Education, Training Needed for Managing Geriatric Otolaryngology Patients

While he was a Boston University School of Medicine fourth-year medical student with the Home Health Service, Brian McKinnon, MD, was introduced to the challenges of caring for the elderly patient. This unique educational experience left an indelible impression and has influenced his career interest in the care of geriatric patients with hearing loss.

However, as Dr. McKinnon and others have discovered, it is rare that students and residents are exposed to a dedicated geriatric educational experience. Unfortunately, most complete their training with little focused education addressing the unique problems of the older adult with otolaryngologic disorders.

Fortunately, there is a forward-thinking society of otolaryngologists dedicated to addressing this gap. The American Society of Geriatric Otolaryngology (ASGO) comprises otolaryngologists and other professionals who realize that the geriatric otolaryngology patient offers a unique challenge to healthcare professionals. This challenge requires a paradigm shift in how we train otolaryngologists, both to prepare them to provide healthcare to older adults and to educate others in the specific needs of this population.

David Eibling, MD, moderated a recent panel held during the American Society of Geriatric Otolaryngology Annual Meeting, held January 23, 2016, during the Triological Society Sections Meeting in Miami Beach, to better define and address the educational opportunities associated with the care of geriatric otolaryngology patients. Robert Miller, MD, Karen Kost, MD, Steven Parnes, MD, Carl Shipp, MD, and Brian McKinnon, MD, joined Dr. Eibling on the panel. This geriatric education panel considered the education and training opportunities that should be created to formally introduce otolaryngology residents, fellows, and colleagues to this topic.

Dr. Eibling opened the discussion by summarizing the conclusions of the 2009 Institute of Medicine report “Retooling for an Aging America.” The report noted that the shortage of geriatricians will dramatically impact the quality of care available for the aging population. Moreover, and not surprisingly, the only viable solution is the education of all physicians, and particularly specialists, to fill this void.

Geriatrician Shortage

The American Geriatric Society (AGS) anticipated the impending shortage of geriatricians more than a decade ago. Formed in 1942 by Ignate Nascher, MD, and Malford Lewis, MD, the AGS is a small organization dedicated to improving the health, independence, and quality of life of all older people. In the late 1990’s, the AGS executive council recognized the explosive growth of U.S. seniors—from 12% to a projected 20% of the population by 2030—and implemented the Geriatrics for Specialists Initiative, collaborating with eleven specialty societies, including the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Dr. Parnes, a past president of ASGO, represented the specialty of otolaryngology in the initiative and played a role in selecting specific learning objectives.

This initiative was followed by the establishment of the Section for Enhancing Geriatric Understanding and Expertise among Surgical and Medical Specialists, a group dedicated to promoting geriatric concerns for all specialties through scholarship funding. The AGS Jahnigen Award and the Professional Development Plan for the National Institutes of Health’s Grants for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSTAR) are two of the established funding streams. The goal of these efforts, in which ASGO members Dr. Shipp, Michael Johns, MD, and Kourosh Parham, MD, PhD, are involved, is to develop and circulate educational materials and, ultimately, to incorporate these principles into residency programs. The AGS has been the driving force behind these initiatives, with financial support from the John A. Hartford Foundation.

Assessing Competencies

The following issues have crystalized over the past several years since the ASGO was established:

1. Geriatric patients have specific otolaryngology issues. Just as children are not “little adults,” geriatric patients are not just “older middle-aged adults.”
2. Knowledge gaps regarding these issues and appropriate care currently extend across the spectrum of medical care. These gaps exist among otolaryngologists, primary care practitioners, nurses and other healthcare workers, and the public.
3. Educating the newest generation of otolaryngologists will best be assured via incentivization. The most effective incentive will be the establishment of specialty-specific competencies that are assessed through formal evaluation on the OTE and American Board of Otolaryngology (ABOto) examinations.
4. Otolaryngologists have the responsibility to educate others in the specific issues of geriatric otolaryngology.
5. The mission statement of ASGO establishes its goal of helping to educate otolaryngologists so that members of our specialty can educate each other, our trainees, referring providers, and the lay public.

Dr. Miller, the executive director of the ABOto, pointed out that there is insufficient emphasis on assessing competencies specific to the care of the geriatric patient. Deficiencies exist both at the specialty level manifested in the ABOto examination process and at the broader level of the Accreditation Council for Graduate Medical Education (ACGME). The conclusion is that a tremendous opportunity exists for the ASGO, the AAO-HNS, the Triological Society, and other otolaryngological societies to collaborate to fill this gap. Through cooperation, we can help the ABOto and the ACGME establish specific competencies, as well as develop and implement educational material and programs on the care of the geriatric otolaryngology patient to address these competencies.

The American College of Surgeons (ACS) recently released a white paper on geriatric competencies for surgeons, and Dr. Parham represented ASGO on this work group. Stakeholders representing several health professions (including the AAO-HNS and the ASGO), patients, and families were all consulted.

These groups, the Centers for Medicare and Medicaid Services, and other payers will vet the ACS standards and contribute to the development of more refined patient-centered outcome measures. Dr. Parham pointed out that although these competencies are applicable to all surgeons, there is little that is specific to otolaryngology, which means that otolaryngologists need to play a role in developing otolaryngology-specific competencies.