Jefferson Medical College of Thomas Jefferson University.

Abstract

Overview of the Geriatrics Curriculum The overall goal of the Jefferson Medical College (JMC) curriculum in gerontology and geriatrics is to provide all students with the foundation for competent, compassionate care of older adults. This foundation includes the attitudes, knowledge, and skills needed by those giving care to older people. The goal of the preclinical years is to provide a sound, comprehensive background in gerontology, including mechanisms of aging, normal aging, and recognition of the special impact of disease on older adults. The goal of the clinical years is to develop competency in physicians caring for older adults. Specific learning objectives are modeled on the Medical School Objectives Writing Group report and recommendations in “Core Competencies for the Care of Older Patients: Recommendations of the American Geriatrics Society” (Acad Med. 2000:252–55). Geriatrics content has been integrated throughout the curriculum, rather than isolated within specific courses. This serves to provide frequent exposure to geriatrics principles, limits impact on total curricular hours, and reinforces the concept that care of older adults is important within nearly every medical discipline, and for every physician practicing in this century. Curriculum Management and Governance Structure The Curriculum Committee is one of the 19 standing committees created by the bylaws of JMC. This committee includes representation from course and clerkship directors, faculty at large, and the dean's office, and also from the second-, third- and fourth-year JMC classes. Students are voting members of the committee. The dean appoints the chair of the committee. The committee is responsible for monitoring and evaluating the design, content, and conduct of the undergraduate curriculum. It may propose changes in the curriculum and will institute such changes in collaboration with the department chairs, faculty members, and administration officials. The committee evaluates the effectiveness of the student educational program in order to ensure that the educational objectives are achieved. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change Jefferson Medical College was actively involved in a comprehensive curricular redesign project that began before the Hartford funding and is ongoing. New comprehensive medical student objectives, based on the AAMC Medical Student Objectives Project, were adopted by the Curriculum Committee and served as the backdrop for a major student and faculty initiative to evaluate and redesign every aspect of the curriculum. JMC encourages faculty members seeking external funding for curriculum projects to present proposals to the Curriculum Committee for review before submission. Feedback from the committee is valuable, in particular as related to content, format, and both short- and long-term feasibility. The proposal for enhancement of the geriatrics curriculum was presented and endorsed in concept by the Curriculum Committee before it was submitted to the Association of American Medical Colleges. The content area was acknowledged to be in need of more attention, and plans for integration throughout all four years were deemed appropriate. The faculty members submitting the proposal were acknowledged to have the credentials and abilities to develop and implement the content. The ongoing curricular change has been largely an opportunity to incorporate enhanced geriatrics training throughout the curriculum. The faculty has generally been open to reassessing content and priorities within and between courses, and we now have a better understanding of what content is actually being covered than we did before the update. A major aspect of curricular reform has been the substantial expansion of problem-based learning, case-based learning, simulated patients, and other nontraditional educational offerings. Thus, it has been possible to incorporate specific geriatrics content throughout the curriculum. The challenge has been to ensure appropriate coverage of geriatrics and gerontologic didactic content at a time when the faculty has recognized the need to substantively reduce lecture hours and total contact hours in the first two years. This has resulted in a need to negotiate for time within courses, and to evaluate content carefully before incorporating it into the curriculum. Theme for the Geriatrics Program The guiding principle for Jefferson's geriatrics program is that all practicing physicians must have a fundamental set of attitudes, knowledge, and skills that will enable them to provide excellent care to older adult patients. These attitudes, knowledge, and skills cut across disciplines and should not be restricted to specialized care provided by geriatricians. Therefore, we have explicitly avoided developing a separate geriatrics course, opting instead to provide gerontologic and geriatrics content throughout the curriculum. Case examples are often structured to compare the management of similar issues across the lifespan. We also recognize the impact of ageism and negative stereotypes of geriatrics on our students’ attitudes toward geriatric care. For this reason, we have chosen to highlight healthy, successful aging, especially in our first- year curriculum. Finally, most clinical education occurs in relatively uncontrolled settings, taught by attending physicians with highly varied expertise in geriatrics, and by resident physicians who might have limited perspectives on the overall care of the older adult. Therefore, an emerging theme for our geriatrics program is to deliver high-quality education around targeted issues, which will raise the general level of knowledge of all our clinical teachers. Learning Outcomes for the Geriatrics Curriculum We have paid attention to developing a more precise knowledge of the geriatrics content included in existing courses. We have formulated priorities and strategies for geriatrics content areas, and those needing additional or ongoing attention. Substantive new geriatrics content is now in place throughout the curriculum. Because this content is largely embedded within the overall course structure, it is likely to be highly sustainable beyond external grant funding. The geriatrician charged with oversight of this curriculum has developed relationships with the course coordinators and an intimate knowledge of the curriculum review process. She is well placed to maintain gains already achieved, as well as to improve the geriatrics curriculum continually. A longitudinal mechanism for tracking outcomes of the geriatrics curriculum, the UCLA Test of Geriatric Attitudes and Knowledge, has been implemented. The geriatrics faculty will continue to work with the dean's staff and the Center for Research in Medical Education and Health Care to monitor changes in this instrument, as well as graduation survey data and potential items in the longitudinal survey of Jefferson graduates. Baseline data from the UCLA attitudes and knowledge test have already been used to identify priority areas for content revision. Special Programs Senior mentor program Jefferson's senior mentor program (JeffGrandparents) is an elective offered to first-year medical students. They are paired with independent-living older adults who are members of the Philadelphia Senior Center. Students and their senior mentors meet over lunch at the senior center and are given six assignments to complete during the academic year. These include a guided life history, highlighting the changing social and technological environment of the 20th century; a medical history and medication review; a discussion of doctors and doctoring from the mentor's perspective; and a “fun” activity. In addition, the students are asked to do something to “give back” to their mentors. Students and their mentors are invited to attend educational sessions with the geriatrics student interest group throughout the year. Many pairs have developed lasting relationships, well beyond the requirements of the program. Community partnerships Jefferson enjoys a well-developed partnership with the Philadelphia Senior Center, Philadelphia's oldest and largest senior center, located several blocks from our campus. JMC's academic geriatrics program has developed a primary care practice within the center, and collaborates with center staff to provide a range of health and wellness programming to the center's 9,000 members. Jefferson's nursing and occupational therapy faculty members are active members of this partnership. Each year, we provide training to hundreds of medical and nursing students, residents, and occupational therapy students in a multidisciplinary, collaborative community setting. Jefferson has teaching collaboratives with two long-term-care facilities, including one continuing care retirement community. Students spend time during one day in these facilities while on their family medicine rotation, to gain an understanding of long-term care options for their patients and the special issues for physicians practicing in these settings. Students complete at least one session of home visits during the family medicine clerkship, to provide a background in the special challenges facing homebound elders and their family caregivers. Geriatric standardized patients/simulations An early product of the Hartford funding was the development of a geriatrics objective structured clinical examination (OSCE) for fourth-year medical students. Jefferson now has a cadre of trained geriatric standardized patients. Fourth-year students rotate through stations addressing iatrogenic illness and polypharmacy, gait and balance assessment, breaking bad news, osteoporosis, and cardiac arrhythmias. Some 30 to 40 students choose this elective annually. Faculty development programs for geriatrics curriculum During Year One of Hartford funding, JMC hosted a one-day faculty development workshop, designed both to enhance specific knowledge of geriatrics content and to improve pedagogical skills, such as delivering a lecture, the use of role playing, and conducting teaching rounds. This session was conducted by guest faculty trained at the Stanford faculty development program, and it was offered to basic science and clinical faculty from Jefferson's main campus and each of our clinical affiliates. The program was well received by attendees, and it generated enthusiasm for enhanced geriatrics content in a variety of courses on campus. Currently, a geriatrician and oncology clinical specialist nurse are finalizing an independent-study continuing medical education (CME) program on the management of pain and other symptoms in the terminally ill patient, appropriate for physicians of any discipline. This program will be distributed to resident and attending physicians and will be piloted at one of our major teaching affiliates. Feedback from this pilot will be incorporated into the program, followed by distribution to physicians at all Jefferson clinical teaching sites. This program will serve as a model for a series of geriatrics education modules designed to increase the overall knowledge of the physicians, residents, and attendings who teach Jefferson medical students. Student interest group Jefferson's geriatrics student interest group has become increasingly active over the past two years. Students are particularly interested in community service projects and in presentation of clinical topics by faculty members. In 2004 the group received formal recognition from the American Geriatrics Society. In the fall of 2003, the geriatrics student interest group delivered an innovative and exciting “Mini-Medical School” curriculum to members of the Philadelphia Senior Center. This was so well received that the program was recapped for center staff, and will be repeated at several senior housing sites in the spring of 2004. (For a detailed program description, see Appendix 1.) A total of 75 first- and second-year students attended a clinical skills session, sponsored by the geriatrics student interest group, that reviewed hypertension, stroke, and diabetes screening protocols, as well as how to administer flu shots in community settings. Palliative care and end-of-life courses The Jefferson Health System is home to both a hospice and palliative care center. The executive director of the latter, a master's-prepared nurse, works with geriatrics and family practice faculty members to deliver required didactic content on breaking bad news, advanced planning, end-of-life treatment choices, physician-assisted suicide, and terminal symptom management in both the preclinical and clinical years. Students rotate with the hospice interdisciplinary team and nursing staff during their required family medicine clerkship in the third year. Resulting Pedagogical Changes The geriatrics curriculum reflects a variety of educational methodologies: Principles of geriatrics are routinely presented as facets of case-based instruction and clinical vignettes presented throughout the preclinical curriculum. An end-of-life curriculum, including reflection papers on medical and psychosocial aspects of dying for a specific patient, didactic education around end-of-life care, and a revitalized memorial service for student cadavers, has been woven into the study of gross anatomy and dissection at the beginning of the first year. (For a detailed program description, see Appendix 2.) Specific geriatrics content has been introduced into the didactic syllabus and lecture series in pharmacology and in Foundations of Clinical Medicine during the second year. All second-year students visit the Philadelphia Senior Center to conduct blood pressure screenings and meet informally with senior center members, in order to gain an appreciation of the active social and community life of older adults. The students also become informed about community-based resources available to both healthy and frail older people. A geriatrics OSCE has been developed, making use of Jefferson's Clinical Skills Center. A new required clerkship, neurology/rehabilitation medicine, has provided an opportunity for coordinated instruction in the importance of functional assessment and functional outcomes in older adults. Clinician–scientist and basic-scientist teams have developed and delivered integrated content, notably in the fourth year. A new model of self-study CME has been developed and is being piloted at this writing. It will be distributed to any interested resident and attending physicians at Jefferson and to our clinical affiliates. Currently available in the form of a printed document, these modules are expected to be made available as Web-based, self-guided learning tools addressing key topics in geriatrics. Application of Computer Technology The Web-based CME geriatrics series described above makes use of our Intranet. Students’ Clinical Experiences in Geriatrics First-year students spend time in physicians’ offices to observe the doctor–patient relationship and to develop their own interviewing skills. Many students will see older adults during this experience. Formal geriatrics experience begins in the third year. Students are exposed to inpatient medical and surgical issues of the older adult during their internal medicine and surgical rotations. The obstetrics and gynecology curriculum includes specific exposure to issues in geriatrics, including incontinence and gynecologic cancers. Students have the option of rotating on a geriatrics psychiatry service during their psychiatry rotation. Specific geriatrics experiences in family medicine include an emphasis on health promotion in the older adult, management of chronic illness, home visits, and nursing home care. In the fourth year, students may choose a geriatrics elective. All students are exposed to principles of functional assessment and rehabilitation of the older adult during a newly redesigned, required neurology/rehabilitation medicine clerkship. Students also rotate through the surgical subspecialties, including ophthalmology, orthopedics, otolaryngology, and urology, each of which addresses common geriatric problems. The Program’s Assessment and Evaluation Instruments JMC has used the UCLA Geriatric Knowledge and Attitudes Questionnaire, as well as the AAMC Graduation Questionnaire, to track long-term global changes resulting from enhancement of the geriatrics curriculum. Jefferson has implemented an enhanced system to track patient encounters by third-year medical students, using a PDA-based tool. In 2003, 21.2% (2,671 among 12,580) of all student encounters in the core clerkships (exclusive of pediatrics) are with patients aged 65 or older. The geriatrics OSCE has been used as an instructive rather than evaluative tool. The end-of-third-year clinical skills exam, which will be implemented in spring 2004, will include geriatrics content. Resources Required Clearly, Hartford funding provided a major impetus to develop and incorporate expanded and enhanced geriatrics content throughout our curriculum. However, even with funding, success would not have been possible without a number of other existing resources. The dean and Curriculum Committee expressed strong support for the project, both in concept and in detail, over the past two years. In addition, we had strong up-front buy-in and support for improved geriatrics education from a number of key faculty members who served on the planning committee for this process and were able to drive change within their courses. This was especially important in the first two years of the curriculum. Finally, a key resource has been the existence of a critical mass of geriatrics expertise and clinical opportunities within the medical school. Like many schools, we have only a small core of geriatrics faculty members, who provide educational support to a fellowship program, the family practice residency, and the medical school. The geriatrics section has been developing and maturing over the past decade; when this project began, we had already developed a wealth of clinical sites in which to provide geriatrics education. In addition, one geriatrics faculty member was well integrated into the overall curriculum reform at JMC and so was well positioned to work with key faculty members, the Curriculum Committee, and the senior associate dean of undergraduate medical education to weave geriatrics content throughout the curriculum. Requirements to Sustain the Program Ongoing decanal support for faculty time to coordinate and oversee the geriatrics curriculum will be needed. In order to stay current and relevant, this curriculum must continue to evolve within the context of ongoing review of our overall curriculum. It is imperative that we maintain the variety of geriatrics clinical and community experiences on which the clinical curriculum is built. Continued faculty development, both to reinforce the importance of geriatrics-specific content and skills and to raise the general level of faculty expertise with specific content, will be critical. Unanticipated Outcomes One unanticipated outcome has been the interest in using geriatrics faculty members and fellows to teach clinical skills and community-based medicine. This has provided an opportunity to generate enthusiasm for geriatrics among students who otherwise might not have selected such experiences. The institutional visibility and importance stemming from this funding has had a positive impact on the academic productivity of the geriatrics faculty in general. The success of the enhanced undergraduate geriatrics curriculum was an important factor leading to decanal and institutional support for the creation of a Division of Geriatrics Medicine within the Department of Family Medicine at JMC in 2003. The increased role of geriatricians in undergraduate and graduate medical education, as well as research, will continue to benefit JMC well beyond the funding period. Impact of External Funding External funding through the AAMC/Hartford program clearly provided an impetus to focus attention on our geriatrics curriculum, both in the dean's office and among course coordinators and affiliated clinical faculty. It also provided critical support for a geriatrician faculty member to focus time and effort on evaluating existing geriatrics content and prioritizing enhancement strategies. External funding also served to legitimize the importance of expanding geriatrics content, given the many competing demands on curriculum time. Little of the enhanced geriatrics curriculum that has been put in place over the past two years would exist without the impetus of this funding. Notably, in several instances (such as our geriatrics OSCE), the mandate provided by this funding allowed new educational strategies arising from our overall curriculum reform efforts to be piloted first with geriatrics content. Additional external funding (Templeton Foundation and private philanthropy) was also secured in part due to the efforts initiated by this program. For further information, contact Christine Arenson, MD, at 〈[email protected]〉. The authors thank the many faculty who have worked with us to develop and teach this course: Richard Schmidt, PhD, Emilie Passow, PhD, and in particular, the MP21 Steering Committee—Mitchell Cohen MD, Karen Glaser PhD, James Plumb MD MPH, James Youakim MD, and Edward T McCann. The authors also thank the following students for their thought-provoking comments: Peter Moffett and Todd Jones.