Ohio State University College of Medicine and Public Health.

Abstract

Overview of the Geriatrics Curriculum The overall goal of the geriatrics curriculum at the Ohio State University College of Medicine and Public Health is to ensure that all medical students participate in comprehensive, high-quality educational experiences designed to develop attitudes, skills, and knowledge necessary to support the health and health care needs of older adults. This goal is firmly based on the health model of aging and focuses on maximizing the functional ability and independence of older adults at any stage of health and wellness. Central to this model is the promotion of cognitive and physical vitality. Wherever possible, the lifespan approach is emphasized, and prevention and wellness initiatives are highlighted to minimize frailty and manage existing concerns. Our geriatrics program does not focus on training some graduates to become geriatricians; instead, the focus is to ensure that all the school's graduates can care for their older patients in the most cost-effective and responsive manner possible. The geriatrics curriculum consists of a four-year longitudinal program, From Aging to Saging … The OSU Senior Partners Program, consisting of a program of senior mentors, an online curriculum, readings and assignments, and small-and large-group didactic sessions (see Tables 1 and 2);TABLE 1: From Aging to Saging: The OSU Senior Partners Program, Years 1 and 2TABLE 2: From Aging to Saging: The OSU Senior Partners Program, Years 3 and 4a required home care curriculum; two geriatrics electives; three hospice electives; a program experience required of all fourth-year students that involves a standardized geriatric patient; and a four-year end-of-life curriculum (in progress). Curriculum Management and Governance Structure The Executive Curriculum Committee (ECC) is responsible for planning, designing, implementing, evaluating and overseeing the curriculum leading to the MD degree. Leadership and management of a coherent and coordinated curriculum are vested in the associate deans for medical education administration and for clinical education. Five academic program directors, each chairing a faculty committee, are responsible to the ECC for organizing, implementing, and monitoring their portion of the curriculum. Each academic program director sits on the ECC in addition to five at-large faculty, a basic science department chair, a clinical department chair, the academic review board chair, the associate deans for medical education administration and for clinical education, the assistant deans of academic services from each affiliated hospital, and two students. Recommendations for major curricular change are submitted by the ECC to Faculty Council for approval with the concurrence of the Council of Chairs. The Office of Medical Education was established more than 30 years ago. For many years the associate dean for medical education was responsible for educational leadership and direction of the curricular programs. More recently, two associate deans, the associate dean for student affairs and medical education administration and the associate dean for clinical education and outreach, share responsibility for the Office of Medical Education. Staff support to the academic program directors and budget support for the implementation of the curriculum are administered through this office. The geriatrics curriculum was developed by a broad-based interdisciplinary committee and then approved by the Executive Curriculum Committee. The geriatrics curriculum is now a core, required part of the medical school curriculum for all students in both the Independent Study Program and Integrated Pathway. The geriatrics curriculum is a required element for successful completion of the Physician Development Academic Program spanning Years One and Two of the curriculum. Similarly it is integrated into the pediatrics, internal medicine, ambulatory care, psychiatry/neurology, and surgery/obstetrics and gynecology third-year clerkships and is currently being implemented in the required chronic care clerkship and the DOC I (emergency medicine) rotation during the fourth year. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change A major reform effort was initiated in 1996 to redesign the clinical curriculum, to be followed by a reformulation of the basic science curriculum. The dean charged a curriculum committee to develop new learning objectives for clinical education; starting with a zero base, define core clinical learning experiences including Med I, II, III, and IV and any longitudinal experiences; and define emphasis programs in primary care and other specialties. After the final committee report was approved by the ECC, clerkship task forces were appointed to plan the details of implementation and evaluation. A year of transition and then a year of full implementation followed this process. As a result of the curricular reform, all preclinical students are enrolled in two courses throughout both preclinical years: Patient-Centered Medicine (PCM) and Physician Development (PD). PCM is taught in a small-group, case-based format and deals with a variety of topics, including ethics, professionalism, self-care, diversity, substance abuse, and a community project. PD includes doctor-patient relationship and clinical interviewing, physical exam, physical diagnosis, and a geriatrics longitudinal care experience. A newly constructed clinical skills laboratory is available to assist instruction through the use of standardized patients and simulations. The preclinical curriculum also allows students to choose between two curricular pathways for the core scientific content—Integrated (IP) and Independent Study (ISP). IP is a two-year curriculum that integrates basic and clinical sciences in organ-specific modules through large-group didactics and small-group critical thinking exercises. It was implemented in 2002 after a complete evaluation and revision of the previous curriculum. IP is also chronologically integrated with PCM and PD. ISP presents the curriculum in an independent-study format guided by written learning objectives related to readings. ISP has a 30-year history of success and is also a critical component of the Integrated Biomedical Graduate Program for MD/PhD students. Ohio State requires successful completion of the United States Medical Licensing Examination (USMLE) Step 1 to continue into the clinical portion of the curriculum. The third year consists of six- to 12-week blocks of the core clinical clerkships: internal medicine (eight weeks), pediatrics (eight weeks), psychiatry/neurology (eight weeks), surgery (six weeks), obstetrics/gynecology (six weeks), and ambulatory care (12 weeks). The ambulatory care clerkship consists of four weeks of general medicine or family practice, four weeks of ambulatory elective in a specialty of the student's choosing, and four weeks of ambulatory subspecialty surgery. All core clerkships must be taken at one of the affiliated teaching hospitals. The fourth year consists of four-week blocks of which four blocks must be selected from the Differentiation of Care (DOC) selectives, and four that must be elective choices. Three blocks are available for preparation for USMLE Step 2, residency interviews, or vacation. The DOC selectives consist of four weeks of the undifferentiated ambulatory clerkship, consisting of four weeks of family medicine, four weeks of ambulatory internal medicine, and four weeks of an ambulatory elective, one month of chronic care (hospice, physical medicine and rehabilitation, or geriatrics), one month of medical subinternship, and one month of surgical subinternship. All DOC selectives must be taken at an affiliated institution. Electives may be taken at any location, including a variety of international health experiences. Successful completion of USMLE Step 2 is required prior to graduation. The process of curricular change provided distinct opportunities for the expansion and evolution of the geriatrics curriculum. At the same time, however, this process also created certain challenges. The mindset of the college was one of change, proactive thinking, and evolution. As a result, new ideas were embraced, and although space and time in the curriculum remained at a premium, the entire curriculum was being given a second look. This environment encouraged the review and ultimate inclusion of many additional and critical topics. One cannot underestimate the impact that the dean of the College of Medicine and Public Health has had on this process. His strong vision and sense of mission have had a significant and powerful influence on education and training in geriatrics. His vision for the educational programs in the college focuses on an active partnership between the three missions of the college. Most specifically, his directive was that without new knowledge, (research) we cannot deliver high-quality patient care education; without dissemination of knowledge (education), the creation of new knowledge (research) is of little value; and without clinical service (patient care), we would not have a classroom for clinical education or a laboratory for clinical research. Our new geriatrics curriculum is a prominent example of the impact of the dean's leadership and the curricular change it embraced. Because our geriatrics programming is fully Web-based, we are able to integrate the latest model/research on aging and apply it directly to and for our students. At the same time, we are able to complete research on the program, and its impacts will be able to contribute to the latest body of knowledge. The committees were in place and meeting to review and recommend the inclusion of geriatrics subject matter. However, the timing of the curricular changes in the college created administrative and substantive challenges. Because change in the undergraduate medical curriculum was being made incrementally, the timing for the Hartford Grant was off by a year. As a result, we needed to create two different curricular initiatives, one to fit the old curriculum and one to meet the needs of the new curriculum. We are still adapting to this change. However, the extra work is a small price to pay for the opportunity to create a state-of-the-art curriculum for our students. Theme for the Geriatrics Program The geriatrics program at Ohio State has several emphases: Maximizing patients’ level of functioning and independence Using nontraditional practice sites Practicing a patient-centered approach to care Acknowledging chronic, multiple, and complex needs of frail older adults Providing care across the continuum Practicing transdisciplinary cooperation with other health professionals Promoting healthy lifestyles by practicing prevention and empowering patients and families through patient education Practicing in racially and culturally diverse settings Meeting the needs of underserved older populations Learning Outcomes for the Geriatrics Curriculum Our geriatrics learning outcomes are drawn from and tied directly to the areas of basic competency for the care of older patients outlined by the American Geriatrics Society (AGS) in the document entitled “Areas of Basic Competency for the Care of Older Patients for Medical and Osteopathic Schools,” which can be found at 〈http://www.americangeriatrics.org/positionpapers/competency.shtml〉. All of the recommended proficiencies are addressed and included as core elements of Ohio State's geriatrics program. Progress for both students and the program is assessed most specifically according to these guidelines, and both instructional strategies outlined are incorporated. The learning outcomes outlined by the AGS have become the learning outcomes for geriatrics education at Ohio State. As the curriculum was developed, each course, lecture, activity and assignment was cross-referenced with this document. The AGS learning objectives proved to be extremely useful on many levels: They provided a focus for core geriatrics faculty and staff and helped them coordinate interventions with others; helped the Executive Curriculum Committee, module and course directors, and curriculum committees fully understand the breadth of the field and the knowledge base required to meet the needs of older patients; ensured accountability at all levels; and determined standards and benchmarks for program and student evaluation. All course objectives also meet the goals and objectives of each of the preclinical and clinical course directors and faculty and have been approved by the Executive Curriculum committee and Med I and II courses and Med III and IV clerkship committees. Special Programs Seniors/Mentor Program: From Aging to Saging: The OSU Senior Partners Program All first-year medical students are assigned to a senior partner, an older adult living independently in the community in either a private residence or an organized community such as a retirement community. Seniors are functionally healthy so that students can observe the aging process over time. After an initial orientation session, students and their senior partner meet one-on-one every four to six weeks throughout the academic year continuing for the four years of medical school. Additional information can be found at 〈http://seniorpartners.osu.edu〉, Username: guest1, Password: guest1, or Username: guest2, Password: guest2. Senior partner meeting topics are coordinated with the basic science and clinical curriculum and directly relate to individual course learning objectives. Some issues central to geriatrics medicine that are addressed in all meetings include: healthy aging; the importance of the home and home health care; health care economics; cultural sensitivity; disease and disability; pain management; function and functionality; quality of life; the role of family caregivers; ethical and end-of-life issues; chronic diseases; medication management; role of religion and spirituality; and death and dying. It is expected that the level of interaction becomes more sophisticated every year in this relationship, requiring greater diagnostic and clinical knowledge. The Senior Partners Program has three major components: the senior mentor component, an online curriculum, and large- and small-group sessions. Administratively, the program is a core component of the Physician Development course during Med I and II; during Med III and IV it is fully integrated into most other required rotations and clerkships. The Senior Partners Program is administratively housed in the Office of Geriatrics and Gerontology but is a collaborative effort of all of the core departments, course directors, and educational committees. Successful completion of the Senior Partners Program is required in each module and clerkship. Failure to complete the senior partners requirements results in an incomplete or unsatisfactory grade. Additional information may be found at the Web address given earlier in this list. Specific assignments and curricular content follow. Two versions of the Senior Partners Program have been developed for Med I and II to accommodate the two curricular tracks: the Integrated Pathway and Independent Study Program. Students enrolled in joint programs (including the MD/JD program, MD/MHA program, and MD/PhD program) and those students requesting a leave of absence complete additional “maintenance” assignments while they are enrolled in other coursework. This program does not involve new curricular time; instead, all participating modules, courses, and clerkships “carved out” time for the program and its requirements. Community partnerships The Senior Partners Program works closely with multiple continuing care retirement communities where the first senior partners were recruited. Expanding our recruitment efforts, we are now working with several area senior centers, family medicine clinics, Asian and Latino medical clinics, select assisted living facilities, and various community and university organizations such as the Ohio State University Retirees Association and the Ohio State University Alumni Association. Most of the major home health care agencies and organizations (including hospital-based programs) work with us to coordinate and staff our home health care program. As part of the geriatrics fourth-year electives, students rotate through long-term care facilities, community-based physicians’ offices, hospices, case-management organizations, family-supported groups, mental health organizations, and community-based organizations such as the Alzheimer's Association and low-vision clinic. Our geriatric standardized patient evaluation simulation program (outlined below) depends heavily on older adult actors and members of semiprofessional theater troupes. Geriatric standardized patients/simulations All fourth-year medical students participate in a capstone clinical experience in which standardized patients are used to model educational and clinical learning objectives in home care and care for older adults. The standardized patients (actors from the Senior Repertory Theatre of Ohio) use scripted scenarios to represent a wide variety of geriatrics issues, showing the impact of social, financial, and spiritual issues, apart from physical health, care needs, and the living situation of the patient. Scenarios are designed to challenge students’ problem solving and measure students’ ability to use deductive reasoning in communicating with the patients. The setting for this program is an efficiency apartment in the medical center with flexible furniture placement and adaptable props. A faculty physician and the standardized patient coordinator, a registered nurse, evaluate students’ development of a treatment plan. Physicians, program staff, and the “patients” evaluate student performance and plan of care, offering immediate feedback, guidance, and additional materials for improvement if needed. The typical standardized home care experience takes approximately 1.5 hours: 15 minutes to review the medical record 25 minutes to do the “home visit” 30 minutes to write the treatment plan 20 minutes to debrief with the coordinator. In addition, students receive feedback from the actor, the written treatment plan is reviewed against a physician template, and the student offers feedback This experience differs significantly from other standardized patient programs. In addition to the focus on home and community-based care, the student must focus on the whole person and family in addition to procedures or diseases. For example, along with the medical and functional assessment, students are responsible for assessing issues such as psychosocial needs, environmental concerns, spiritual issues, sexual health, care giving needs, and financial arrangements. While ensuring the integrity of the program, we also respond to unique interests and practice plans of individual students. Each case scenario is tailored to make it more meaningful to particular students. Here are some examples: Those students who are pursuing a career in pediatrics may be doing a house call on Marion Demint. Mr. Demint is a retired farmer who is now raising his 11-year-old grandson due to family problems. He is stressed by this new role and the different perspectives he and his grandson have on the world. His grandson also is experiencing some adjustment problems. Mr. Demint is having increased chest pain with a history of previous heart attack. Medication is partially ineffective due to outdated prescriptions and his failure to get his nitroglycerin patch prescription filled. A student pursuing a career in infectious diseases may be assigned purposely to Way Geaque. Mr. Geaque is a 65-year-old closeted gay man whose life partner died six months ago. He is showing a great deal of unexpressed grief. He is isolated and depressed and lacks information about grief and loss. He is not taking his blood pressure medication and thus experiencing high blood pressure and increased risk of stroke. A budding radiologist will be challenged by Sarah Michaels. New, severe back pain after tripping at home has caused this divorcee to take to bed in an attempt to minimize pain with movement. Living alone, she is now dependent on her neighbor to bring her food and check on her. She will demand pain medication and will make the student explain why she needs further evaluation in light of her osteoporosis history. What if further radiological tests are in order? Would a mobile x-ray be effective, or should this woman be transported to an outpatient or hospital setting? This is a very labor-intensive program that requires a half-time coordinator in addition to a physician who oversees the program and remains accessible by pager during each student's session. The coordinator works very closely with the actors to ensure that the situations are realistic and medically sound. The actors are given an outline of the physical symptoms, the psychological symptoms, medications, medical histories, and family/social and financial situation that each actor studies with the coordinator. The nature of the visit requires improvisation by the actor. The coordinator plays the student role with the actor initially and asks common questions a student might ask. The actor is coached on how to respond to the questions both verbally and nonverbally. The coordinator observes the visit via a video monitor outside the room. Faculty development program for geriatrics curriculum All the offices of geriatrics medicine in the State of Ohio participate in statewide geriatrics faculty development workshops. Program topics focus on undergraduate and graduate medical education issues and innovative teaching strategies. Statewide programs are held annually in October, and regional programs supplement this initiative at least once a year. The statewide workshops are held the day before the three-day annual, statewide geriatrics medicine conference at Salt Fork State Park to maximize convenience of the participants and program planners. The workshops, which have been held annually since 1994, have promoted the sharing of syllabus material among the geriatrics faculty in the state. The programs are well attended and receive very positive evaluations. The close cooperation of the seven offices of geriatrics medicine in developing the programs is a major factor in their success. The most recent program, held October 17, 2003, was entitled “Teaching Geriatrics Where You Work: Delivering Geriatrics Education in a Variety of Clinical Settings.” Student interest groups The Geriatrics Interest Group, part of AMSA (the American Medical Student Association), seeks to promote awareness of geriatrics issues and interest in the field of geriatrics. This group recognizes the ever-growing demand for clinicians who are sensitive to the needs of older adults. Activities range from lectures to volunteer work, each with the goals of increasing interest in geriatrics and helping medical students to get early experience advocating the unique needs of older adults. The following are examples of activities this group has sponsored: Student/Older Adult Community Outreach Program: Students spend a morning at the home of an older adult in the community helping out with various household projects, to gain a better understanding of what it means to “age in place” in the community. The students and older adults then meet for lunch to share thoughts and experiences. Informational meetings: Students and program coordinators present information on research and internship/externship opportunities open to medical students. Guest speakers/panel discussions: Geriatrics clinicians are invited to come to the OSU College of Medicine and Public Health to speak on topics of interest or concern to students, older adults, and clinicians. The Geriatrics Interest Group also has the distinct honor of being the first official student chapter of the American Geriatrics Society. This, along with strong support from the Office of Geriatrics at Ohio State, ensures the Geriatrics Interest Group plays a key role in spreading awareness of key issues in geriatrics to students at the OSU College of Medicine and Public Health. Palliative care and end-of-life courses Two distinct end-of-life curricular products and programs are now central to the college's educational efforts. End-of-life care is now a prominent part of the Physician Development course in Med I and II. In fact, the first nine hours of this course in Med I are devoted to end-of-life care (two large-group and two small-group sessions). Because end-of-life care involves more than a geriatric population, the focus of this new curricular initiative is on care and caring across the lifespan. The curriculum begins by helping students reflect on their own mortality. Following this, we help them understand that death and dying are a natural part of the life course and do not represent a failing of the medical community. An end of-life module is being created as a unique feature of the Senior Partners Program. All other modules, sessions, and assignments are to be completed on a schedule that we establish. However, we chose to separate out the end-of-life module because of its unique characteristics and our desire to make this module as meaningful as possible for each and every student. Therefore, all students must complete the end-of-life module by the end of their Med IV year. Our suggestion to them is to access the information and complete the tasks when it is most useful to them and their senior partner. For example, if the senior partner dies or has a significant other who dies, the end-of-life material will have special significance for both the student and the senior partner. If it was a sudden death, the information in the sudden death portion will have extra relevance. Similarly, when the senior partner is grieving the loss of a loved one, the student will be especially interested in the grief and bereavement portion of the module. In other words, we have taken a problem-based learning approach to end-of-life care. We believe the students will get the most out of the material when it means the most to them. To ensure it is completed, pre- and posttests are being developed, and we will know when and for how long the material has been accessed by the student. Required home care curriculum: Is there a doctor in the house? All Med IV students complete a required home care curriculum that includes readings, didactic sessions, and house calls. This program is a part of the DOC 3, chronic care rotation. The goal of the program is to ensure that all students have the skills, knowledge, and positive attitude to integrate home care into their practices either by completing house calls or collaborating with others. In addition to learning about how to deliver and provide care in the home, the curriculum also focuses on critical thinking ability and clinical and interpersonal skills. Resulting Pedagogical Changes The response of the College of Medicine to the above geriatrics initiatives has been both swift and dynamic. The ability to implement new programs during a time of change is both noteworthy and gratifying. The following changes have been put in place: Each of the preclinical programs and required clinical rotations has “carved out” time and space for these new and, in some cases, reformatted curricular initiatives. This is extremely important because most College of Medicine's curricula are already quite full, and new requirements are not easily inserted by faculty and accepted by students. The “carve out” process has proved to be a key determinant of the overall success of the geriatrics programs. From Aging to Saging … The OSU Senior Partners Program is the first longitudinal, four-year course for the College of Medicine. It represents a significant departure from previous initiatives. As such, it shows the flexibility that the Ohio State governance structure both facilitates and encourages. (See Tables 1 and 2.) Geriatrics is now fully integrated into other rotations, clerkships, and courses. As a result, students do not see geriatrics as an “add-on” or something that is “done over on 9 West.” Instead, students understand that no matter what specialty they will be pursuing, the care of older patients will be a significant part of this effort. Most of the geriatrics initiatives are computer-based. As a result, responsiveness is enhanced, up-to-date information can always be inserted, and adult learning styles are respected and fully integrated. Geriatrics is now a required component of all four years of the undergraduate medical curriculum. Successful completion of the geriatrics curriculum is required before students can complete their rotation, course, current year of study, and, of course, graduate. A four-year end-of-life curriculum that is responsive to students’ concerns is being implemented. Additional preceptorship experiences are now available to students through clinical encounters with their community-based senior partner and his or her physician. Students now spend additional time in community-based settings that were not formerly central to their educational efforts. Application of Computer Technology From Aging to Saging … The OSU Senior Partners Program is an on-line course (see 〈http://seniorpartners.osu.edu〉). All course materials including learning objectives, background information, activity descriptions, assignments, and forms for downloading, and readings are online. Assignments are also submitted and graded on-line using a sophisticated grading system and progress reports developed by our in-house Webmaster. Students access course materials via individual password that helps maintain confidentiality with any patient information. Students also keep a running journal over the four years of the progra