Integration of Geriatric Education Within the American Board of Emergency Medicine Model

Background Emergency medicine (EM) resident training is guided by the American Board of Emergency Medicine Model of the Clinical Practice of Emergency Medicine (EM Model) and the EM Milestones as developed based on the knowledge, skills, and abilities (KSA) list. These are consensus documents developed by a collaborative working group of seven national EM organizations. External experts in geriatric EM also developed competency recommendations for EM residency education in geriatrics, but these are not being taught in many residency programs. Our objective was to evaluate how the geriatric EM competencies integrate/overlap with the EM Model and KSAs to help residency programs include them in their educational curricula. Methods Trained emergency physicians independently mapped the geriatric resident competencies onto the 2019 EM Model items and the 2021 KSAs using Excel spreadsheets. Discrepancies were resolved by an independent reviewer with experience with the EM Model development and resident education, and the final mapping was reviewed by all team members. Results The EM Model included 77% (20/26) of the geriatric competencies. The KSAs included most of the geriatric competencies (81%, 21/26). All but one of the geriatric competencies mapped onto either the EM Model or the KSAs. Within the KSAs, most of the geriatric competencies mapped onto necessary level skills (ranked B, C, D, or E) with only five (8%) also mapping onto advanced skills (ranked A). Conclusion All but one of the geriatric EM competencies mapped to the current EM Model and KSAs. The geriatric competencies correspond to knowledge at all levels of training within the KSAs, from beginner to expert in EM. Educators in EM can use this mapping to integrate the geriatric competencies within their curriculums.


INTRODUCTION
Emergency medicine (EM) residents have 3-4 years of training to learn an extensive array of skills.This includes the skills needed to care for older patients, who make up 16-20% of their patients. 1,2The American Board of Emergency Medicine (ABEM) codifies the skills needed for competency in EM in the Model of the Clinical Practice of Emergency Medicine (EM Model) and the 2021 knowledge, skills, and abilities (KSA). 3,4The EM Model lists clinical presentations and disease types and the KSAs are a list of skills and abilities integral to EM practice.Many residency programs base their curriculums on these documents.However, it is unclear how Volume 25, No. 1: January 2024 Western Journal of Emergency Medicine 51

ORIGINAL RESEARCH
best to integrate geriatric teaching within these complex curricula.
In 2010 Hogan et al published eight domains with 26 competencies of geriatric education derived from an expert consensus panel that are considered essential learning during EM residency for the care of older adults in the emergency department (ED). 5These competencies are also used for categorizing geriatric continuing education for geriatric ED accreditation and have been pivotal to the development of geriatric EM as a subspecialty. 6,7Despite this guidance, geriatric concepts are still only minimally integrated into resident education. 8][11] But there is currently no guidance on how to integrate the geriatric competencies within an EM residency curriculum.
Our curriculum is based on the EM Model and KSAs.Our goal was to determine whether the geriatric competencies can be covered by an EM Model-based curriculum.

METHODS
This project is not human subjects research and did not require institutional board review.The study was a descriptive comparison of the 2019 EM Model and the 2021 KSAs to the 2010 geriatric competencies using a consensusbased process.The KSAs include both a description and a level.They are divided into overarching categories (eg, diagnosis, pharmacotherapy, reassessment) which are then divided into steps. 4Each step is given a hierarchy in training (with A the highest and E the lowest).Level A is for advanced knowledge or skills.Level B is the minimal competency level for passing EM residency.Levels C, D, and E are skill steps to reach level B.
In the first phase of consensus mapping, two residents (a second-year EM resident and a fourth-year EM/internal medicine resident) and a geriatric fellowship-trained EM attending independently mapped geriatric competencies using Excel (Microsoft Corporation, Redmond WA).They were instructed to first use the search button to look for exact language and then go item by item through the EM Model and the KSAs to map similar language or concepts.For example, the concept of delirium could be described as altered mental status or encephalopathy.A clear association was defined by the team as 1) a keyword match or 2) consensus that it was likely that an emergency physician lecturing/teaching on the EM Model content item would, in normal teaching practices, teach the geriatric competency.If this was not the case, but the geriatric competency could be incorporated under this topic by someone intentionally teaching the competencies, this was listed as a suggested area for incorporation.Reviewers were instructed to be generous with mapping during this first round.
If all three or 2/3 agreed, this was considered initial consensus.Any remaining discrepancies were then independently reviewed by another emergency physician with expertise in resident education (former EM program director and current ABEM executive committee member).The full group met and reviewed the final discrepancies until consensus was reached.The consensus tables were then reviewed independently by two more emergency physicians at external residency programs for content validity.A similar process was used for mapping KSAs.Reviewers were blinded to the KSA level (A-E designation).

Incorporation into the 2019 EM Model
The EM Model has 963 items.On the first round, 126 items (13% of content) were identified as potential matches, including all of 17.1 Drug and Chemical Classes.Round 1 consensus was 96.2% (927 items).Initial disagreements included whether signs and symptoms were meant to be used to formulate a differential diagnosis for that symptom or to describe management of the symptoms.There was also a question as to whether G11, which discusses "irritating tethers" as a cause of delirium, should be mapped to all procedures such as 19.4.1.4.Nasogastric tube.The group decided that this would be better encompassed under the EM Model item for delirium.Table 2 lists the six geriatric competencies without a clear fit within the EM Model and suggestions from the team on where to include them.

Incorporation into the 2021 Knowledge, Skills, and Abilities
The initial independent mapping resulted in consensus on 84% of the items (179/214).Of the geriatric competencies, 216 (81%) mapped onto KSAs (Table 3).The most common categories were Communication & Interpersonal Skills (CS0), Pharmacotherapy (PT0), and Transitions of Care (TC0).Of the five competencies that did not map directly onto the KSAs, all had mapping items in the EM Model except one.The one competency that did not map directly to any EM Model or KSA was Effects of Comorbid Conditions (G24): "Assess and document the presence of comorbid Volume 25, No. 1: January 2024 Western Journal of Emergency Medicine 53 conditions (eg, pressure ulcers, cognitive status, falls in the past year, ability to walk and transfer, renal function, and social support) and include them in your medical decisionmaking and plan of care."Incorporating the potential consequences of comorbid conditions is included in KSA PR2: "Perform the indicated procedure on an uncooperative patient, patient at the extremes of age (pediatric, geriatric), multiple co-morbidities, poorly defined anatomy, hemodynamically unstable, high risk for pain or procedural complications, sedation required, or emergent indication to perform procedure, and recognize the outcome and/or complications resulting from the procedure" (KSA Level B).While the geriatrics competency addresses medical decisionmaking and the KSA address difficult procedures, there is some overlap in the training required.

DISCUSSION
The geriatric competencies for EM residency training integrate well within the EM Model and KSAs, with only one competency not having a direct match.Demonstrating this overlap between the suggested subspecialty curriculum and the EM model can help EM educators ensure that the geriatric competencies are incorporated into their curricula.This mapping could also guide the development of board exam questions, lectures, or simulation cases.
The EM Model is very brief, which can make directing education difficult.For instance, training on the EM Model item 18.3 Multi-system Trauma: Falls is expounded upon in geriatric competency #4: "In patients who have fallen, evaluate for precipitating causes of falls such as medications, alcohol use/abuse, gait or balance instability, medical illness, and/or deterioration of medical conditions."Or another example, KSA DX1 "Synthesize chief complaint, history, physical examination, and available medical information to develop a differential diagnosis" can include a discussion of geriatric competency #3 "Document consideration of adverse reactions to medications, including drug-drug and drug-disease interactions, as part of the initial differential diagnosis."They both describe the initial generation of a differential diagnosis, but the geriatric competency adds pharmacology interactions and adverse reactions to be considered in the differential.
A second finding of this study was that the geriatric competencies align with elements required for minimal KSA competency.This implies that different aspects of geriatric care can (and we argue, should) be taught throughout a resident's training.It also suggests that the geriatric competencies were well developed for the residency level of training and should not be considered "too advanced" or "subspecialty training."While prior research has evaluated separate geriatric-specific curricula, [9][10][11] our work shows that geriatric competencies can be integrated throughout a curriculum based on the EM Model and KSAs.As of 2021, there were only 25 geriatric fellowship-trained emergency physicians, which is not enough for every residency program. 12Programs without faculty who have no interest or training in geriatrics could also use external training resources such as the online learning modules at https://geri-em.com/ and at the Geriatric Emergency Department Collaborative (https://gedcollaborative.com/ online-learning/).

LIMITATIONS
One limitation of this project was the consensus definitions used.We were unable to find any existing methods to help us   Volume 25, No. 1: January 2024 Western Journal of Emergency Medicine 59 define curricular overlap.While we were strengthened by having representation from multiple EM residency programs, other education experts may have a different interpretation of the domains and competencies and how they are typically taught.Additionally, the reviewers were not all attendings and not all geriatric-fellowship trained.Despite this, first-round consensus was very high (84-96%), which suggests shared knowledge among the group.The EM residents involved in this project have since started fellowships in medical education and palliative medicine, demonstrating their passion and additional understanding in these areas.

CONCLUSION
The geriatric competencies are included within the EM Model and knowledge, skills, abilities list.The competencies provide more detail for education or board questions.We identified areas of overlap where these subspecialty competencies can be emphasized in EM residency curriculums.
Table 1 lists the 20 geriatric competencies (77%) included in the 2019 EM Model.Key word matches included competency #6: "Demonstrate ability to recognize patterns of (physical/sexual, psychological, neglect/abandonment) that are consistent with elder abuse[,]" which maps to "Model Content 14.6.1.3Patterns of Violence/Abuse/Neglect: Intrapersonal Violence: Elder."Others were matched by concept, such as competency #11: "Assess and correct (if appropriate) causative factors in agitated elders such as untreated pain, hypoxia, hypoglycemia, use of irritating tethers (defined as monitor leads, blood pressure cuff, pulse oximetry, intravenous access, and Foley catheter), environmental factors (light, temperature), and disorientation [,]" which could be incorporated into teaching on 12.14 Nervous System Disorders: Delirium.

Table 1 .
The geriatric teaching competencies mapped onto the Emergency Medicine Model of Care.
1.3.41General-shockG8Assesswhetheran elder is able to give an accurate history, participate in determining the plan of care, and understand discharge instructions.12.8.1 Other conditions of the braindementia 14.5.2Organic psychoses-dementia 20.4.5.4 Regulatory/legal-consent, capacity and refusal of care G9 Assess and document current mental status and any change from baseline in every elder, with special attention to determining whether delirium exists or has been superimposed on dementia.1.3.1 General-altered mental status 12.8.1 Other conditions of the braindementia 12.14.1 Delirium-excited delirium syndrome 14.5.2Organic psychoses-dementia G10 Emergently evaluate and formulate an age-specific differential diagnosis for elders with new cognitive or behavioral impairment, including selfneglect; initiate a diagnostic workup to determine the etiology; and initiate treatment.1.3.18General-failure to thrive G11 Assess and correct (if appropriate) causative factors in agitated elders such as untreated pain, hypoxia, hypoglycemia, use of irritating tethers (defined as monitor leads, blood pressure cuff, pulse oximetry, intravenous access, and Foley catheter), environmental factors (light, temperature), and disorientation.12.14.1 Delirium-excited delirium syndrome (Continued on next page)

Table 1 .
Continued.G12Recommend therapy based on the actual benefit to risk ratio, including but not limited to acute myocardial infarction, stroke, and sepsis, so that age alone does not exclude elders from any therapy.
17.1 Drug and chemical classes: entire sectionG16Explain all newly prescribed drugs to elders and caregivers at discharge, assuring that they understand how and why the drug should be taken, the possible side effects, and how and when the drug should be stopped.20.1.1.3Interpersonalskills-patientandfamily educationG19With recognition of unique vulnerabilities in elders, assess and document suitability for discharge considering the ED diagnosis, including cognitive function, the ability in ambulatory patients to ambulate safely, availability of appropriate nutrition/social support, and the availability of access to appropriate follow-up therapies.NSAID, non-steroid anti-inflammatory drug; ED, emergency department.

Table 2 .
Suggestions for teaching the geriatric competencies that do not fit clearly within the Emergency Medicine Model.
Could be discussed under Practice-based Learning and Improvement: Patient safety and Medical Errors.G26 Communicate with patients with hearing/sight impairment Could be discussed under Interpersonal and Communication Skills: Cultural Competency.ED, emergency department; PCP, primary care physician.Volume 25, No. 1: January 2024 Western Journal of Emergency Medicine 55

Table 3 .
The geriatric competencies were mapped onto the 2021 ABEM knowledge, skills, and abilities list.