Undergraduate training in geriatric medicine: getting it right

Abstract

It is perhaps inevitable that every specialty within medicine believes that its fundamental principles should be included in the core undergraduate curriculum and should be accompanied by a compulsory placement. The General Medical Council’s (GMC) policy document ‘Tomorrow’s Doctors’ [1] stresses the importance of students learning about the special problems associated with older people’s health. For example, it states that young doctors must respect age and the vulnerability of particular patient groups including older people. They also emphasise that graduates must understand human development, which includes growing old. Importantly, the document states that students must have opportunities to interact with a range of people including visiting an older person, a learning experience that is now included in many curricula. However, they are silent on the issue of whether there should be a compulsory attachment to a geriatric medicine unit, as indeed they are, about other hospital specialties. The present policy suggests that a quarter to a third of the curriculum should be based on studentselected components. The interpretation and implementation of such advice will be different in each medical school but the risk is, that at this time of demographic change, with growing numbers of older people, and with other demands on the curriculum, exposure to geriatric medicine might be overlooked and reduced. The concern that the teaching of geriatric medicine now has a reduced place in UK medical schools has been supported by the findings of a recently published survey [2]. Questionnaire responses from UK medical schools found that although geriatric medicine is taught to all students in almost all responding medical schools (21/23), it was taught as a distinct discipline in only two. This contrasts with the findings of studies undertaken twenty years ago [3, 4] when geriatric medicine was more likely to be taught as a separate subject. The 1981 survey found that geriatric medicine was formally taught separately in all but two of the thirty medical schools. The comparable figures in the 1986 follow-up survey were 25 out of the 27 medical schools. The mode of teaching then, was mainly clinical instruction (74% in 1981 and 70% in 1986) with tutorials taking up about 25%. Although placement in geriatric medicine is now less likely, some positive changes are noted. For example, geriatric medicine subjects are now more likely to be included in examinations than during the 1980s and geriatric medicine cases are being included in problem-based learning. Alongside the apparent decline in geriatric medicine content in the curriculum is a decline in the number of medical schools with separate departments or divisions of Geriatric Medicine. At the time of writing, at least seven medical schools in England which previously had academic departments no longer have professorial appointments in the subject. The effects of the reduction in academic support on the research agenda has been commented upon by the House of Lords Select Committee on Science and Technology [5, 6] and the effects of this loss on training is equally worrying. The presence of a professor within the discipline is likely to result in that subject having a greater share of the curriculum as was highlighted by the previous survey [3]. These issues pertaining to the teaching of geriatric medicine are not confined to the UK. In the USA there is no national medical curriculum and the inclusion of geriatric medicine placements is optional, although geriatric medicine is to some extent included in most curricula [7]. One recent publication has identified geriatric medicine education there as having the ‘largest education gap in any field’ in terms of the number of educators available [8]. The American Geriatrics Society has promulgated suggested core competencies in geriatric medicine that should be included in the training of all doctors at the undergraduate level [9]. A WHO survey of geriatric medicine teaching [10] found that of countries that had national regulations governing the overall curricula, only 41% mentioned geriatrics in the regulations in some way. It was reported that of these, only half had mandatory geriatric medicine training and that 27% of the 161 schools participating in the survey had no training in geriatric medicine at all.