A community-based approach for integrating geriatrics and gerontology into undergraduate medical education

Medical school accreditation requirements require educational opportunities in geriatrics. Twenty-six minimum graduating competencies in geriatrics have recently been identified for medical students. The authors describe how these competencies are being integrated into a new medical curriculum through coursework and community-based experiences. This approach is intended to expose students to older adults from diverse communities and adequately prepare students to address the complex and individual needs of these patients. Initial results indicate proficiency in the minimum geriatric competencies covered. The growth and diversity of the older adult population makes it important to integrate and evaluate geriatrics education in undergraduate medical education.     

Integrating geriatric content into a medical school curriculum: description of a successful model

Most medical school curricula do not equip students with adequate attitudes, knowledge and skills to care for elderly populations. We describe an effective geriatric curricular infusion model compatible with preserving the overall curricula schema. Course and clerkship directors, staff and faculty from the Office of Educational Development, Center on Aging, curriculum committee and Associate/Assistant Deans of Education, and faculty from the schools of medicine, nursing, and allied health collaborated in the effort. Each of these components and institutional financial commitment were critical to successful basic science and clinical geriatric content infusion addressing the American Geriatric Society (AGS) Core Competencies. Delivery modalities included problem- based learning cases, lectures, standardized patient portrayals for teaching and assessment, and experiential activities with elderly. Assessments were conducted and outcomes tracked in several ways, including: (1) annual course reviews, focus groups, and student evaluations; (2) mandatory geriatrics 4th year graduation competency exam; and, (3) AAMC Graduation Questionnaire responses. Initial data indicate that student knowledge and competencies have increased with increasing exposure in the desired areas, and support infusion as a viable approach to enhancing gerontology and geriatric curricular content.     

Geriatric education. Part I: Efficacy of a mandatory clinical rotation for fourth year medical students.

OBJECTIVES: To describe the curriculum of a mandatory, fourth-year geriatrics clerkship and assess its impact on medical students' knowledge of geriatric medicine and attitudes toward the elderly. DESIGN: One group, before/after trial. SETTING: Mount Sinai School of Medicine of the City University of New York. PARTICIPANTS: Entire fourth year class of medical students (n = 127). INTERVENTION: Four-week-long clinical geriatrics clerkship. MEASUREMENTS: Pre- and post-rotation: test of knowledge; Aging Semantic Differential (ASD) attitude scale; Modified Maxwell-Sullivan attitude scale; questionnaire. MAIN RESULTS: Seventy percent of students found the rotation to be educationally valuable; however, only one-third of students would have taken the clerkship had it not been required. Mean geriatric knowledge score increased by 18.7% (P less than 0.001). Mean ASD attitude score did not change significantly (130.5 +/- 19.2 pre-rotation versus 126.6 +/- 18.8 post-rotation, P = 0.15), but students started the rotation with a neutral attitude. Over 90% of students agreed they would welcome elderly into their future practice. CONCLUSION: If a national curricular goal is to improve medical students' knowledge of geriatric medicine, required rather than elective rotations may be in order.     

Geriatrics training and education for nongeriatrician faculty: the Dean's Faculty Scholars in Aging Program

The University of South Carolina School of Medicine in Columbia implemented the Dean's Faculty Scholars in Aging (DFSA) Program in 2001 to strengthen the knowledge of geriatrics of nongeriatrician faculty members. The primary indicator of strengthening physicians' geriatrics knowledge was the development of new educational experiences by physicians in the DFSA Program. Twenty-six nongeriatrician faculty in seven departments were recruited to participate as scholars. Most scholars were in key educational positions, including assistant deans, department chairs, and clerkship and residency directors. Scholars received special training to develop geriatrics educational experiences based on their medical specialty and interests. Training encouraged cross-departmental collaboration. Scholars also had access to resources, including professional geriatric educators. Funds were available to support development of educational experiences and for a small amount of salary support. Since the program was implemented, 36 new geriatric experiences have been developed, 29 of the 36 were implemented, and 11 of the 36 were evaluated. Experiences included an elective for residents in the care of older patients in the emergency room and a required hospice rotation in the psychiatry clerkship for third-year medical students. All scholars developed a geriatrics educational experience, and most implemented one. This suggests that scholars demonstrated successful progress in geriatrics training.     

Retooling for an Aging America: Building the Healthcare Workforce

In Chicago, Illinois, on May 7, 2009, a group of 53 medical educators representing many U.S. certification boards, residency review committees, and medical societies met to review and approve a white paper intended to promote Recommendation 4.2 of the Institute of Medicine report of April 14, 2008, “Retooling for an Aging America: Building the Healthcare Workforce.” This recommendation is one of 14 and states: “All licensure, certification and maintenance of certification for healthcare professionals should include demonstration of competence in care of older adults as a criterion.” Background information given included the growing numbers of older adults, review of a 15‐year initiative by a section of the American Geriatrics Society (AGS) to include geriatric education in all surgical and some related medical specialties, a recent announcement of 26 elder care competencies to be expected of graduating medical students from Association of American Medical Colleges (AAMC) affiliated schools, and the American Board of Medical Specialties (ABMS) approach to “Reinforcing Geriatric Competencies through Licensure and Certification Examinations.” Nine points involved in the implementation of this recommendation received discussion, and approaches to realization were presented. In conclusion, this white paper, which those listed as being in attendance approved, proposes that all ABMS member boards whose diplomates participate in the care of older adults select the floor competencies enumerated by the AAMC that apply to their specialty and add or subtract those completed during their trainees' initial (intern) year and then define those needed in subsequent years of residency and ultimate practice. This would fulfill the requirements of Recommendation 4.2 above.     

A vertically integrated geriatric curriculum improves medical student knowledge and clinical skills

The objective of this study was to determine the effect of a vertically integrated curriculum intervention on the geriatric knowledge and performance in clinical skills of third-year medical students. This observational cohort study conducted at the University of Michigan Medical School evaluates the performance of 622 third-year medical students from the graduating class years of 2004 through 2007. An integrated curriculum intervention was developed and implemented for the class of 2006. Its elements included identification and tracking of geriatric learning outcomes in an individualized Web-based student portfolio, integration of geriatric content into preclinical courses, development of a geriatric functional assessment standardized patient instructor, and an experience in a geriatrics clinic during the ambulatory component of the third-year internal medicine clerkship. Medical student performance was assessed on a geriatric knowledge test and during a geriatric functional assessment station administered during an Observed Structured Clinical Examination (OSCE) at the beginning of the fourth year. Student performance on the geriatric functional assessment OSCE station progressively improved from pre-intervention performance (mean performance+/-standard deviation 43+/-15% class of 2005, 62 + 15% class of 2006, 78+/-10% class of 2007; analysis of variance, P<.001). Similarly, student performance on the geriatric knowledge test was significantly better for the classes of 2006 and 2007 than for the class of 2005 (model F ratio=4.72; P<.001). In conclusion, an integrated approach to incorporating new educational geriatric objectives into the medical school curriculum leads to significant improvements in medical student knowledge and in important clinical skills in the functional assessment of older patients.     

A Multidisciplinary Clerkship in Geriatric Medicine

A multidisciplinary clerkship was developed as a required course for third year medical students. The drawbacks of traditional medical education as it applies to the field of geriatrics are reviewed. The development of a week-long clerkship in geriatric medicine is described with special focus on a multidisciplinary geriatric home assessment required of all students. Evaluation of the clerkship and the home assessment is described.     

Mi Casa o Su Casa? Assessing Function and Values in the Home

Clinical instruction for medical students traditionally occurs in hospitals and offices, whereas patients and families face many health issues in their homes. This is particularly true for frail older adults, those with chronic illness, and patients at the end of life. The authors sought to incorporate geriatrics, primary care, and palliative care into house calls for medical students by integrating a home visit experience into their ambulatory clerkship. Using a guide jointly developed by geriatrics, primary care, and palliative care faculty, students conduct three home visits with a patient from their community preceptor's practice. The first visit focused on medical diagnoses and symptoms, the second on functional assessment/geriatric syndromes, and the third on social/cultural and end-of-life values. Students completed a 2,000-word write-up, including a narrative using the "voice" of the patient. Students presented the cases in small groups facilitated by geriatric and palliative care faculty. Eighty-three percent of students reported positive feedback about the experience. Based on write-ups and program evaluation, students voiced improved knowledge of functional assessment, geriatric syndromes, and progression of chronic illness. Students also poignantly expressed advantages of home visits in exploring psychosocial aspects of medicine, including affirming the humanity of medicine, understanding family systems, providing patient-centered care, and understanding patient beliefs. Several students expressed pursuing a house calls career. A longitudinal home visit experience for medical students can successfully enhance the geriatric, ambulatory care, and palliative care curricular content of undergraduate education and positively affect student's attitudes toward the chronically ill and homebound.     

A Collaborative National Model to Assess Competencies for Medical Students,Residents, and Other Healthcare Practitioners in Gait and Falls Risk Evaluation

To ensure that the healthcare workforce is adequately prepared to care for the growing population of older adults, minimum competencies in geriatrics have been published for medical students and primary care residents. Approaches to teaching and assessing these competencies are needed to guide medical schools, residencies, and continuing medical education programs. With sponsorship by the Education Committee and Teachers Section of the American Geriatrics Society (AGS), geriatrics educators from multiple institutions collaborated to develop a model to teach and assess a major domain of student and resident competency: Gait and Falls Risk Evaluation. The model was introduced as a workshop at annual meetings of the AGS and the American College of Physicians in 2011 and 2012. Participants included medical students, residents, geriatrics fellows, practicing physicians, and midlevel practitioners. At both national meetings, participants rated the experience highly and reported statistically significant gains in overall competence in gait and falls risk evaluation. The largest gains were observed for medical students, residents, and practicing physicians (P < .001 for all); geriatrics fellows reported a higher level of baseline competence and therefore had a lower magnitude of improvement, albeit still significant (P = .02). Finally, the majority of participants reported intent to disseminate the model in their institutions. This article describes the design, implementation, and evaluation of this collaborative national model. A number of institutions have used the model, and the goal of this article is to aid in further dissemination of this successful approach to teaching and assessing geriatrics competencies.     

Description and Students' Perceptions of a Required Geriatric Clerkship in Postacute Rehabilitative Care

This article describes medical students' evaluation of a geriatric clerkship in postacute rehabilitative care settings. This was a cross-sectional study of fourth-year medical students who completed a mandatory 2-week rotation at a postacute care facility. Students were provided with three instructional methods: Web-based interactive learning modules; small-group sessions with geriatric faculty; and Geriatric Interdisciplinary Care Summary (GICS), a grid that students used to formulate comprehensive interdisciplinary care plans for their own patients. After the rotation, students evaluated the overall clerkship, patient care activities, and usefulness of the three instructional methods using a 5-point Likert scale (1=poor to 5=excellent) and listed their area of future specialty. Of 156 students who completed the rotation, 117 (75%) completed the evaluation. Thirty (26%) chose specialties providing chronic disease management such as family, internal medicine, and psychiatry; 34 (29%) chose specialties providing primarily procedural services such as surgery, radiology, anesthesiology, pathology, and radiation oncology. Students rated the usefulness of the GICS as good to very good (mean±standard deviation 3.3±1.0). Similarly, they rated overall clerkship as good to excellent (3.8±1.0). Analysis of variance revealed no significant group difference in any of the responses from students with the overall clerkship ( F (112, 4)=1.7, P =.20). Students rated the geriatric clerkship favorably and found the multimodal instruction to be useful. Even for students whose career choice was not primary care, geriatrics was a good model for interdisciplinary care training and could serve as a model for other disciplines.     

Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.     

Medication management in older adults and interprofessional education: A needs assessment

ABSTRACT

Elderly, multi-morbid patients are at high risk for suffering adverse drug events. Safe medication management is a key process in preventing these adverse events, and requires interprofessional teamwork. We performed a needs assessment survey of graduating medical students and faculty to evaluate student training in medication management, in particular students’ preparedness in the three minimum geriatrics competencies pertaining to medication management, interprofessional educational opportunities, and optimal learning methods. Response rates were 45/105 (43%) for students and 38/93 (41%) for faculty. The majority of students felt that they did not receive sufficient training in medication management in older adults. Faculty either agreed with students or were unsure whether students received sufficient training. Neither students nor faculty felt that students were extremely prepared to carry out the three minimum geriatrics competencies at the time of medical school graduation. Students and faculty identified direct patient care experiences as the optimal learning method, and inappropriate medications as the highest priority topic. Students and faculty felt that students do not receive sufficient interprofessional educational opportunities. The results of this study are currently being used to create customized interprofessional educational experiences for medical students related to medication management in older adults.     

Telehealth Competencies in Medical Education: New Frontiers in Faculty Development and Learner Assessments

Telehealth visits have become an integral model of healthcare delivery since the COVID-19 pandemic. This rapid expansion of telehealthcare delivery has forced faculty development and trainee education in telehealth to occur simultaneously. In response, academic medical institutions have quickly implemented clinical training to teach digital health skills to providers across the medical education continuum. Yet, learners of all levels must still receive continual assessment and feedback on their skills to align with the telehealth competencies and milestones set forth by the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME). This paper discusses key educational needs and emerging areas for faculty development in telehealth teaching and assessment of telehealth competencies. It proposes strategies for the successful integration of the AAMC telehealth competencies and ACGME milestones into medical education, including skills in communication, data gathering, and patient safety with appropriate telehealth use. Direct observation tools in the paper offer educators novel instruments to assess telehealth competencies in medical students, residents, and peer faculty. The integration of AAMC and ACGME telehealth competencies and the new assessment tools in this paper provide a unique perspective to advance clinical practice and teaching skills in telehealthcare delivery.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07564-8.KEY WORDS: telehealth, telemedicine, virtual visits, medical education, competencies, milestones, electronic health records     

Evaluation of a national curriculum reform effort for the medicine core clerkship

BACKGROUND: In 1995, the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) developed and disseminated a new model curriculum for the medicine core clerkship that was designed to enhance learning of generalist competencies and increase interest in general internal medicine. OBJECTIVE: To evaluate the dissemination and use of the resulting SGIM/CDIM Core Medicine Clerkship Curriculum Guide. DESIGN: Survey of internal medicine clerkship directors at the 125 medical schools in the United States. MEASUREMENTS AND MAIN RESULTS: The questionnaire elicited information about the use and usefulness of the Guide and each of its components, barriers to effective use of the Guide, and outcomes associated with use of the Guide. Responses were received from 95 clerkship directors, representing 88 (70%) of the 125 medical schools. Eighty-seven (92%) of the 95 respondents were familiar with the Guide, and 80 respondents had used it. The 4 components used most frequently were the basic generalist competencies (used by 83% of those familiar with the Guide), learning objectives for these competencies (used by 83%), learning objectives for training problems (used by 70%), and specific training problems (used by 67%); 74% to 85% of those using these components found them moderately or very useful. The most frequently identified barriers to use of the Guide were insufficient faculty time, insufficient number of ambulatory care preceptors and training sites, and need for more faculty development. About 30% or more of those familiar with the Guide reported that use of the Guide was associated with improved ability to meet clerkship accreditation criteria, improved performance of students on the clerkship exam, and increased clerkship time devoted to ambulatory care. CONCLUSION: This federally supported initiative that engaged the collaborative efforts of the SGIM and the CDIM was successful in facilitating significant changes in the medicine core clerkship across the United States. Presented at the Society of General Internal Medicine annual meeting, San Francisco, Calif, April 1999. This work was supported in part by Contract No. 240-930029 from the Bureau of Health Professions, Health Resources and Services Administration.     

Medical students' understanding of geriatric medicine

With the rapid aging of Japan's population, medical professionals who specialize in geriatric medicine are in unprecedented demand. At Ehime University School of Medicine, the Department of Geriatric Medicine was established on April 1,1997. To assess the status of geriatric medicine in undergraduate education, we surveyed the opinions of medical students on geriatric medicine. A questionnaire was sent to both fourth-year medical students before their classes on internal medicine and geriatric medicine had ended and to sixth-year medical students after their classes had already ended. Medical students of Ehime University School of Medicine had significantly more interest in geriatric medicine than students at other medical schools. From a clinical viewpoint of problems in old age, they considered that cerebrovascular disease, cardiovascular disorders, neurocognitive disorders and pulmonary disease were important. A total of 60% agreed that all medical schools should have classes in geriatric medicine, which is a higher rate than that of previous reports. To study the opinions of medical students on textbooks on geriatrics, we also conducted a questionnaire among medical students. Although 90% of students had their own textbooks of internal medicine and almost half (42%) had textbooks on physical examination, none had their own textbook of geriatric medicine. The most frequent reason was "hard to choose the best textbook". The present study indicates that to develop education in geriatric medicine, it is important to make a recommendable text book for medical students, which is easily understood with high quality and originality.     

Does It Stick? Effects of an Integrated Vertical Undergraduate Aging Curriculum on Medical and Surgical Residents

Experts acknowledge the unmet need for all physicians to have basic knowledge of aging and competency in geriatric care given the context of population aging. The University of South Carolina (USC) School of Medicine implemented a highly successful program of aging-oriented undergraduate medical training, including a geriatrics vertical curriculum and its senior mentor program—a required, 4-year experience matching students with older community volunteers, referred to herein as the integrated vertical curriculum in geriatrics (IVC). In earlier work, it was established that IVC graduating classes were significantly more likely to report exposure to and coverage of various geriatrics topics than prior USC classes or other U.S. medical graduates. Here the results of a follow-up survey of USC graduating classes before and after exposure to the IVC and contemporaneous Medical University of South Carolina (MUSC) graduates after two to three years of residency (before the initiation of a senior mentor program at MUSC) is reported. Of 403 graduates, 227 returned questionnaires (response rate 56%). Significantly more IVC (2004) than pre-IVC (2003) and 2003 and 2004 MUSC graduates rated themselves fairly or very well prepared by their undergraduate education to treat older adults seen in residency (95% vs 77% and 52%; P <.001). Implications of this and other findings are discussed.     

Evaluation of geriatrics education at a Chinese University: A survey of attitudes and knowledge among undergraduate medical students

ABSTRACT

Despite widespread reforms in medical education across China, nationally there has been no mandate or movement toward systemically incorporating geriatrics into curricula. To what degree medical students are trained and have exposure to geriatric topics remains unclear. We surveyed 190 medical students during their final year of medical school at a Chinese medical university, graduating from reformed and also traditional curricula. The survey was comprised of a subjective assessment of attitudes and reported knowledge, as well as an objective assessment of knowledge via a multiple choice test. Student attitudes were favorable toward geriatrics, with 91% supporting the addition of specialized clinical experiences to the curriculum. Students generally reported low exposure to geriatrics, with no statistically significant differences between reform and traditional curricula. There was a statistically significant difference in performance on the multiple choice test between curricula but at a degree unlikely to be practically significant. Students had very favorable attitudes toward geriatrics as a field and specialty; however scored poorly on competency exams, with the lowest performance around diagnosis and treatment of specific geriatric conditions. Our results suggest that there is a need and desire for increased geriatric-oriented learning at Chinese medical schools.     

A Fourth‐Year Medical School Clerkship That Addressed Negative Attitudes Toward Geriatric Medicine

Despite extensive educational efforts, many medical students still have negative attitudes toward the field of geriatric medicine and the care of older adult patients. This article describes a fourth‐year geriatric clerkship that addressed this issue by providing opportunities for students to actively discuss many of the negative stereotypes that exist regarding geriatric medicine. Emphasis was also placed on personalizing the course content to show the relevance of geriatric medicine to all medical students. During the 2008/09 academic year, 150 students completed the rotation. Although no students expressed an interest in pursuing a career as a geriatrician, they expressed a highly favorable evaluation of this personalized geriatric clerkship and voted this clerkship “the most outstanding clinical course” at the medical school.     

A case-oriented web-based curriculum in geriatrics for third-year medical students

OBJECTIVES: This paper describes the development, implementation, and evaluation of a case-oriented, web-based curriculum in geriatric medicine for third-year medical students. DESIGN: Single cohort, pre/post trial. SETTING: University of Kansas School of Medicine, Kansas City, Kansas. PARTICIPANTS: Third-year medical students (n = 130). INTERVENTION: A web-based curriculum, offered during a clinical geriatrics clerkship, is composed of 13 case-oriented, web-based modules spanning key topics in geriatric medicine. Each module topic is also reviewed in a post-module, faculty-led discussion session. MEASUREMENTS: A pre-and post-rotation test of knowledge was completed. Student feedback about the curriculum was collected through web-based and written evaluation. MAIN RESULTS: Pre-and post-rotation comparison of examination scores demonstrated an average increase of 13 correct items on a 40-item exam. Seventy-five percent of students rated each module favorably at the time of completion (range 53-89%). Most modules (10/13) were rated as excellent or good after all modules had been completed. CONCLUSIONS: A case-oriented web-based curriculum in geriatrics was rated favorably by third-year medical students. Students' knowledge increased in key geriatric topics. Student feedback allows for continuous improvement of the curriculum. This model of curricular innovation may be useful for other institutions seeking to develop or enhance geriatric medicine content in the medical school curriculum.