Residency Education in the Nursing Home: A National Survey of Internal Medicine and Family Practice Programs PAUL R. KATZ, MD, JURGIS KARUZA, PhD, NElL HALL, MD Objective: To assess the role o f the nursing home in postgraduate medical education. Design: A survey questionnaire addressing the following issues: 1)prevalence o f nursing home rotations in i n t e r n a l medicine and f a m i l y practice residency program& 2) duration and type o f rotation, 3) extent o f residents" responsibilities, 4) patterns o f faculty supervision, 5) p r o g r a m directors" assessments o f nursing home experience, and 6) frequently encountered problems. Participants: D i r e c t o r s o f accredited i n t e r n a l medicine and f a m i l y practice residency p r o g r a m s in the United States. Measurements and m a i n results: A total o f 502 surveys

were returned f o r a response rate o f 60%. Nursing home rotations were more f r e q u e n t in f a m i l y practice p r o g r a m s (87%) compared with internal medicine p r o g r a m s (32%). Rotations in internal medicine were generally optional and limited to a short block o f time compared with f a m i l y practice, where rotations were most often required and longitudinal Internal medicine residents received more intense s u p e r v ~ o n , whereas f a m i l y practice residents had g r e a t e r clinical responsibilities. Few faculty bad f o r m a l geriatric training or certificatiom Reimbursement f o r physician services was low. Although availability o f faculty, resident interes~ and conflict with other clinical services were identified as problem areas, p r o g r a m directors in both internal medicine and f a m i l y practice were supportive o f nursing home rotations f o r their trainees. Key words: nursing homes;family practice; internal medicine; resident education; p r o g r a m directors. J GEN I N ~ I MED 1992;7:52 - 56.

CURRENTLY2 0 , 0 0 0 nursing homes in the United States care for over 1.5 million residents. 1 One-third of individuals requiring long-term care reside in nursing homes, and these numbers will increase substantially over the next 50 years, as the elderly p o p u l a t i o n expands. Nursing homes offer a large patient pool with a wide spectrum of acute and chronic disease. Further, this p o p u l a t i o n serves to highlight a variety of ethical, legal, economic, and administrative problems. Physician knowledge of these issues is key to the delivery of high-quality and comprehensive medical care, regardless of the level of care. Despite this, nursing homes

Received from the Division of Geriatrics/Gerontology, School of Medicine and BiomedicalSciences, State Universityof NewYork at Buffalo (PRK, JK), the Veterans Administration Medical Center (PRK), and the State Universityof New York College at Buffalo (JK), Buffalo, New York; and the Program in Geriatrics, State Universityof New York, Health Sciences Center at Syracuse, Clinical Campus in Binghamton, Binghamton, New York (NH). Address correspondence and reprint requests to Dr. Katz: University of Rochester School of Medicine and Dentistry at Monroe Community Hospital, 435 East Henrietta Road, Rochester, NY 14620. SZ

have not traditionally been used as postgraduate physician training sites. The fact that fewer and fewer medical students are opting for careers in primary care specialties 2 speaks to the need to redirect graduate and postgraduate educational efforts away from the acute, inpatient unit to sites w h e r e long-term comprehensive management of patients is possible. Medical educators are b e c o m i n g sensitive to the role of the nursing home in physician training and are showing renewed interest in more fully integrating long-term care into the curriculum. Over the past decade, family practice (FP) programs have consistently embraced nursing home rotations to fulfill part of their primary care requirements in gerontology/geriatrics. 3 In contrast, internal medicine (IM) programs have only recently begun to integrate nursing home experiences into residency training. The Accreditation Council for Graduate Medical Education (ACGME) for resident training in IM has provided impetus to include nursing homes as training sites, although not explicitly requiring them. 3 S e c t i o n IIIB.IO. Resident experience must include for-

mal teaching and regular supervised experience in geriatric medicine. W h e n available, assignments to geriatric services (inpatient, nursing home, home based or ambulatory) are desirable. [p. 51] S e c t i o n IBE.4. Acute care hospitals which are affiliated with extended care facilities (chronic care hospitals, skilled nursing facilities, etc.), satellite clinics, or home care programs are e n c o u r a g e d to involve residents in activities at these settings . . . . [p. 48] (italics authors')

Acceptance of the nursing h o m e as a training site is seen in the recent issues paper on geriatric training in the internal medicine residency by the Subcommittee on Aging of the American College of Physicians, w h i c h states: "Training sites must not be limited . . . Programs should provide adequate support for the develo p m e n t of well-supervised affiliations so that residents will participate in institutional long term care, as for example in a nursing h o m e " 4; and the American Geriatrics Society position paper, w h i c h describes the nursing h o m e as "an important location for educational activities." ~ Although medical schools have made great strides in integrating geriatrics into their curricula over the past several years, this is not always carried over into postgraduate education.6 Reuben et al.7 recently documented that of all accredited FP and IM residency pro-


grams, only 57% have geriatrics curricula in place. Although 92% of such curricula are required in FP residencies, they are optional in 39% of the IM programs. These and other surveys8 provide needed preliminary information about the current status of geriatric and nursing home experiences in physician training. However, none explored the structure and specifics of the educational experience, including residents' clinical and teaching responsibilities, degrees of supervision, extents of faculty training in geriatrics, and administrative problems. This information is useful in evaluating the current status of nursing home rotations and providing direction to programs developing or modifying their nursing home residency rotations. In light of this, the current study has several themes: 1) to determine the prevalence of nursing home rotations in postgraduate medical education programs; 2) to define the durations, structures, and types of rotations offered; and 3) to document program directors' perspectives and attitudes toward nursing home experiences and plans to develop nursing home experiences. A major adjunct theme explored was differences in the structures of residency programs in IM and FP.

METHODS A closed-ended questionnaire was mailed to all directors of accredited FP and IM residency programs in the United States, as identified by the Directory of Graduate Medical Education Programs ( 1 9 8 9 - 1 9 9 0 ) . 3 Standard mail survey techniques were employed in accordance with the method of Dillman. 9 A follow-up mailing was performed three weeks after the initial correspondence. A total of 832 surveys were mailed. Of these, 502 were returned for a response rate of 67.7% (266 of 393) for FP programs and 53.6% (236 of 439) for IM programs (total response rate of 60.3%). This rate is in keeping with other well-accepted survey studies in medicine and related disciplines. 9 While a reasonable response rate was obtained, a potential concern is the possibility of a responder bias, which could affect the generalizability of the results. To unequivocally determine response bias, the responses of the nonresponders need to be known, which is not possible. However, in keeping with standard practice, preliminary analyses were performed to examine whether responders and nonresponders differed in their program characteristics, i.e., geographic location, size, and university-affiliation status. No obvious trend was found. Statistical analyses consisted of descriptive statistics, i.e., means, percentages, and frequency counts. This was followed, depending on the dependent variable's level of measurement, by chi-square and between-group analyses of variance in order to examine differences between programs with and without nursing home rotations and between IM and FP.


TABLE 1 Percentages of Internal Medicine and Family Practice Programs Offering Specialized Educational Activities in the Nursing Home Internal


Medicine Practice Medical director acting as preceptor* Residents work with nurse practitionerst Residents work with physician assistants* Didactic seminars in facility§ Research projects in progress¶ Research grant awarded to facility within past five yearsll Teaching site for medical students *Differences between disciplines X 2 = tDifferences between disciplines X z = tDifferences between disciplines X z = §Differences between disciplines X z = ¶Differences between disciplines X z = IIDifferences between disciplines X z =

76.3 42.1 15.8 61.8 52.0

55.1 23.2 6.1 44.5 25.9

25.3 38.0

8.8 36.8

10.75, p < 0,001. 10.06, p < 0.001. 6.85, p < 0.01. 6.83, p < 0.01. 17.59, p < 0.001. 13.68, p < 0.001.

RESULTS Prevalence and Academic Characteristics of Nursing Home Rotations The majority, 230 of 266, of FP programs responding offered a nursing home assignment to its trainees (86.5%). In contrast, only 76 of 236 IM programs offered a nursing home experience (32.2%). Family practice's nursing home rotations (47% more than 5 years old) had been in existence significantly longer than IM's (I4% more than 5 years old; Z2 = 36.48, p < 0.001). Programs in FP were significantly more likely to have required nursing home experiences (ranging from 44.8% in PGY-1 to 93.6% in PGY-3) than were programs in IM (ranging from 35.3% in PGY-1 to 39% in PGY-3). A majority of rotations in IM programs were still optional in PGY-2 and PGY-3. Multiple rotation formats were offered by both FP and IM programs, with longitudinal format significantly more prevalent in FP (92%) compared with IM (27%; Z2 = 121.93, p < O.001), and block time format more likely in IM (7.3%) than FP (62%; Z2 = 9.51, p < 0.01). Episodic (e.g., consultation) rotations were equally available in IM (43%) and FP programs (62%). As can be seen in Table 1, IM programs had a more traditional academic "flavor" compared with FP programs, as evidenced by larger numbers of research experiences and didactic seminars. Faculty and Resident Clinical Involvement and Supervision Degrees of on-site faculty involvement in the nursing home differed between specialties. As can be seen in Table 2, IM faculty participation in nursing homes usually took the form of direct patient care and, less frequently, medical direction and participation in



quality assurance activities. Responsibility for patient care was primarily that of the resident physician (67%) in FP c o m p a r e d with IM (12%; Z2 = 71.84, p < O.O01). The average n u m b e r of nursing h o m e patients assigned to resident physicians in FP was l o w e r (X = 7.16, SD = 18.28) than in IM (X = 12.13, S D = 17.33; F ( 1 , 3 0 4 ) = 4.21, p < 0.05). Within each discipline, the sizes of the faculty did not differ a m o n g those programs w i t h and w i t h o u t nursing h o m e experiences. For those programs offering such experiences, IM programs (X = 39.1 full-time; 42.3 part-time) w e r e significantly larger than FP programs (X = 6.8 full-time; 4.5 part-time; F ( 1 , 3 0 0 ) = 43.02, p < 0.OI for full-time; F ( 1 , 2 5 7 ) = 98.17, p < O.O1 for part-time). The n u m b e r of full/part-time faculty did not relate to the scheduling of the experie n c e (i.e., longitudinal versus b l o c k rotation). Few supervising faculty had formal geriatric fellowship training or special certification in geriatrics. O n l y 6% of IM part- and full-time faculty had formal geriatric fellowship training, c o m p a r e d w i t h 1% of FP faculty (F ( 1 , 1 3 0 ) = 6.41, p < O.O1); 10% of IM and 14% of FP faculty had added certification in geriatrics (p = NS). For each discipline, the n u m b e r of faculty w i t h fellowship training in geriatrics was unrelated to the p r e s e n c e of a nursing h o m e rotation. On-site faculty supervision was m o r e frequent in IM programs than in FP programs 0( 2 = 25.57, p < O.001). As seen in Table 1, the medical director was m o r e often utilized as a p r e c e p t o r in IM than in FP programs.

Organizational and Structural Correlates T h e average n u m b e r o f n u r s i n g h o m e s u t i l i z e d f o r

residency training was significantly l o w e r in IM (X ---1.58, SD----1.22) than in FP programs (X = 2.63, SD = 2.35, p < 0.05). The sizes and religious affiliations of nursing h o m e s did not differ b e t w e e n programs. However, FP-affiliated nursing h o m e s w e r e m o r e likely to be p r o p r i e t a r y in nature. As can be seen in Table 2, less than 50% of all services p r o v i d e d to the nursing h o m e w e r e r e i m b u r s e d in some fashion. While affiliation w i t h a geriatric education center (Z 2 = 4.15, p < O.05), aging center (Z 2 = 19.65, p < 0.O1), or geriatric fellowship (X2 = 38.39 p < O.OO1) was m o r e likely for IM programs than for FP programs, the i m p a c t of these linkages on the existence of a nursing h o m e e x p e r i e n c e was inconsistent. IM programs w i t h a geriatric fellowship w e r e m o r e likely to offer their residents a nursing h o m e e x p e r i e n c e (Z 2 = 13.33, p < O.OO1) than w e r e those w i t h o u t a fellowship. Within FP programs, the p r e s e n c e of a geriatric fellowship was not related to the availability of a nursing h o m e e x p e r i e n c e . Surprisingly, those FP programs associated w i t h an aging center w e r e less likely to offer a nursing h o m e rotation (Z 2 = 7.37, p < 0.01) than

w e r e those w i t h o u t such an association. The likelihood of residents' going on to a geriatric fellowship was unaffected by the existence of a nursing h o m e rotation.

Perceptions of the Nursing H o m e E x p e r i e n c e and Identified P r o b l e m s While overall p e r c e p t i o n s of the rotations w e r e positive, FP directors w e r e significantly m o r e positive than IM directors in rating (on a five-point scale) the nursing h o m e rotation's ability to m e e t the educational needs of the residents (X = 3.6 FP; X = 3.3 IM; p < 0.01 ) and of the residents' receptiveness to the experience (X = 3.4 FP; X = 3.0 IM; p < 0.01). As can be seen in Table 3, c o m p e t i t i o n w i t h other rotations for time, faculty availability, and interests of the residents w e r e frequently identified by b o t h FP and IM directors as p r o b l e m s detracting from the nursing h o m e experience.

Plans for the Future O f those IM programs currently not offering nursing h o m e rotations to their resident trainees, 27.4% have plans to d e v e l o p such rotations within the next two years. In contrast, 71.9% of similarly situated FP programs have plans to a d o p t nursing h o m e rotations ( Z z = 22.71, p < O.001). Neither the total n u m b e r of faculty nor the extent of geriatric training correlated with future plans to d e v e l o p a nursing h o m e rotation.

TABLE Z Percentagesof Internal Medicineand Family Practice Programs Providing SpecificServicesin the Nursing Home and Receiving Reimbursementfor the Services Internal Medicine

Family Practice

Offering Services Offering Services Service Reimbursed Service Reimbursed Faculty serve as medical directors* Patient careby facultyt Patient care by residents* Supervisionof nonphysicians§ Faculty participation in quality assurance¶ Faculty participation in utilization review

73.7 92.1

47.4 28.9

48.5 81.7

39.6 28.7

















*Differences between disciplines offering service Xz = 14.64, p < 0.001. tDifferences between disciplines offering service X2=4.69, p < 0.05. *Differences between disciplines offering service X2 = 34.47, p < 0.001. §Differences between disciplines offering service X2=6.71, p

Residency education in the nursing home: a national survey of internal medicine and family practice programs.

To assess the role of the nursing home in postgraduate medical education...
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