Clinical Education in Geriatrics

Innovative and Trusted Approaches Leading Workforce Transformation in Making Health Care More Age-Friendly

Judith L. Howe, Thomas V. Caprio

• Publisher: Taylor & Francis
• Year: 2020
• Print ISBN: 9781032089782
• eBook ISBN: 9781000650624
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

This book highlights both recent innovations in professional health curricula and continuing education and interventions aimed at improving student attitudes towards geriatrics and aging.

The contributors cover areas including simulation, online training, and standardized patients for evaluation, but also emphasize the important end-result of clinical training: to take care of real older adults outside the classroom. Importantly, this underscores the development of powerful learning experiences of students by sensitizing them to the frameworks of palliative care, cancer care, sexuality, and aging research, all of which serves as a powerful catalyst for creating a 'pipeline' of students who embrace aging as a central theme of their future work.

As increased training in geriatrics is required to attune the health care workforce to the needs of older adults, this book will be of interest to those seeking to create a more age-friendly healthcare curriculum. This book was originally published as a special issue of the Gerontology & Geriatrics Education journal.

A problem-based learning curriculum in geriatrics for medical students

Mamata Yanamadala, Victoria S. Kaprielian, Colleen O’Connor Grochowski, Tiffany Reed, Mitchell Tod Heflin

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.

Introduction

The Institute of Medicine (IOM; 2008) has identified a critical need to expand geriatrics competence among all physicians. Older adults currently make up about 12% of the U.S. population, yet account for 26% of all physician office visits and 35% of all hospital stays. Effective care of this growing population requires knowledge and skills in the management of complex medical and psychosocial problems. In response, the IOM report recommends that all primary care and subspecialty physicians receive enhanced training in geriatrics. Unfortunately, deficiencies exist in preparation of medical students to care for geriatric patients in the United States. (Eleazer, Doshi, Wieland, Boland, & Hirth, 2005) As a result, students graduate with inadequate knowledge and skills in the care of older adults and, furthermore, may perceive geriatrics as a less valuable medical specialty and undesirable career option. (Anderson, 2004; Bagri & Tiberius, 2010; Ory, Kinney Hoffman, Hawkins, Sanner, & Mockenhaupt, 2003)

Over the last decade, grant-funded initiatives have targeted these deficiencies. Educators in geriatrics have applied novel strategies for medical student training, including senior mentor programs, community partnerships, and standardized patients. (Anderson, 2004) To provide consistent expectations for these efforts, a national taskforce published a set of minimum competencies in care of older adults for graduating medical students in 2009 (Leipzig et al., 2009). Significant efforts are underway to disseminate the competencies, but, to date, few models describing and evaluating experiences in medical schools to teach these competencies have been published (Atkinson, Lambros, & Davis et al., 2013).

Multiple barriers exist to effective instruction in geriatrics, including shortage of faculty and student time and funding. (Helms, Denson, Brown, & Simpson, 2009; Oates, Norton, & Russell et al., 2009; Strano-Paul, 2011; Sutin, Rolita, Yeboah, Taffel, & Zabar, 2011) Teaching geriatric competencies is also uniquely challenging for educators due to the complexity and multiplicity of medical, psychosocial, and functional issues. This complexity demands further development of effective and efficient curricula in geriatrics for medical students. Problem-based learning, particularly in examination of real cases, presents an educational strategy proven to enhance learning, particularly around psychosocial and teamwork issues so critical to geriatrics. (Koh, Khoo, Wong, & Koh, 2008) In this article we describe a week-long problem-based learning experience in geriatrics delivered to second-year medical students and its relative effectiveness in promoting learning geriatric competencies.

Method

Curriculum development

Interventions that include contact with older adults in a variety of settings have the highest success rates over time in increasing positive attitudes of medical students toward geriatric patients (Voogt, Mickus, Santiago, & Herman, 2008). In addition, problem-based learning (PBL) in medical school positively affects physician competencies essential to the care of older adults, including appreciation of social and ethical aspects of health care, communication skills, and self-directed learning. (Koh et al., 2008)

Review of the existing curriculum for medical students revealed opportunities to increase medical student interaction with geriatric patients. A subsequent curriculum revision led to the creation of a series of one-week intersessions between the standard clinical clerkships. These week-long experiences addressed key topics spanning multiple medical specialties, including geriatrics. Geriatrics faculty met regularly with the course director and administrators over a 6-month period to plan the curriculum. Given limited time, faculty elected to focus didactics and clinical experiences on selected core issues on care of older adults, including falls, cognitive impairment, polypharmacy, and caregiver stress.

Curriculum description

This week-long course titled “Clinical Core on Aging” was delivered to second-year medical students after completion of their first clinical clerkship. Learning objectives included the following:

By the end of the week, students will be able to:

(1) Analyze the case of an older adult suffering from one of four core problems (falls, polypharmacy, caregiver stress, or cognitive impairment) for root causes and contributing factors

(2) Cite evidence on the epidemiology of the problem, common contributing factors, and methods of prevention

(3) Describe community resources available to prevent or manage this core problem

(4) Propose specific recommendations at the patient and system level for improving care in this area

(5) Demonstrate teamwork skills.

We aimed to use a PBL strategy to teach teamwork, clinical reasoning, and care planning. PBL is defined as a method and philosophy, involving problem-first learning via work in small groups and independent study (Maudsley, 1999). This method encourages learners to use critical thinking and problem-solving skills as they apply content knowledge to real-world problems and issues.

During the week, students worked in teams of five on a project with a real patient affected by one or more of four core problems, including falls, cognitive decline, caregiver stress, and polypharmacy. Faculty reviewed and identified core issues for each case. Polypharmacy cases included not only those with multiple medications but also those with potentially inappropriate medications. Faculty and fellows recruited case patients by contacting primary providers in different settings including nursing homes, assisted living, independent living, community dwelling, and hospital. Course faculty aimed to achieve an even distribution of types of patient problems and locations of care among the student teams to optimize the value of discussions at the end of the week. Ten faculty members specializing in geriatrics and six geriatric fellows were recruited to conduct the introductory and final care plan discussions. In preparation for the week, faculty and fellows participated in an hour-long development session on PBL methodology.

The week-long course started with an introductory discussion of a real patient case (see Figure 1). This 90-minute small group discussion was facilitated by geriatric medicine faculty and fellow pairs. At the beginning of the session, students received a case packet that included a brief introductory paragraph describing the patient’s age, gender, major medical problems, and chief concern or problem as well as resources and instructions for activities for the remainder of the week. With this information, students brainstormed a differential diagnosis for the brief information provided in the case. By the end of the session, student teams identified specific issues to research between sessions and a basic plan for their final presentation. On the afternoon of Day 1, students received a series of brief lectures on the core topics, including cognitive disorders, gait problems and falls, medication management, and caregiver stress. On Day 2, students performed an interview and assessment of the patient and (when possible) the caregiver. Students used Mini Mental Status Exam and Get Up and Go tools for cognitive and gait assessments, respectively (Folstein, Folstein, & McHugh, 1975; Podsiadlo & Richardson, 1991). In addition, they performed a systematic medication review that included dosage, timing, and indication of prescription and nonprescription drugs. They did not use a specific tool to assess caregiver burden. Interviews focused on the patient experience and the identification of causative factors for problems. Students were encouraged to begin to identify steps for prevention or management of subsequent events or problems. On Day 3 students met with members of the interdisciplinary team at a local continuing care retirement community and then attended a panel discussion at the local senior center with representatives from Meals-on-Wheels, a nonprofit assisting older adults in managing medications, a publicly supported senior transportation agency, the State Health Insurance Information Program (SHIIP), caregiver support groups, and home care agencies. They also toured an Adult Day Health Program located there in the senior center.

Figure 1. Organizational scheme for clinical core on aging. F = falls; CI = cognitive impairment; CS = caregiver stress; and P = polypharmacy.

Independent teamwork

Student teams also met independently in three predesignated 2-hour meeting times to work collaboratively on the patient case activity. Between meetings, students independently researched their patient’s primary problem, etiology, and appropriate management strategies. Key references and contacts were provided for the core problems identified in their case. Faculty members were also available for questions during designated “office hours” for answering student questions.

Final activity

On the final day (Day 4), students met in large groups of four teams (20 students), each with a different core problem, to present their cases to each other. Teams took turns presenting with faculty facilitating the discussion. In their presentation, each team was directed to address the patient’s problem(s), pertinent evidence from the literature, and approaches for the care of the patient. Although each case was linked with a core problem, they were allowed (and in some cases encouraged) to include disc...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Citation Information
• Notes on Contributors
• Foreword: Clinical Education in Geriatrics: Innovative and Trusted Approaches Leading Workforce Transformation in Making Health Care More Age-Friendly
• 1 A problem-based learning curriculum in geriatrics for medical students
• 2 The development and evaluation of mini-GEMs – short, focused, online e-learning videos in geriatric medicine
• 3 Resident learning across the full range of core competencies through a transitions of care curriculum
• 4 Development and preliminary evaluation of the resident coordinated-transitional care (RC-TraC) program: A sustainable option for transitional care education
• 5 Geriatrics fellowship training and the role of geriatricians in older adult cancer care: A survey of geriatrics fellowship directors
• 6 Geriatric education utilizing a palliative care framework
• 7 Improving health care student attitudes toward older adults through educational interventions: A systematic review
• 8 Effect of short-term research training programs on medical students’ attitudes toward aging
• 9 Medical students’ reflections of a posthospital discharge patient visit
• 10 Medical student reflections on geriatrics: Moral distress, empathy, ethics and end of life
• 11 Addressing sexual health in geriatrics education
• Index