Texas Tech University Health Sciences Center School of Medicine.

Abstract

Overview of the Geriatrics Curriculum The geriatrics program, “Healthy Aging in the Southwest: The Challenges of Rural Space and Ethnic Variability,” launched a new era in geriatrics education at the Texas Tech University School of Medicine at Texas Tech University Health Sciences Center (TTUHSC). A series of 12 case modules and multiple special educational activities deepened student understanding of aging and broadened faculty experience with small-group learning and curriculum evaluation. Through teaching activities funded by the John A. Hartford Foundation and the Association of American Medical Colleges (AAMC) grant, basic scientists and clinicians at TTUHSC engaged in a series of dialogues on how to integrate the science and care of the aging more effectively into the curriculum. Curriculum Management and Governance Structure The TTUHSC is headed by the dean, who oversees five associate deans who are responsible for curriculum, student affairs, admissions, faculty development, and finance. At the time of the AAMC/Hartford grant in 2000–02, the associate dean for educational programs was responsible for curriculum management and incorporation of the geriatrics curriculum into the undergraduate program of study. The position of associate dean for curriculum was established in April 2003. The person appointed to that position also served as principal investigator on the TTUHSC AAMC/Hartford geriatrics initiative and was appointed executive director of the TTUHSC Institute for Healthy Aging in May 2002 (discussed below). TTUHSC spans four campuses and 108 counties of West Texas, an area larger than all of New England. Students in the School of Medicine complete their first two years of basic science coursework on the Lubbock campus. During their final two years of clerkship and clinical experiences, students are divided among campuses in Lubbock, Amarillo, and El Paso. The educational policy committee (EPC), a combined faculty and student committee that spans all campuses and disciplines, is responsible for establishing educational policy and providing oversight of the educational programs of the School of Medicine, including curricular initiatives and changes. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Historically, geriatrics education in the School of Medicine was distributed piecemeal among various courses and clerkships, with no unifying vision or structure. One goal of the AAMC/Hartford initiative was to provide such a structure and identify a cadre of faculty champions for geriatrics education. Over the course of the two-year project, the grant team, composed of faculty members from basic sciences and clinical departments (principally internal medicine, family medicine, neuropsychiatry, and obstetrics/gynecology), met weekly and later monthly to administer program activities. Interested students also attended these meetings, and they were instrumental in providing effective communication to their peers about curricular changes and program activities. Guided by the associate dean for educational programs, the grant team chose the strategy of incorporating the geriatrics curriculum into existing courses and clerkships for which team members had responsibility and oversight. Programs related to aging have now been centralized under the TTUHSC Institute for Healthy Aging (IHA). The IHA's board of directors includes the deans of each of the four TTUHSC schools (Allied Health, Medicine, Nursing, and Pharmacy) and is chaired by the vice president for policy planning and federal relations. AAMC/Hartford activities have been strongly integrated into IHA programs. The principal investigator of the AAMC/Hartford program was named executive director of the IHA in May 2002. Institutional Involvement in Curricular Change In the past four years, there has been remarkable growth in aging programs, one of five strategic priorities for the 21st century across the entire TTUHSC. During this period, the Administration on Aging (AoA), part of the U.S. Department of Health and Human Services, awarded $3 million to TTUHSC; this has funded a major grants program supporting 21 grant projects in clinical care and research, an interdisciplinary educational program spanning our four schools, and a core administrative staff in aging issues. The project coincided with the appointment of a new dean of the School of Medicine, and with that school's successful accreditation review by the Liaison Committee on Medical Education (LCME). The new dean was previously chair of the Department of Family and Community Medicine and is a certified geriatrician. He has played an active in the AAMC/Hartford initiative, and has been highly supportive of all project activities. Also supportive was the TTUHSC president, who has since been appointed Chancellor of the Texas Tech University System. Using the Dean's Teaching Scholars in Geriatrics Program as a model, he appointed four Presidential Scholars in Geriatrics, one from each school, to take advantage of institution-wide efforts and enthusiasm for geriatrics education, outreach and research. The AAMC/Hartford project evaluator was appointed as director of the presidential scholars program. Funding provided by the AAMC/Hartford Foundation also coincided with the construction of a unique teaching nursing home on the TTUHSC campus, which opened in the fall of 2002. The Mildred and Shirley Garrison Geriatric Education and Care Center is a 120-bed, state-of-the-art facility managed by the Sears Methodist Retirement Systems, a long-standing senior care corporation with facilities throughout West Texas. Due in part to its student and resident teaching activities, the Garrison center has just received the 2003 Innovation of the Year award from the American Association of Homes and Services for the Aging. During the LCME review, the geriatrics curriculum provided a model for curricular change and comprehensive evaluation. Following the review, in an effort to implement LCME recommendations, the EPC appointed an ad hoc committee to establish institutional goals and objectives for the School of Medicine. The subgroup appointed to write the goals and objectives document consisted of members of the AAMC/Hartford team, in recognition of their experience in marshalling successful curricular change within the School of Medicine. Overall, the curricular change fostered by the AAMC/Hartford project had a dramatic and positive effect on change in the undergraduate curriculum by creating new teaching alliances between basic and clinical faculty members and students and by demonstrating the value of objective evaluation data in the continuous improvement of key curricular initiatives. The project also greatly increased the number of non-didactic teaching hours in the curriculum and gave faculty members first-hand experience with modified problem-based learning (PBL) small-group teaching methods. Very few obstacles were encountered. The grant team found faculty members to be very receptive to teaching the case modules—the associate deans for educational programs, for faculty development, and for research all volunteered spontaneously to be small-group facilitators. Evaluation documented that first- and second- year students had positive responses to the case modules and special activities—their suggestions were incorporated into case redesign in the second year of the project. Themes for the Geriatrics Program Special themes for the program were identified for each year of the medical curriculum: First Year—Positive Aging: The Goal of the Life Cycle Second Year—Aging: Rural and Cultural Variations in Health and Disease Third Year—Geriatric Care: Functional Assessment and Ethics Fourth Year—Geriatric Care: The Challenges of Rural Geriatrics Learning Outcomes for the Geriatrics Program The Texas Tech geriatrics program, entitled Healthy Aging in the Southwest: The Challenges of Rural Space and Ethnic Variability, had four educational goals: To develop 12 case modules integrating the science of aging with clinical care To improve and measure core skills in geriatrics care, including interviewing, physical examination, and functional assessment of both healthy and ill elderly To highlight three priorities in the geriatrics curriculum: cultural competence; rural health-care needs; and ethical issues arising from cultural disparities, language barriers, and problems of access to care over long distances To establish and measure positive student attitudes toward healthy and successful aging The 12 case modules constitute an integrated core curriculum in geriatrics across all four years and were introduced simultaneously in each of the four years at the outset of the grant period in July 2000. The geriatrics curriculum and the courses that included each of the modules are displayed in grid form in Table 1. Specific learning objectives for each case module promoted student-centered learning of the fundamental knowledge and assessment skills related to history taking and physical examinations of patients in each case module. (For case module topics, see the section on pedagogical changes below.)TABLE 1: Texas Tech Geriatrics Curriculum and Educational ActivitiesFunctional assessment was directly addressed in both the internal medicine and family medicine clerkship rotations, which include nursing home visits, and it has been further amplified as a teaching goal in the Garrison Center, the new teaching nursing home at TTUHSC. In addition, the project included three project objectives: To link project administration to the administrative structure of the Institute for Healthy Aging To align selected faculty members known to be talented and innovative teachers with this curricular change process through a new program of Dean’s Teaching Scholars in geriatrics To integrate geriatrics into current courses and rotations using integrated teaching teams of basic science and clinical faculty; a workshop on teaching geriatrics; and ongoing curriculum feedback, evaluation, and remodeling To enlist faculty support for the new curricular initiative and enhance the profile of geriatrics, the grant team launched the Dean's Teaching Scholar Program to recognize and reward faculty participation. The dean of the School of Medicine was highly supportive and earmarked matching funds for six Dean's Teaching Scholars in both 2000–01 and 2001–02. Each scholar was awarded a $6,000 stipend and asked to conduct a series of educational activities in geriatrics. All of the scholars served as small-group leaders for the three second-year case modules (six sessions total) and gained valuable experience in small-group teaching in a previously lecture-based curriculum. After grant Year I, a need to improve the skills of small-group facilitators became apparent, and many of the scholars participated in three special workshops brought to TTUHSC for this purpose. Most of the scholars made a presentation in geriatrics in an educational forum, ranging from grand rounds to a course or clerkship teaching exercise. This raised interest in geriatrics throughout TTUHSC. Special Programs MSI Healthy Ager Project Special educational activities were built into each year of the medical curriculum to reinforce the geriatrics “theme” for that year. The most ambitious of the special programs implemented was the first-year Healthy Ager Project. Pairs of students were matched with older members of the community who had been identified and recommended by community contacts. Healthy Agers were defined as persons over age 60 who continued to be “able to give to others.” The grant team made special efforts to ensure that the healthy ager group was representative of Lubbock community's ethnic and cultural composition. For their interviews, students used a suggested list of questions to elicit a healthy ager's life history, thoughts on aging, and advice to young physicians. As part of their orientation, students observed a sample interview and role play before the interview. After the interview, each student wrote a paper of three to five pages about his or her experience and participated in a small-group debriefing. A group of grant team members conducted extensive review and evaluation of the healthy ager project, including an intensive review of student papers. Using a review instrument specially developed for this project, team members closely reviewed all papers to determine trends in healthy aging in West Texas (the agers’ key life events and values, evidence of generativity, and ego integrity) and revelations about the students and their views of aging and providing health care to the elderly. Preliminary findings from this project have been presented locally, at combined internal medicine/family medicine grand rounds, and also nationally at the AAMC annual meeting, and at meetings of the Society of Teachers of Family Medicine. Rural-physician roundtables For second-year students, these roundtables were presented during lunch-hour sessions and were attended by over 80 students each year. Students highly rated these opportunities to hear practicing physicians from small West Texas communities discuss the challenges and rewards of providing care to their elderly patients. Resulting Pedagogical Changes Using sources in the literature, including guidelines from the American Geriatrics Society, faculty members constructed 12 case modules that would engender the student knowledge, skills, attitudes, and behaviors needed for sensitive and informed geriatric care in our graduates. Module topics included: First Year—healthy aging, demographics and economics, nutrition (Foundations of Medical Practice) Second Year—breast mass, weight loss and colon cancer, and prostate conditions (Introduction to Clinical Medicine), correlating with pathology and also making use of the Cancer Teaching and Curriculum Enhancement in Undergraduate Education (CATCHUM) templates developed by a consortium of Texas medical schools). Third-Year Clerkships—prostate cancer and death and dying (psychiatry); hypertension, stroke, and incontinence (internal medicine); functional assessment and falls (family medicine); and osteoporosis, hormone replacement therapy, and sexuality (obstetrics-gynecology) Fourth-Year Clerkship—dementia and depression, and pneumonia and delirium (neuropsychiatry). Using modified PBL, the format for the case modules consisted of a one-hour small-group session where students reviewed a case and identified focused questions relating to geriatric issues, aided by the faculty facilitator; this was followed by a 60–90 minute session two weeks later, where each student presented a five-minute answer to his or her question. The geriatrics PBL cases were introduced on the Lubbock campus during the first grant year, then expanded to campuses in Amarillo and El Paso in the second year. As a result of the AAMC/Hartford initiative, geriatrics has become synonymous with curriculum innovation at TTUHSC. Realizing that small-group learning based on PBL is time-intensive and requires significant faculty development, a subset of faculty members from the grant has pursued team learning as an exciting and feasible methodology for teaching geriatrics in small groups. The demonstration effect of the grant has expanded small-group teaching from one course and one clerkship in 1999–2002 to five courses and five clerkships currently. Application of Computer Technology Responding to strong faculty interest in using computer technologies not just for teaching geriatrics but for enriching the entire curriculum, the curriculum office hired the School of Medicine's first director of educational technology in October 2003. The director's first mandate was to work with course and clerkship directors on standardizing educational formats across the curriculum, using WebCT. All PBL cases and many other materials are available for download from the internet at the AAMC website (services.aamc.org/geriatrics). Students’ Clinical Experiences in Geriatrics In May 2001 and May 2002, a total of 13 fourth-year students participated in the pilot geriatric home visit. Evaluation of the students by standardized patients reflected the students’ thoroughness, excellent verbal skills, and ability to express genuine concern for patient problems. Some of the students felt uncomfortable being videotaped, but the experience allowed them to apply their knowledge of “real-life” geriatrics problems. The curricular materials that were tested were well received for this experience. The videotapes revealed that further training in functional assessment in the home is needed. The first and second years of the geriatrics curriculum focus primarily on attitude change, cognitive learning about aging, and case-based problem solving. Functional skills are addressed in the third-year cases for the internal medicine and family medicine clerkships and in the fourth-year pilot geriatrics home visit. Third- and fourth-year students currently make nursing home rounds on all three campuses and see geriatrics care in practice on all their clinical rotations. Reflecting strong student interest in more training in geriatrics, the EPC has approved a required two-week geriatric neuropsychiatry block in the fourth-year neuropsychiatry rotation and an additional two-week block in clinical geriatrics. Family medicine is developing a proposal to introduce the required two-week clinical geriatrics block on all campuses in the third or fourth year. This “required geriatrics experience” will be implemented in July 2004. In addition, the IHA and members of the grant team developed an interdisciplinary experience at the Garrison Center for students from all four TTUHSC schools, beginning in fall 2002. The Garrison Center in Lubbock, the Sears-Methodist nursing home system in Amarillo, and community clinics and hospice program of El Paso continue to be excellent sites providing clinical geriatrics experiences for students. The Program’s Assessment and Evaluation Instruments Evaluation and assessment were major emphases of the project from its first day. In addition to focus groups, the grant team designed a series of new assessment tools to provide comprehensive evaluation of the geriatrics curriculum. These include: Surveys of student knowledge and attitudes Instruments to qualitatively evaluate life history papers and elicit student and healthy-ager feedback Instruments to evaluate case modules Instruments to evaluate special educational activities A standardized geriatric home visit piloted with fourth-year students All evaluation instruments gather basic demographic data, including the respondent's gender, ethnicity, and age of his or her oldest living parent and grandparent. These demographic variables help determine differences or trends in responses to evaluative questions. Based on research by Miller and Dodder and by Reuben et al., the project team developed a 49-item survey tool that first gathers demographic information about respondents’ personal and education experience with the elderly, then queries their basic knowledge about aging and their opinions and priorities regarding the elderly. (See: Miller RB, Dodder RA. A revision of Palmore's Facts on Aging Quiz. Gerontologist. 1980;20:63–79; Reuben RB, et al. Development and validation of a geriatrics attitude scale for primary care residents. J Am Geriatr Soc. 1998;46:1425–30.) The 24 questions for the knowledge portion came from the Miller and Dodder article (with some minor updates), and the 14-item attitude portion was sent to us by Drs. Rueben and Lee at the University of California, Los Angeles, David Geffen School of Medicine at UCLA. The knowledge and attitude survey instrument provides a somewhat “soft” measure of students’ substantive knowledge about the elderly; nevertheless, the Miller and Dodder and Palmore instruments were widely used and well validated, and the Miller and Dodder version allowed us to administer an instrument within weeks of notification that the grant had been received; thus, activities could begin in the summer of 2000. Among the results: Most students reported having visited an elderly person residing in a long-term care facility or having worked with the elderly in job, volunteer, or community activities. Slightly fewer students in 2001 (77% versus 81%) reported having visited a resident of a long-term care facility, however. Few students in either year (about 14%) had taken a course that dealt primarily with older people or aging issues. In 2000, both first- and third-year students, as a group, scored about 69% on the knowledge portion of the instrument, with the first-year students scoring slightly higher (69.2% compared to 68.5%). In 2001, third-year students’ scores rose to 70%, but first-year students’ scores fell to 66%. Students in both years tended to overestimate both the number of elderly persons in long-term care institutions and the size of the population over 65. From their own youthful vantage point (88% to 92% are younger than 30), students tended to see the elderly as unhappy, lonely, poor, and increasingly religious, none of which is borne out by the facts. Both groups scored highest on questions that attempt to stereotype the elderly excessively. For example, students overwhelmingly recognized as false statements suggesting that older people are senile or have no capacity for sexual relations. Both first- and third-year students demonstrated positive attitudes toward the elderly, with the former group somewhat higher than the latter on an overall attitude scale. The overall attitude rating in 2000 was 2.72 (2.83 for first-year students); the similar rating in 2001 was 2.73 (2.76 for first-year students). In both years, students showed personal interest in being with older persons and listening to their experiences. However, students seemed to doubt that physicians pay more attention to their elderly patients than to their younger ones. With some variation to account for teaching or course-structure differences, all case module evaluation instruments asked for assessment of both process (e.g., the ability of students and facilitator to identify and discuss focused questions, the availability of resources, and so on) and content (e.g., integration of basic sciences, ethics, and clinical management of the elderly, and so on). All evaluation instruments asked for an overall evaluation of the experience. A five-point Likert scale provided continuity among questions and instruments. In general, students rated the case module experience highly. They liked the small-group format and the ownership of their own learning that the PBL method invoked. Case module evaluations consistently revealed the difficulty of incorporating ethics into the teaching experience and integrating the clinical and basic sciences. Moreover, in the second-year cases especially, evaluation results varied widely by group, demonstrating the importance of facilitator training and the students’ enthusiasm for the process. As a direct outgrowth of the geriatrics program, several faculty members have embarked on a formal comparison of team learning and PBL for teaching the three geriatrics case modules in the second year. Initial data from grant team faculty members were instrumental in launching a new online student evaluation system for all courses and clerkships beginning in 2001. Faculty interest in new teaching methodologies and better curriculum evaluation has also generated a new monthly medical education seminar series linked by satellite to all four campuses. Resources Required Clearly, support from the AAMC/Hartford Foundation provided the most essential resource to launch curricular change in geriatrics at TTUHSC. As important as the financial support was the energy and creative momentum for change it fostered. Although the total amount of funding from the AAMC/Hartford grant was modest (supporting only a small percentage of effort for two faculty members, 0.5 full-time equivalent of a staff member, and materials for evaluation and special programs), Texas Tech was able to launch a wholesale curricular initiative across all three School of Medicine campuses and all four years of the curriculum. As described above, AoA funding, coming to TTUHSC simultaneously with the AAMC/Hartford grant, allowed us to leverage the project funding and provide complementary efforts. AoA funds were available to each TTUHSC school to use for curriculum development in geriatrics; the School of Medicine chose to use its share to fund the Dean's Teaching Scholars program, the development of which was a project objective of the AAMC/Hartford curricular effort. Also key to the success of curricular change at TTUHSC and especially the School of Medicine was an institution-wide recognition—with full administrative encouragement—of the importance of preparing health care professionals to care for an aging population. It is unlikely that the curriculum could have been launched without such support from the institution's president, deans, department chairs, and faculty members. Requirements to Sustain the Program Responding to aging as a top priority, the dean, associate deans, and regional deans continue to provide support and resources to facilitate proposals for external funding for programs in geriatrics. The AAMC/Hartford award has demonstrated to senior leadership that new resources are needed for further innovation and faculty involvement in geriatrics. Grant team members and faculty from the Schools of Nursing, Pharmacy, and Allied Health have been active in developing the educational programs of the IHA, including new interdisciplinary educational experiences for students at the Garrison Center. Further AoA funding has supported an internal grants program in aging; funded faculty members have participated in a number of student educational activities related to the science of aging. Two of the grant team members were instrumental in obtaining a successful HRSA award in the Residency Training in Primary Care Program, effective July 2003. This funding will help to develop a combined longitudinal geriatrics training curriculum for family practice and internal medicine residents. The curriculum includes six training modules: Aging and Culture Core Skills in Aging Distance Health Care Special Needs in Aging Science of Aging Exploring Aging In addition, grant team members supported the establishment of a new geriatrics fellowship in Amarillo beginning in July 2004. This fellowship will provide a much-needed stream of trained geriatricians to strengthen geriatrics training and patient care in the West Texas area. The School of Medicine regional dean has raised over $500,000 to develop geriatrics in Amarillo. In Lubbock, the vice president for health policy, the dean, and the chair of neuropsychiatry have raised a similar amount to recruit top faculty people to leadership positions in the IHA. Unanticipated Outcomes Students’ positive reaction to increasing exposure to geriatrics has been an unanticipated outcome of the AAMC/Hartford project. Grant team members were surprised to hear students at the EPC meetings push for more training. Students who attended meetings of the grant team did so willingly, providing their suggestions for speakers at physicians’ roundtable sessions, giving feedback from course and clerkship activities, and volunteering to participate in the fourth-year OSCE experience. As outlined above, students’ overall evaluation of curricular initiatives was positive as well, although some students expressed resentment toward activities they perceived to be added to their requirements by mandate of a funded project. Thus, in the first project year, all references to the grant were omitted from evaluation and other materials distributed to students. Faculty resistance to curricular change and to adding content and activities to an already full curriculum was projected as a barrier to success at the time AAMC/Hartford funding was sought. Thus, a pleasant surprise was faculty receptiveness to the new activities—their willingness to try new pedagogical techniques, to look for logical places to integrate geriatrics into their ongoing courses and clerkships, to serve as small-group facilitators, and to attend countless planning and evaluation meetings. The magnitude of the spinoffs from the project has also been a welcome but surprising result. As outlined above, integrating geriatrics into the curriculum has served as a model for interdisciplinary collaboration, curricular change, and continuous evaluation. The model has prompted integration of other broad-based issues such as nutrition, complementary and alternative medicine, and substance abuse. Successful completion of the AAMC/Hartford project certainly enhanced the institution's ability to compete for additional external funding. Using the motto “Texas Tech Goes Geriatric,” the project has generated presentations at local, state, and national meetings, with additional publications projected in the coming months. Impact of External Funding In 2000, aging was identified as one of five strategic priority areas for the four TTUHSC schools. Since then, the institution has experienced a tremendous synergy of activity in aging that has both reinforced, and been reinforced by, our new undergraduate geriatrics curriculum: a reorganization of the IHA, continued funding for research and clinical programs from the AoA, the opening of the Garrison Center, and strong support from the all administrative levels in the School of Medicine. These activities have sparked a strong interest in pursuing funding for a deeper and more comprehensive geriatrics curriculum at the School of Medicine that would embrace a formal seniors/mentor program and stronger community partnerships through a student geriatrics interest group and the area agencies on aging. The grant team has participated in two Reynolds Foundation and two Health Research Services Administration submissions related to geriatrics education and training, as well as a series of proposals for internal grant funding related to team learning and geriatrics. The grant team would like to strengthen training linked to actual outcome measures of healthy aging, deepen teaching about ethics, and develop new rotations in geriatrics that include rural and multicultural care. The associate dean for faculty development continues to sponsor workshops to enhance teaching in geriatrics, and grant team members recently participated in the second-most highly attended continuing medical education symposium at TTUHSC, “Ages and Stages: The Challenges of Healthy Aging,” featuring Dr. Thomas Perls from Boston University. Faculty members in both Lubbock (in critical care) and Amarillo (in psychiatry) are currently developing a curriculum on palliative care and end-of-life care. The impact of external funding on geriatrics at Texas Tech cannot be underestimated. The AAMC/ Hartford grant has brought a new era in teaching and learning about geriatrics to TTUHSC. It has allowed the School of Medicine to revolutionize student learning about aging through an innovative and varied geriatrics curriculum. This curriculum seeks to change student attitudes about aging in the lifecycle and ensure that these future physicians will leave our school prepared for the realities of caring for their elderly patients throughout their careers. For further information, contact Lynn Bickley, MD, at 〈[email protected]〉.