions with clearly defined objectives, goals, and critical actions; a list of geriatrics education resources; and supplemental teaching handouts containing a summary of the corresponding synthesized literature.

The time required to develop each case-based presentation involved approximately 2 hours for geriatricians and 6 to 8 hours for the information specialist, depending on the complexity of the clinical question, the number of related questions posed, the information specialist's familiarity with the research base for the topic, and the quantity and quality of the relevant primary literature available.

Case presentations were delivered during mandatory division teaching conferences. Geriatricians introduced the cases and conducted interactive small-group discussions about the cases with the specialty resident audiences. A typical case discussion lasted 30 minutes and consisted of 15 minutes for the case presentation and 15 minutes for small-group discussion. The presentation to the residents included clearly stated educational objectives, a critical actions list, and appended resources in addition to the evidence-based information packet concerning tube feeding in dementia patients.

Resident and program directors provided verbal feedback following the presentations to determine additional learning objectives and corresponding competencies for development of future cases and new evidence-based information packets. Baseline and subsequent geriatric consult requests and electronic access to geriatric information summaries were also tracked to measure the effect on specialty service awareness of the availability of geriatric expertise hospital wide.

Forty enhanced case-based presentations were distributed to specialty resident training programs at our institution during a 4-year period. There was a surge in geriatric clinical consults among hospitalized patients, including 141 consults from 64 different providers in the first year, compared with a previous average of 10 sporadic geriatric consults yearly. Consult requests mirrored competencies and identified educational needs (1949-8357-4-1-83-box01box). Currently, 39 geriatrics summaries have been added to the Geriatrics Library repository since October 2006. Twelve summaries were used for the case-based presentations and were subsequently viewed through the electronic medical record portal a total of 193 times (4.29 views per month) and via the Geriatrics Library 182 times (4.04 views per month) between October 30, 2006, and June 30, 2010. Because of the individualized approach in developing the curriculum, a summative evaluation of the program, including comprehensive qualitative data analysis, was not performed.

The increase in geriatric clinical consults, online viewing of topically related geriatric information summaries, positive subjective feedback received from residents, and program directors' requests for additional presentations validated our approach to enhance geriatric education by incorporating skilled information specialists into a case-based learning approach. Additional complex clinical questions were generated from discussions that arose during case presentations, and these literature summaries will be incorporated into the development of future case-based presentations.

A major strength of our approach for training residents in geriatric competencies is the provision of evidence-based literature summaries for geriatric topics mapped to competencies to enhance case-based presentations with just-in-time learning tailored to specialty needs. Additionally, the curricular needs assessment conducted after each presentation further informed the educator for the next presentation, targeting new competencies and revisiting complex aspects of those previously taught. A limitation of our approach is the use of surrogate markers as outcomes, including the change in the number of accesses to the Vanderbilt University Knowledge Management/Eskind Biomedical Library literature summaries, change in the number of subsequent geriatric consults, and subjective feedback, to measure the success of the curriculum.

The use of an electronic medical record messaging tool through which physicians can communicate their complex clinical questions to information specialists may be unique to the Vanderbilt setting. At the same time, the training and collaborative ventures between librarians as expert information specialists and medical educators to answer physicians' complex clinical questions during hospital rounds or via the Internet has been used in other settings.15–18 Although a committed geriatric teaching faculty and receptive specialty training programs are prerequisites, replication of our collaborative approach to delivering enhanced case-based presentations is feasible for geriatric faculty at other academic medical institutions with access to appropriately trained information specialists.

Case-based presentations enhanced with evidence-based summaries of research literature generated by information specialists is a feasible and effective approach to teaching clinical content targeting geriatric educational competencies to resident trainees in nongeriatric specialties. Presentations to nongeriatric residents are associated with an increase in clinical geriatric consults.