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M. Cheslock1,2, A. Nahas1,2,3, A.R. Orkaby1,4, A.W. Schwartz1,4,5


1. New England Geriatric Research Education and Clinical Center (GRECC), VA Boston Health Care System, Boston, MA, USA; 2. Harvard Medical School Multicampus Geriatrics Fellowship, Beth Israel Deaconess Medical Center, Boston, MA, USA; 3. 11th Ave. Family Medicine Clinic, Yakima Valley Farm Workers Clinic, Yakima, WA, USA; 4. Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA, USA; 5. Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA

Corresponding Author: Megan Cheslock, MD, 200 Spring Road, MC 182 B2, Bedford, MA 01730, Megan.Cheslock@va.gov (781) 809-5630

J Frailty Aging 2024;13(2)189-192
Published online March 12, 2024, http://dx.doi.org/10.14283/jfa.2024.26



BACKGROUND: Knowledge of frailty is essential for meeting the Accreditation Council for Graduate Medical Education core competencies for US trainees. The UK General Medical Council requires that frailty be included in undergraduate and graduate medical education curricula. Trainees are expected to appropriately modify care plans and help make patient-centered decisions, while incorporating diagnostic uncertainty, such as frailty, in older adults. Little is known about current needs for frailty instruction in graduate medical education in the US and beyond.
OBJECTIVE: We sought to capture faculty perceptions on how frailty should be defined and identified, and what aspects and level of detail should be taught to residents.
DESIGN: The authors developed a 4-item short response questionnaire, and faculty had the option to respond via electronic survey or via semi-structured interviews.
SETTING AND SUBJECTS: Respondents included 24 fellowship-trained geriatricians based at 6 different academic medical centers in a single urban metropolitan area.
METHODS: An invitation to participate in either an electronic survey or semi-structured virtual interview was e-mailed to 30 geriatricians affiliated with an academic multi-campus Geriatric Medicine fellowship. Responses were transcribed and coded independently by two authors.
RESULTS: Responses were received from 24 geriatricians via a combination of digital questionnaires (n=18) and semi-structured online interviews (n=6), for a response rate of 80%. Responses revealed significant diversity of opinion on how to define and identify frailty and how these concepts should be taught.
CONCLUSIONS: As frailty is increasingly incorporated into clinical practice, consensus is needed on how to define and teach frailty to residents.

Key words: Frailty, geriatrics, graduate medical education, elderly, residents.


Background: The Importance and Lack of Frailty Education in Medical Training

Frailty refers to the age-related decrease in physiologic reserve which makes older adults more vulnerable to experiencing morbidity and mortality when faced with stressors (1). Frailty is highly prevalent in both community and hospital settings, though due to varied definitions and measurement tools, the exact prevalence is unclear and estimates range from 4% to over 50% (2). Clinicians in all specialties benefit from awareness of frailty, as it can impact clinical decision making and treatment decisions (3). For physician trainees, education about frailty is critical, as they will encounter older adults with frailty regardless of their faculty setting or subspeciality of practice. Several medical subspecialties, such as cardiology, oncology, and surgery incorporate frailty into treatment plans (4, 5). Knowledge of frailty is essential for meeting the US Accreditation Council for Graduate Medical Education core competencies, as it is expected that Family (6) and Internal Medicine (7) residents appropriately modify care plans and engage in patient-centered decision making, while incorporating diagnostic uncertainty, such as frailty, in older adults with complex needs. In the UK, the General Medical Council requires instruction on frailty in several training programs, including stage 1 of Internal Medicine and several subspecialties (8). In a recent survey of United Kingdom medical schools, Winter et al. found that undergraduate frailty education is ‘predominantly opportunistic’ and mainly occurred within geriatric medicine rotations (9).
Limited data report on teaching frailty in health professional education for non-geriatricians (10-12). An area that has been identified is the need for a consensus on frailty definition. One possibility to the limited guidance on frailty education may be due to the heterogeneity of how frailty can be measured (13-15). Therefore, we undertook a needs assessment to capture faculty perceptions on how frailty should be defined, what aspects should be taught and at what level of detail when teaching residents.



In this educational quality improvement project, we developed a needs assessment to inform effective frailty education for residents during a geriatric medicine rotation at a Veteran’s Affairs Hospital. The local clinical learning environment includes several affiliated academic hospitals which each have their own frailty initiatives, including multiple different frailty indices at various stages of integration into the electronic health record (16-18).
We created a needs assessment with 4 questions about frailty education (see Table 1). The survey questions were drafted by a geriatrician with expertise in frailty and reviewed by two other content experts. The questions were piloted with geriatrics fellows for face validity; these fellows did not participate in the survey itself. We invited physician faculty with formal geriatrics fellowship training to participate. We used a convenience sample of faculty affiliated with a multi-campus fellowship, all of whom provide instruction to residents. Faculty were given the option to participate via electronic questionnaire distributed via e-mail or via a web-based semi-structured interview using a secure university-affiliated Zoom videoconferencing platform (Zoom Video Communications, Inc., San Jose, CA). All web-based interviews were conducted by a geriatrician (author AN) and were recorded using Zoom’s live transcription feature with the faculty’s permission to facilitate further analysis. No motivational tools or incentives were used in this study.

Table 1. A Needs Assessment of Geriatrics Faculty Regarding Frailty Education for Residents: Thematic Analysis of Survey and Focus Group Responses


Responses were analyzed using a Grounded Theory approach for qualitative analysis, as it allows for both deductive and inductive approaches to content analysis. Two coders (authors MC and AWS, both geriatricians) independently reviewed the responses and generated potential codes/themes. Data was then analyzed and re-coded for common themes related to frailty education. The local Education Office deemed this study to be for educational quality improvement purposes and exempt from further review.



Twenty-four geriatricians representing 6 academic medical centers in the region of Boston, Massachusetts, USA responded to the survey. Eighteen responded using the electronic questionnaire via e-mail and 6 participated in a web-based semi-structured interview. On average, each semi-structured interview lasted between 15-25 minutes. Respondents indicated that they provide care for older adults in a variety of settings, including primary care and specialty consultation (i.e., oncology, orthopedics) clinics, medical and surgical wards, rehabilitation centers, and skilled nursing facilities. When faculty were asked about challenges that residents face when managing patients with frailty, several themes emerged, including: 1) misunderstanding of the concept or definition of frailty (n=14), 2) uncertainty of how to incorporate frailty information into treatment plans (n=13), and 3) prior training focused on a disease-based approach (n=6). When asked to identify important objectives and skills, several themes emerged, including: 1) how to identify frailty and use validated frailty assessment tools (n=11), 2) being able to use frailty information to inform treatment plans (n=8), and 3) understanding that frailty is multidimensional and has varied definitions (n=7).When asked about which model(s) of frailty residents should be familiar with, faculty responses varied and included: the deficit accumulation model of frailty (n=9), the phenotypic model of frailty (n=7), both (n=7), or neither (n=3). Additionally, there was significant variety among faculty regarding which frailty assessment tool they use in their own clinical practice, though frailty index (n=12), Clinical Frailty Scale (n=10), and FRAIL questionnaire (n=8) were the most frequent responses. Table 1 shows the most common themes and representative quotations from faculty.



An educational quality improvement project conducting a needs assessment among Geriatrics faculty revealed several common themes on the challenges of teaching about frailty, but varied responses about how and which concepts to teach medical residents. This project sought to identify geriatric faculty perceptions on frailty and how they are incorporated into graduate medical education. Interestingly, limited time was not identified as a challenge to teaching about frailty. The most important concepts identified in our survey for residents to learn were defining frailty, measurement with objective, validated tools, and understanding how to use this data to inform the treatment plan.
Strengths of this study include recruitment of geriatricians from a variety of academic medical centers with expertise in Geriatrics. Additionally, these geriatricians care for older adults in a variety of settings, including primary care and specialty consultation (i.e., oncology, orthopedics) clinics, medical and surgical wards, rehabilitation centers, and skilled nursing facilities. Other strengths include our rigorous qualitative analysis of the faculty responses. To our knowledge, this is the first needs assessment on frailty education for medical residents and reveals the need for further consensus building among Geriatrics experts on how to teach frailty.
Limitations of this study include that interviews were not conducted with residents themselves. A better understanding of residents’ perspectives on what they hope to learn about frailty could make curricula more approachable and meaningful to them as learners. Additionally, interviewed faculty were all drawn from one metropolitan area which may not be generalizable to other settings. This study used different methods for data collection (digital questionnaires and semi-structured interviews). We did not detect a difference in the types of responses in surveys compared to interviews, though future studies could examine whether different modes for data collection yield a different response. Next steps should include interviewing residents and other Internal Medicine and Family Medicine faculty in various health care settings and geographic locations. Ultimately frailty education should be integrated with other geriatrics topics in resident education.
A noteworthy topic that did not arise explicitly in our qualitative analysis is the importance of how we speak about frailty, especially when acting as role models for learners. Winter and Pearson have explored some of the challenges around the language of frailty and confusion and negativity surrounding frailty due to its colloquial use (19).
In conclusion, frailty is prevalent in the community and hospital settings, and Internal Medicine and Family Medicine residents need to be prepared to manage people living with frailty in their practice. Identification and understanding of frailty are critical for providers so that they may create person-centered care plans for older adults. This study illustrates some of the challenges in developing frailty education curricula due to the lack of consensus among geriatric educators regarding what is most important for this critical part of medical resident education. Further research and clarification are needed to standardize frailty education for non-geriatricians so they will be adequately prepared to care for the aging population. Examples of existing resources for promoting geriatrics education for non-geriatricians include the PROGRAMMING (PROmoting GeRiAtric Medicine IN countries where it is still eMerGing) COST Action website (20) and the Geriatrics for Specialty Residents Toolkits available through the American Geriatrics Society’s Geriatrics Care Online website (21).

Key Points

• Frailty is a complex concept with varying definitions and multiple methods for measurement.
• Physicians in training care for older adults with frailty, yet consensus is lacking regarding which content should be taught.
• We surveyed US geriatricians and found marked differences in opinions on how to teach resident physicians about frailty.
• Faculty felt residents should be able to define frailty, identify assessment tools, and use this data to inform the care plan.


Acknowledgements: The authors would like to thank Drs. Katie Dawson, Benjamin Seligman and Shivani Jindal as well as the faculty who participated in the survey. AWS would like to acknowledge the support of the Harvard Medical School Dean’s Innovation Award. ARO would like to acknowledge the support of the VA CSR&D CDA-2 award IK2-CX001800.

Declarations: This material is the result of work supported with resources and the use of facilities at the VA Boston and New England Geriatric Research Education and Clinical Center. The contents do not necessarily represent the views of the VA or the United States Government. The VA Boston Education Office deemed this study to be for educational quality improvement purposes and exempt from further review.

Disclosure statement: On behalf of all authors, the corresponding author states that there is no conflict of interest that relate to the research described in this paper. This material is the result of work supported with resources and the use of facilities at the Veterans Affairs Boston Healthcare Center and the New England Geriatric Research Education and Clinical Center. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government.



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