Emergency medicine management of the geriatric patient: an educational program for medical students

This article describes the experience of fourth-year medical students participating in a geriatric education program integrated into a 4-week emergency medicine student clerkship. Between July 2002 and April 2003, all students in this required clerkship participated in a geriatric educational program consisting of a small group discussion of medical and psychosocial issues of older adult emergency department (ED) patients. Students used learned skills to evaluate older adult ED patients for medical and psychosocial issues and later followed up with these patients by telephoning them at their homes or visiting them in the hospital. Students tracked their evaluations of the medical problems, functional abilities, and social supports of patients in the ED. Students also noted when their assessments resulted in the acquisition of new skills or knowledge and when their evaluation of geriatric syndromes resulted in a change of the patient care plan. Seventy-seven students evaluated 217 patients in the ED, of whom 167 (77%) received a follow-up visit or phone call. Students documented learning new skills while caring for 80 (48%) of the older adult patients. Qualitative survey responses from students indicated that students had increased understanding of the importance of assessing functional status and social supports and providing interdisciplinary care. Integrating geriatric education modules into existing emergency medicine clerkships is an effective method to expand the geriatric curriculum in medical schools and to emphasize the importance of geriatric assessment and syndromes in emergency care.     

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 problem-based learning curriculum in geriatrics for medical students

ABSTRACT

A geriatrics curriculum delivered to medical students was evaluated in this study. Students were instructed to review real patient cases, interview patients and caregivers, identify community resources to address problems, and present a final care plan. Authors evaluated the course feedback and final care plans submitted by students for evidence of learning in geriatric competencies. Students rated the efficacy of the course on a 5-point Likert scale as 3.70 for developing clinical reasoning skills and 3.69 for interdisciplinary teamwork skills. Assessment of an older adult with medical illness was rated as 3.87 and ability to perform mobility and functional assessment as 3.85. Reviews of written final care plans provided evidence of student learning across several different geriatric competencies such as falls, medication management, cognitive and behavior disorders, and self-care capacity. Assessment of the curriculum demonstrated that medical students achieved in-depth learning across multiple geriatric competencies through contact with real cases.     

Evaluating immediate and long-range effect of a geriatric clerkship using reflections and ratings from participants as students and as residents

This article describes a longitudinal study developed to assess perceived usefulness of a mandatory geriatric clerkship from the perspective of junior students completing the newly initiated program in 1998-1999 and 1999-2000 and these same students as second- or third-year residents. End-of-clerkship student evaluations were compared with follow-up resident surveys of those same students to identify the utility of information provided and strengths and weaknesses of the initial course experience. Students participated in hospice, outpatient clinics, nursing homes, and transitional care venues during their clerkship experience at the Donald W. Reynolds Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences. Two hundred eighty-five student evaluations were collected, and 143 resident surveys were returned. Quantitative and qualitative data from students and residents corroborated each other in identifying strengths and weaknesses of the clerkship. Hospice information was successfully incorporated into residency practice. In contrast, outpatient clinic, nursing home, and transitional care segments of the clerkship were perceived as inadequate. Survey responses validated faculty changes that were initiated in the following years. These changes use settings and patients that more accurately mirror those seen in typical resident encounters.     

Early clinical exposure to geriatric medicine in second-year medical school students--the McGill experience

This study examined the effect of a curriculum change on early clinical exposure to geriatrics for second-year medical students at McGill University and its effects on learning and students' appreciation of geriatrics as a subspecialty. Second-year medical students (N = 200) were exposed to a change in the curriculum involving the integration of 10 weekly sessions into one integrated week in geriatric medicine. Students participating in 10 weekly sessions were Group 1 and students participating in one integrated week were Group 2. Students rated their rotation using two different scales. The students completed 12-item questionnaires during their feedback sessions at the end of the 10-week session experience or the integrated week. The first six items assessed the students' appreciation of their improvement of knowledge in the subject of geriatrics and aging. The second and third part of the survey (questions 7 and 8) included the students' opinions about the quality of the instruction (teaching feedback) and evaluation. Students in Group 2 found their rotation more effective as a learning experience and expressed greater satisfaction with interaction with the tutors, community settings, and multidisciplinary team sessions. Grades obtained on final examinations showed a better and more-effective acquisition of knowledge by Group 2. The integrated week is a more-effective learning tool in the early clinical experience for medical students in geriatric medicine than 10 weekly sessions as the first introductory experience to the field of geriatric medicine.     

Effect of a 1-week clinical rotation in palliative medicine on medical school graduates' knowledge of and preparedness in caring for seriously ill patients

OBJECTIVES: To assess the effect of a required 1‐week clinical rotation in palliative medicine during a 12‐week internal medicine–geriatrics clerkship on graduating medical students' knowledge and self‐assessed preparedness in caring for seriously ill patients. DESIGN: Historical control trial. SETTING: Mount Sinai School of Medicine (MSSM), New York, New York. PARTICIPANTS: Students from the MSSM classes of 2007 (MS07) and 2008 (MS08). INTERVENTION: MS08 was the first class to complete the required clinical rotation in palliative medicine. MS07 served as a historical control, having received only didactics in palliative care but no clinical rotation. MEASUREMENTS: Both classes were invited to complete an anonymous online survey designed to assess experiences and preparedness in caring for seriously ill patients and a 30‐question multiple choice knowledge examination. RESULTS: Fifty‐eight (55%) students from MS07 and 59 (51%) students from MS08 completed the survey. Students from MS08 rated their skill level in several areas of pain management and communication more favorably than did students from MS07. Mean scores on the knowledge portion of the survey were not significantly different between the two classes. CONCLUSION: Graduating medical students who had a 1‐week clinical rotation in palliative medicine had higher self‐assessed skills in pain management and communication than students who received no clinical exposure. A brief clinical experience in palliative care should be considered for integration into the curriculum at all medical schools.     

Effect of a mandatory geriatric medicine clerkship on third-year students

A nationwide push has increased geriatric medicine instruction within medical school curricula. Some institutions have proceeded with an integrated 4-year curriculum while others have constructed discrete courses in the third or fourth year of medical school. This paper describes the impact of a new mandatory 4-week geriatric medicine clerkship on third-year students developed by the Donald W. Reynolds Department of Geriatric Medicine at the University of Oklahoma Health Sciences Center. In the first year of implementation, 135 students took the course on both the Oklahoma City and Tulsa campuses. Clinical sites included inpatient, VA extended care unit, outpatient clinics, dementia clinics, home care, long-term care settings, and hospice. Didactic instruction used formal lectures and problem-based learning. The impact of the clerkship on students was assessed in three areas: knowledge, skills, and attitude using a pre- and postknowledge test, student satisfaction survey, and written comments. This article discusses how the clerkship resulted in increased knowledge of geriatric medicine. Student self-report indicates that the clerkship enhanced clinical evaluation and patient assessment skills. Students indicated that the experience was positive and recognized the importance of geriatric medicine in their development as doctors.     

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 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.     

Continuous Quality Improvement Principles Used in an Interdisciplinary,Multisite Geriatrics Clerkship

This article describes how Continuous Quality Improvement (CQI) principles have been used in the development and support of a Geriatric Medicine Clerkshipb for fourth-year medical students. Among these principles, consumer orientation, repeated evaluation of clerkship components, and improvement through a team approach are central to the basic pedagogy of the course. The clerkship has many educational components including lectures, community agency visits, clinical work in a nursing home, interviews with caregivers, home visits and geriatric rehabilitation assessments. CQI principles set the framework for the evaluation and improvement of all these elements. The incorporation of students, faculty and the other teaching professionals into the CQI process facilitates a teamwork understanding of older patient care, and a commitment to the interdisciplinary teaching of geriatric medicine.     

Learning primary care in medical school: does specialty or geographic location of the teaching site make a difference?

PURPOSE: The Liaison Committee on Medical Education mandates a core curriculum in primary care but does not specify its content or structure. In this study, we explored the question of whether primary care specialty or geographic location affects student learning and satisfaction. METHODS: From 1994 to 1996, 294 third-year medical students at one medical school in New York state were randomly assigned to multiple teaching sites for a required 5-week primary care clerkship. Independent predictor variables were primary care specialty of the preceptor (family medicine, medicine, pediatrics, or joint medicine and pediatrics) and geographic location of the site (urban, suburban, rural). Outcome measures included four areas of student satisfaction, one of patient volume, and two of student performance. RESULTS: Primary care specialty had no detectable association with the outcome measures, except for a lower rating of patient diversity in pediatric experiences (P <0.001). Geographic location of the site had a significant association with all measures of student satisfaction and patient volume (all P values <0.001). Students at rural sites rated the experience more highly and saw on average 15 more patients per rotation. Ratings of student satisfaction remained high after adjusting for patient volume. Primary care specialty and geographic location did not influence student performance in the clerkship or scores on standardized patient examination. CONCLUSIONS: Rural geographic location of teaching site, but not primary care specialty, was associated with higher student satisfaction. However, higher student satisfaction ratings did not correspond to better student performance. Provided that all sites meet the screening criteria for inclusion in a teaching program, these findings support the continued development of high-quality, heterogeneous, interdisciplinary, primary care experiences.     

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.     

Changing the fourth-year medicine clerkship structure

The fourth-year medicine clerkship was restructured at one of four sites. Teams consisting of one attending physician and three students cared for eight new patients per week. The overall experience of the restructured clerkship was rated significantly more positively than the experiences at all other sites and the teaching effectiveness of the faculty more positively than those at two of the other sites. This clerkship structure was perceived by students to be a positive experience. It could serve as a model for housestaff training programs to successfully care for patients without housestaff.     

Web-based curriculum

OBJECTIVE: To address the need for women's health education by designing, implementing, and evaluating a self-study, web-based women's health curriculum. DESIGN: Cohort of students enrolled in the ambulatory portion of the medicine clerkship with comparison group of students who had not yet completed this rotation. PARTICIPANTS/SETTING: Third- and fourth-year medical students on the required medicine clerkship (115 students completed the curriculum; 158 completed patient-related logs). INTERVENTION: Following an extensive needs assessment and formulation of competencies and objectives, we developed a web-based women's health curriculum completed during the ambulatory portion of the medicine clerkship. The modules were case based and included web links, references, and immediate feedback on posttesting. We discuss technical issues with implementation and maintenance. MEASUREMENTS AND MAIN RESULTS: We evaluated this curriculum using anonymous questionnaires, open-ended narrative comments, online multiple-choice tests, and personal digital assistant (PDA) logs of patient-related discussions of women's health. Students completing the curriculum valued learning women's health, preferred this self-directed learning over lecture, scored highly on knowledge tests, and were involved in more and higher-level discussions of women's health with faculty (P<.001). CONCLUSIONS: We present a model for the systematic design of a web-based women's health curriculum as part of a medicine clerkship. The web-based instruction resolved barriers associated with limited curriculum time and faculty availability, provided an accessible and standard curriculum, and met the needs of adult learners (with their motivation to learn topics they value and apply this knowledge in their daily work). We hypothesize that our web-based curriculum spurred students to later discuss these topics with faculty. Web-based learning may be particularly suited for women's health because of its multidisciplinary nature and need for vertical integration throughout medical school curricula.     

Medical Students' Attitudes:

Although education in the care of the elderly is widely recommended for all medical students, the specifics of this aspect of pressional education are widely variable and their effects unclear. This study evaluated the effects of a short-term interdisciplinary clinical rotation in geriatrics on medical student attitudes toward elderly patients, as well as attitudes toward non-physician health professionals. We also evaluated whether assignment to long-term care facilities as geriatrics clinical sites had a deleterious effect on attitudes of medical students taking this rotation. Our analysis demonstrated no measurable beneficial effects of the week-long geriatrics rotation on medical student attitudes toward elderly patients. The brief rotation did improve student attitudes toward the importance of non-physician health professionals in patient care; at the end of the course the students had more positive attitudes toward social workers, psychologists, and occupational therapists. Assignment to long-term care clinical sites during this geriatric curriculum had no negative effect on student attitudes toward elderly patients. This study suggets that clinical geriatrics education in long-term care settings need not adversly affect medical students' attitudes toward the elderly. Furthermore, medical students' attitudes toward health professionals caring for the elderly may be positively influenced by even a short didactic and clinical experience in geriatrics which emphasizes the interdisciplinary approach.     

Hazards of Hospitalization: Hospitalists and Geriatricians Educating Medical Students About Delirium and Falls in Geriatric Inpatients

ABSTRACT

Geriatric patients are at increased risk for complications from delirium or falls during hospitalization. Medical education, however, generally places little emphasis on the hazards of hospitalization for older inpatients. Geriatricians conducted a faculty development workshop for hospitalists about the hazards of hospitalization for geriatric patients, focusing on two common geriatric syndromes: delirium and falls. The hospitalists then ran workshops for third-year medical students during their inpatient medicine clerkship, introducing two simple tools for assessing fall risk and diagnosing delirium. Students used these tools to evaluate their own patients and then reviewed cases with a geriatrician at the end of one month. A total of 101 students participated in the project and completed a post-intervention multiple choice test, and 73 (72.2%) returned the records of 278 patient evaluations. Compared to the control group from the end of the previous year, test scores increased by an average of 0.84 out of 9 points (9.3% increase, p?=?0.005, t _117,.05/2?= 2.87, p?=?0.0048). Students also identified 81 patients with delirium and 65 patients at high risk for falling. Hospitalists and geriatricians can effectively partner to increase students' knowledge of two major hazards of hospitalization for geriatric patients.     

Interdisciplinary Faculty Collaboration for Developing Introductory Level Geriatric Curriculum

Health care educational programs have been slow to introduce geriatrics in the curriculum although demographic data demonstrate the need for increased geriatric emphases. Four general problems - institutions, professions, scholarship, and faculty - are discussed in terms of their influence on geriatric curriculum development and implementation. A creative curriculum development approach is described that addresses the problem of faculty. The product is an interdisciplinary, time-efficient set of eight faculty instructional guides that assures the availability of introductory level geriatric content. Program and faculty benefits include increased interdisciplinary awareness, expanded geriatric knowledge, enhanced presentation and instructional skills, and increased commitment to geriatric education and curriculum development.     

Multisite Geriatrics Clerkship for Fourth-Year Medical Students: A Successful Model for Teaching the Association of American Medical Colleges' Core Competencies

As the population ages, it is important that graduating medical students be properly prepared to treat older adults, regardless of their chosen specialty. To this end, the Association of American Medical Colleges (AAMC) and the John A. Hartford Foundation convened a consensus conference to establish core competencies in geriatrics for all graduating medical students. An ambulatory geriatric clerkship for fourth-year medical students that successfully teaches 24 of the 26 AAMC core competencies using an interdisciplinary, team-based approach is reported here. Graduating students (N=158) reported that the clerkship was successful at teaching the core competencies, as evidenced by positive responses on the AAMC Graduation Questionnaire (GQ). More than three-quarters (80–93%) of students agreed or strongly agreed that they learned the seven geriatrics concepts asked about on the GQ, which cover 14 of the 26 core competencies. This successful model for a geriatrics clerkship can be used in many institutions to teach the core competencies and in any constellation of geriatric ambulatory care sites that are already available to the faculty.     

Maximizing the Impact of a Symposium to Facilitate Change in Student Attitudes about Interdisciplinary Teamwork

Elderly patients, including those with dementia, have more complex health care needs, which may be more effectively served by interdisciplinary teams. Yet, few health care students receive interdisciplinary education. This article describes the improved outcomes of a second annual symposium for health care students on interdisciplinary care for older adults with dementia. Students (n = 109) completed a pre/post assessment using the Attitudes Toward Healthcare Teams Scale. A t-test for paired samples indicated a statistically significant increase in pre-post test scores (p < .001); we observed a larger effect size of change in student attitudes for this symposium than the first (η² = .48). The results support the value of pedagogical changes in facilitating a greater change in student attitudes about interdisciplinary teamwork.