Indiana University School of Medicine.

Abstract

Overview of the Geriatrics Curriculum The geriatrics curriculum at Indiana University School of Medicine (IUSM) was significantly enhanced using funding provided by the John A. Hartford Foundation. IUSM has a competency-based curriculum that was adopted in 1999. The goal of the undergraduate curriculum in geriatrics medicine at IUSM is to provide fundamental knowledge, skills, and attitudes for the competent, compassionate care of older adults and to integrate these goals into the current undergraduate competency-based curriculum. Ten specific objectives in geriatrics medicine were developed within four of the established IUSM curriculum competencies, including effective communication; basic clinical skills; using science to guide diagnosis, management, therapeutics, and prevention; and the social and community contexts of health care. Specific objectives within these competencies are to develop awareness of the various myths and stereotypes related to older people; develop skills to perform a comprehensive history and physical examination of older patients; recognize the physiology of aging and how that differs from the pathology of disease; state the pharmacologic changes in aging and their relevance to therapeutic decisions; identify risk factors, causes, signs and symptoms, differential diagnosis, diagnostic evaluation, and preventive strategies of common geriatric syndromes; recognize the heterogeneity of older persons; state the role of different disciplines in the care of older persons; demonstrate competence in the basic elements of geriatric assessment; identify individual patient needs and barriers to maintaining independent living; and accept personal responsibility to advocate practices and policies that improve the health of individual patients and patients in general. A variety of educational methods were used to accomplish these objectives, including use of standardized patients (SPs); Web-based technology; small-group discussions and didactics to complement encounters with SPs and the Web; self-directed learning; and clinical applications during block and longitudinal experiences followed by faculty and interdisciplinary team interactions. The geriatrics curriculum was integrated across the four years of medical school as well as across courses. Curriculum Management and Governance Structure In 2001, a new dean was appointed at IUSM, and he subsequently created a new administrative structure for the school. He appointed five executive associate deans (clinical affairs, research, educational affairs, administration, and academic affairs) and gave each the authority and responsibility for overseeing his or her respective missions in the school. The executive associate dean for educational affairs is responsible for oversight of student affairs, undergraduate medical education, graduate medical education, and continuing medical education. The associate dean for medical education and curricular affairs (MECA) reports to the executive associate dean for educational affairs. Based on input from MECA and/or faculty voting processes, members are appointed by the dean to the Curriculum Council and the Academic Standards Committees, the two IUSM curricular governing bodies. These groups work in concert with MECA and the executive associate dean for educational affairs to oversee the curriculum. The dean appoints a director for each competency to oversee and coordinate its integration and evaluation in the curriculum. In a matrix-organizational format, the competency directors, course directors, and MECA work to ensure that competency content is taught, assessed, and tracked throughout the curriculum. The director of the Clinical Skills Education Center, who has oversight over the IUSM standardized patient program, reports to the associate dean for MECA. To assist with structuring a proposal for the Hartford grant, one of the present authors (GRW) presented her ideas for incorporating geriatrics into the curriculum to the IUSM Curriculum Council (CC) and to MECA. Both groups approved her proposed plan and strongly encouraged her to proceed with the project. She incorporated a variety of educational methodologies throughout all four years of the undergraduate curriculum. As mentioned earlier, these methodologies include standardized patients, Web-based technology, small-group discussions, self-directed learning, clinical applications, and faculty/interdisciplinary team interactions. In addition to incorporating geriatric content into the curriculum, she took great care to integrate competencies into the curriculum as well. The competencies specifically addressed in this project include communication; basic clinical skills; using science to guide diagnosis, management, therapeutics, and prevention; and social and community context of health care. It is important to note that the comprehensive and integrative approach to the geriatrics curriculum at IUSM permits all 280 students (per class) to have exposure to geriatrics and the related competencies in each of the four years of our undergraduate curriculum. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change IUSM underwent curricular change and fully implemented a competency-based curriculum for the class entering medical school in 1999 (graduating class of 2003). Course directors have been strongly encouraged to integrate course and competency content fully into the curriculum. During the 2001-02 academic year, the clinical component of the Curriculum Council restructured the third and fourth years of the curriculum into three 16-week blocks charged to integrate clinical experiences/material. The three groupings include medicine/neurology/psychiatry, family medicine/pediatrics, and surgery/obstetrics and gynecology/surgical subspecialties. There are two intersession days between the blocks dedicated to integrating content and competency-based material assigned to each of the disciplines represented in the block. Additionally, the Clinical Skills Education Center has begun coordinating an unannounced standardized patient (USP) program, whereby standardized patients visit real clinics and are trained to evaluate USP-student interaction. Geriatric patients are used in unannounced standardized patient visits to clinics. The changes in the IUSM curriculum, including block scheduling in the third year, the formation of the Clinical Skills Education Center, and the adoption of competencies, provided multiple opportunities for incorporating geriatrics topics into the curriculum. Theme for the Geriatrics Program Integrating the geriatrics curriculum across years of medical school training Integrating geriatrics across disciplines, including a variety of specialties and subspecialties (e.g., gynecology or psychiatry) Defining a minimum competency in geriatrics for medical students Learning Outcomes for the Geriatrics Curriculum The Curriculum Council reviewed the objectives and learning outcomes for the project in 2001. The council includes clerkship directors and the deans of medical education and curricular affairs. The Curriculum Council decided on the minimum standard that medical students must achieve after Web-based geriatrics training. Students are required to meet that standard to successfully pass the clerkships where the Web modules have been inserted. Standardized patients evaluate second-year medical students in required sessions where the students perform histories and physical examinations on the SPs. Objective structured clinical examinations (OSCEs) are conducted at the end of the second and third years. A geriatrics case has been inserted into these OSCEs. Students are required to pass the OSCEs prior to graduation. The Geriatrics Education Committee meets monthly and as part of its agenda discusses outcomes from the project for quality improvement. Special Programs Geriatric standardized patients/simulations Standardized patients are used for both training and evaluative purposes. During their Introduction to Clinical Medicine course, second-year medical students perform a history and physical examination on an SP for training purposes. Prior to this interaction a small-group preceptor reviews with the group of 15 to 20 students the physiology of aging and how that differs from the pathology of disease and modifications in the history and physical examination that are needed for older adults. Students then interview their older adult SP in groups of two, complete a written assessment of the patient, and receive feedback from the SP on the interaction. After the history and physical examination, students discuss their findings with the preceptor and the remaining students in the small group. Preceptors encourage students to discuss what occurred that they expected during the interview and what occurred that was a surprise. At the end of their second year, all medical students are required to pass an OSCE. One case on this examination is a geriatrics case and tests students on their ability to manage an older adult patient who has dementia. We have also introduced SPs into a junior student teaching clinic without the students’ knowledge that the SP was not a “real” patient. The teaching clinics are low in their volume of patients and are precepted by clinician educators. Students are unaware that the SPs whom they see in these clinics are actors. These unannounced SPs provide opportunity to assess students’ geriatrics knowledge and skills as well as attitudes, professionalism, and communication. Student interest group The Indiana Geriatrics Student Interest Group participates in patient education activities such as health fairs, local fundraisers for Alzheimer's disease, and service medicine projects for older adults. Faculty advisors help the Geriatrics Interest Group Student Advisory Board organize student education activities that promote the importance of all students learning fundamentals in geriatrics medicine. One example of such an activity is a panel discussion with older adults to which the entire student body is invited and lunch is provided. The panel consists of well older adults who describe for the students their experiences with geriatricians versus other primary care providers. Resulting Pedagogical Changes Major pedagogical changes include small-group sessions where geriatrics cases and topics are discussed, the use of SPs, and integration of Web-based modules in clinical years. SPs are used in clinical venues and in the Clinical Assessment Center for training and assessment purposes, respectively. Application of Computer Technology A Web-based pharmacology module was created for second-year medical students. The module related the basic science of pharmacology (e.g., calculating creatinine clearance for an older adult) to clinical application (drug prescribing and dosages in older adults, considering the reduced creatinine clearance). Students complete online pre- and posttest questions for the module. Four Web-based, interactive modules were created and implemented beginning in 2002. The modules contain knowledge content on the four topic areas (dementia, depression, urinary incontinence, and falls) and offer opportunity for skills practice through audio and video streaming. Each module takes approximately one to two hours to complete. Modules also contain pre- and posttesting that allow students to receive immediate online feedback about their performance. The four Web-based modules have been integrated into third-year clerkships: dementia in internal medicine, depression in psychiatry, urinary incontinence in gynecology, and falls in family medicine. Clerkship directors receive information during each rotation on which students have completed the modules and achieved the minimum standard required on the posttest to pass the module. Small-group discussions occur with opportunity for questions after students complete the Web-based modules. Students’ Clinical Experiences in Geriatrics All third-year students since initiation of Hartford funding have a clinical experience in geriatrics. During their required inpatient rotation during the internal medicine clerkship, students attend the acute care for elders (ACE) service interdisciplinary team meeting. During the meeting, one of the students’ ward patients who is 65 or older is discussed. The student acts as a liaison between his/her ward team and the ACE team, providing additional input about the plan of the ward team and relaying the ACE team's recommendations to the ward team. Students learn the roles of different members of the interdisciplinary team and learn how to optimize function in the acute care setting and reduce iatrogenic complications. Students complete an ambulatory block rotation that is one month long during their third-year internal medicine clerkship. Students receive a two-hour workshop during this rotation that covers geriatrics assessment and dementia versus delirium. Following the workshop, students are scheduled to one half-day session in the Center for Senior Health, a clinic where frail older adults receive primary, consultative, and subspecialty care. Each student is preassigned a patient in the Center for Senior Health on which the student completes a geriatrics assessment with a geriatrician attending. Additionally, students see other primary care older adult patients with the geriatrician. Students who are not scheduled to the Center for Senior Health for their clinical geriatrics experience are assigned to one half-day in the Housecalls for Seniors Programs. Students make house calls with a geriatrics fellow on patients who receive their primary care through the program. Students complete a geriatrics assessment on one of the patients seen. Senior medical students will be scheduled to make follow-up visits on the patients they performed geriatrics assessments on in the Center for Senior Health or Housecalls for Seniors programs when they were junior medical students. These visits will be coordinated during required senior rotations. The Program’s Assessment and Evaluation Instruments A psychometrician was consulted to ensure reliability of questions written for pre- and posttests included in all Web-based modules. Students must achieve a minimum standard of 80% correct on each module to “pass” that module. SPs’ evaluations of students were incorporated in both the training and testing sessions with SPs. SPs complete a written checklist assessing each student's performance and give each student verbal feedback on his/her performance that summarizes the written assessment. Students are required to pass the end-of-second-year OSCE that includes a geriatrics case on dementia. Resources Required The Clinical Skills Assessment Center is the site for all SP activities, including the training sessions for Introduction to Clinical Medicine as well as the OSCEs. The center has video cameras in all 15 examination rooms and monitors in a central location to review the student-SP interactions in real time. A coordinator schedules use of the center, recruits patients, and participates in training the patients. A full-time trainer and director of the SP program and center also participate in training. All resources for use of the center, including personnel, have been in-kind support. Personnel time, including that of the principal investigator, co-principal investigator, co-investigators, and clerical support staff, has been an in-kind resource. Support for the development and implementation by a Web expert has been an in-kind resource. Clerkship directors dedicated time to monitor students’ progress on the Web-based modules. Requirements to Sustain the Program The sustainability of the geriatrics curriculum is evidenced by the permanent integration into the competency-based curriculum at IUSM. The dean, competency directors, and clerkship directors support new programs, such as our geriatrics program, that use the competency-based curriculum. The dean and the competency course and clerkship directors are dedicated to ensuring the continued integration of geriatrics into the courses. This integration has been successful and has been deemed a model for other programs that will be integrated across disciplines. Our large geriatrics section will be used to continually upgrade the Web-based modules with the most current information. Unanticipated Outcomes After initiation of the Geriatrics Education Program for medical students, funding from the Donald W. Reynolds Foundation will allow the program to be integrated into the undergraduate curriculum statewide. Indiana University School of Medicine has eight regional campuses in addition to the Indianapolis campus, where half the students are scheduled in the preclinical years of their training and all are scheduled during their clinical training. Most of the geriatrics curriculum has been implemented at the Indianapolis campus. Funding from the Reynolds Foundation will ensure standard geriatrics education for all students not only across years of training, but also across campuses. Impact of External Funding All medical students at IUSM currently receive some training in geriatrics. Our geriatrics program is a model for other programs that plan to integrate their curriculum across disciplines. Other institutions may adopt our materials, including the Web-based modules. Institutions where there are few geriatricians may find the materials particularly helpful in educating trainings about geriatrics content. For more information, contact Glenda R. Westmoreland, MD, MPH, at 〈[email protected]〉.