University of California, Irvine, College of Medicine.

Abstract

Overview of the Geriatrics Curriculum The Student/Senior Partnership Program (SSPP) is the cornerstone of the geriatrics education program for medical students at the University of California at Irvine, College of Medicine. Each first-year medical student is partnered with an older adult who lives in the local community. The students are paired and each pair of students interacts with their senior partner for each module. These partnerships are designed to be maintained through the first three years of the students’ predoctoral education, with plans for elective 4th year participation. Three SSPP modules, each consisting of a preparatory didactic presentation, the student/senior encounter (at the senior partner's home), and a faculty-facilitated small-group discussion, are scheduled for each of the first three years of undergraduate medical education. They are incorporated into the times dedicated to geriatrics as a “content theme” in the required courses listed below. The scheduled student/senior interactions have both structured educational objectives and enough flexibility to make use of other learning opportunities as they arise. Topics for the first year include Healthy Aging/History Taking, Transitions, and Functional Assessment. Topics for the second year include Cardiovascular and Pulmonary Issues in Older Adults, Community Activities and Resources, and Pharmacology Issues in Geriatrics. Topics for the third year include Periodic Health Evaluations, Advance Directives, and Closing a Physician/Patient Relationship. Topics (and logistics) for the fourth year are being developed. The first class of students who participated in the Student/Senior Partnership Program began their third year of medical school in the 2003–04 academic year. The program has received enthusiastic reviews from students, seniors, and faculty. Curriculum Management and Governance Structure At the University of California, Irvine College of Medicine (UCI COM), the faculty is responsible for the curriculum. This responsibility is implemented via the faculty senate Executive Committee and the Curriculum and Educational Policy (CEP) Committee. The CEP committee in turn delegates authority to the various departments in terms of sponsoring courses and to the dean's office in terms of implementing curricular oversight activities. The dean in turn delegates authority to the senior associate dean for educational affairs, who oversees all educationally related activities. The senior associate dean has assigned an associate dean for curricular affairs to oversee medical education. The associate dean for curricular affairs chairs the Office of Curricular Affairs (OCA), which is a work group charged with the oversight/organization of medical education. It is responsible for the development, implementation, and assessment of educational programs. The OCA serves as a resource to departments, individual faculty, the CEP committee and the dean's office. Input from, and feedback to, course directors, clerkship directors, content theme coordinators, and other faculty members are organized through the OCA. When the director and faculty in the geriatrics program decided to develop a more organized predoctoral curriculum in geriatrics, they worked with the OCA to identify available time in the curriculum and opportunities to collaborate with other courses and clerkships. The project director for the AAMC/Hartford project was appointed as a member of the OCA, and the Task Force for Geriatrics Education (a subcommittee of the OCA) was created to explore and direct the development of the geriatrics curriculum. Concurrently, there was a major change in the predoctoral curriculum at UCI, and geriatrics became one of eight “content themes” with dedicated time in a number of required courses (see below). THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The UCI College of Medicine is involved in ongoing efforts to enhance predoctoral education by integrating clinical experiences throughout the four years. UCI made a dramatic change in the predoctoral curriculum shortly after we submitted our proposal to AAMC/Hartford. Eight “content themes,” not previously well addressed in the curriculum, were identified as being important to professional development and suitable for longitudinal integration throughout the medical school curriculum. These themes were geriatrics, medical ethics, spirituality, communications, medical informatics, medical humanities, behavioral science, and cultural diversity. UCI's commitment to the development of these content themes is reflected in the fact that the OCA has established protected time for each of the content themes in several required courses (listed below). The Program in Geriatrics has had an important influence in the most recent curricular changes in the College of Medicine. The project director for our AAMC/Hartford project is a member of the College of Medicine's Office of Curricular Affairs (OCA), the central organizing/oversight body for medical education. As stated earlier, geriatrics is now one of the eight content themes, whose introduction is the most recent change in the medical school curriculum. Patient, Doctor, and Society (MS I). A six-week-long course that is presented at the beginning of the students’ first year of medical school, Patient, Doctor, and Society is a multidisciplinary course that focuses on professional role development (SSPP #1). The Patient–Doctor course (MS I). Five modules that make use of standardized patients and problem-based learning to teach, practice, and evaluate communication skills, history taking, physical examination, and clinical reasoning (SSPP #3). Community “tag-alongs” (MS I and II). The medical students are required to do two “tag-alongs” with community practitioners or community service organizations in each of their first two years. Clinical experiences (MS II). The second-year students spend one half-day each week with a community physician. The educational value of these clinical experiences is enhanced through problem-based learning and small-group discussions with faculty facilitators (SSPP #5). Selectives (MS I–IV). A number of selective courses are available to students in all four years of medical school. They are primarily attended by first- and second-year students. Those related to geriatrics include Care of the Aging, Hospice and End-of-Life Care, and Diversity in Medicine Team teaching by basic science faculty and clinicians (MS I and II; SSPP #4 and 6). Evaluation strategies (MS II and III). UCI uses objective structured clinical examinations OSCE/Clinical Practice Examination (CPX) to teach and to evaluate the clinical skills of our students. Internal medicine and family medicine clerkships (MS III; SSPP #7 and #8). “Clinical Correlates” (MS I) and “Topics in Medicine” (MS II). These components of the curriculum use a small-group discussion format to integrate case presentations and clinical vignettes throughout all of the basic sciences. Patient–Doctor IV (MS IV). A course entitled Through the Patient's Eyes encourages fourth-year medical students to become reacquainted with health care from the consumers’ perspective. Five medical students are assigned to an experience in geriatrics that our faculty oversees and administers. These changes have allowed us to shift our efforts to implement a new geriatrics curriculum from minimizing disruption of an established curriculum to taking advantage of the opportunities created by a new curriculum. Before the changes, our major challenge was curriculum time—coming up with creative ways to introduce the new geriatrics curriculum while minimizing the impact on a well-established curriculum. Now, our challenge is faculty time—having enough faculty time to make use of the many new teaching opportunities. We are in the process of developing creative ways to use the faculty we have and increasing our efforts at faculty development. Theme for the Geriatrics Program The geriatrics clinical faculty identified the major content areas for our new geriatrics curriculum. We used the American Geriatrics Society (AGS) list, “Areas of Basic Competency for the Care of Older Patients for Medical and Osteopathic Schools,” as a starting point and created a much shorter list of topics we believed to be the most important for medical students. These included ethical issues, demographics, normal aging, physiological changes, preventive health/screening, dementia, medications/pharmacology, common geriatric syndromes (falls, pain, and incontinence), disability (physical, cognitive, and sensory), functional assessment, psychosocial issues, developmental issues, mental health, communication, health care finances, levels of care, community resources, community support systems, multidisciplinary teams, cultural issues, and elder abuse. We then arranged these topics into six general categories: demographics, normal aging, functional assessment (cognitive and physical), communication, care in the community, and common geriatric syndromes. We identified appropriate learning objectives in each category across the four years of the medical school curriculum and incorporated them into the SSPP. Learning Outcomes for the Geriatrics Curriculum First Year Session 1: Healthy Aging/History Taking List at least three patient/doctor communication “tips.” Identify personal goals for the students’ own healthy aging. Session 2: Transitions Discuss the role of loss and life transitions in working with older adults. Identify your own coping mechanisms and those used by your senior partner. Session 3: Functional Assessment Demonstrate the process of conducting a mini mental status exam (MMSE). Demonstrate an understanding of how to use the Tinettti Gait and Balance Exam. Second Year Session 4: Cardiovascular and Pulmonary Issues Demonstrate proper techniques for physical examination, including vital signs and orthostatic blood pressures. Discuss strategies to prevent cardiovascular and pulmonary disease in older adults. Session 5: Community Resources Recognize older adults’ needs for community resources. Increase your knowledge about community resources that maintain or improve the health of older adults. Session 6: Pharmacology Issues in Geriatrics Discuss strategies to prescribe appropriately and to avoid polypharmacy. Discuss age-associated changes in pharmokinetics and pharmacodynamics. Third Year Session 7: Preventive Health/Periodic Health Evaluations Determine what screening tests are appropriate for patients 65 and older. Research one recommendation relevant to your senior partner. Session 8: Advance Directives Determine the beliefs of your senior partner regarding aggressiveness of care. Discuss and document an advance health care decision with your senior partner. Session 9: Closing a Physician/Patient Relationship Discuss strategies to end a patient–physician relationship in a professional manner. Participate in an evaluation and improvement process of the SSPP program. Fourth Year The curriculum content and logistics are being developed. Special Programs Seniors/mentors program The Student/Senior Partnership Program (SSPP), which is described at the beginning of this article. Community partnerships Our faculty have developed strong ties with many community organizations. We are active participants in the Alzheimer's Association, the county's multidisciplinary team, the Fiduciary Abuse Specialist Team, county programs for low-income elderly (such as the Multipurpose Senior Services Program), numerous senior centers, and the county mental health program for elders (Older Adult Services). The Program in Geriatrics enjoys broad-based community support for both its clinical and its academic endeavors. Standardized patients/simulations One of the five modules in the first-year students’ Patient–Doctor Course uses a standardized patient who portrays an elderly woman with Parkinson's Disease. Our third SSPP session builds on that module, instructs the students in functional assessment, has them practice their new skills with their senior partners, and gives them the opportunity to discuss their findings in small-group discussions. UCI uses OSCE and CPX exercises and examinations to train and to evaluate our students. Several of the standardized situations address geriatric patients’ issues. We have recently developed a standardized patient simulation for dementia. There are two separate but related faculty development programs for our geriatrics curriculum. A Hartford/ADGAP (Association of Directors of Geriatric Academic Programs) grant has funded development of both. The first focuses on the geriatrics clinical faculty and stresses clinical teaching skills. The second focuses on the primary care faculty who teach our students and residents in the clinics. It addresses both geriatrics issues in primary care and clinical teaching skills. Both groups of faculty teach students in the SSPP. Student interest groups We have already succeeded in reinvigorating the student interest group. It has grown from two students in 1998 to 14 students this academic year (2003–04). We became a student chapter of AGS this year. We have planned health fairs, visits to community service organizations, and clinical experiences for this year. Palliative care and end-of-life courses In addition to our SSPP sessions (Transitions, given in the first year, and Advance Directives, given in the third year), there is a longitudinal curriculum in pain management, palliative care, and end-of-life issues. The course director is one of our geriatricians who is also board-certified in hospice and palliative medicine. The longitudinal experiences include MS I: a lecture/workshop in the PDS course (see above), a selective course in palliative care and hospice, and a pain management module in the Patient-Doctor course; MS II: a problem-based learning module on pain management; MS III: three didactic presentations and two clinical (home care) experiences that address palliative care and end-of-life issues in the internal medicine clerkship; and MS IV: PD IV, Through the Patient's Eyes, a longitudinal experience through which each participating student works with one patient who has dementia, the patient's family, and a faculty member to explore the challenges of living with dementia. The students prepare and present a seminar for their classmates and faculty at the end of the year. Resulting Pedagogical Changes Over the past five years, UCI has made a number of pedagogical changes designed to make a transition from the traditional medical school curriculum (first two years in the classroom and laboratory, last two years in clinical clerkships) to integrating relevant clinical experiences longitudinally through the first two years and exploring strategies to reintroduce didactic content in basic sciences throughout the clinical clerkships. Specific changes in the curriculum and the effect on and by the geriatrics curriculum are outlined above. Application of Computer Technology Several of our SSPP sessions incorporate computer technology as part of the preparatory didactic presentation, the home visit, and the subsequent small-group discussion: Functional Assessment (SSPP #3). MS I—The students meet in small groups for their Patient–Doctor Course, interview a standardized patient (an elderly woman with Parkinson's Disease), develop student-generated “learning issues” to explore issues raised in the evaluation of the patient, research their topics, and present them in small-group discussions the following week. Our third SSPP session (Functional Assessment) is incorporated into this PD module and expands upon many of the students’ learning issues. Community Resources (SSPP #5). MS II—The second-year students meet with their senior partners to discuss the senior's needs and interests. The students then research available community resources specific to their patients and report on them to their classmates and to the senior partners. Periodic Health Evaluations (SSPP #7). MS III—The third-year students choose one periodic health evaluation or screening test that they think is pertinent to their senior partner, research the evidence-based medicine supporting the evaluation, and then discuss their findings with the senior and in our small-group discussions. We anticipate incorporating computer-based modules for SSPP in the students’ fourth year. Topics may include communicating with patients via email, fax, phone calls, etc. The clinical use and teaching of evidence-based medicine is also part of our faculty development program. Students’ Clinical Experiences in Geriatrics The students’ experiences with geriatric medicine during their clinical clerkships vary greatly. They all have exposure to geriatric patients and their health care needs, but this has not been an organized “geriatrics curriculum.” The specific learning objectives and required competencies for each rotation are developed, implemented, and evaluated by the faculty in each department. The geriatrics components that are present are not coordinated between departments nor identified as a specific “geriatrics curriculum.” The Elective Geriatrics Block Rotation is a month-long elective, modeled after the family medicine residency block rotation in geriatrics. It has a strong community component, exposure to geriatric patients, and participation on the interdisciplinary clinical teams. This elective is becoming increasingly popular with our fourth-year students. The Program’s Assessment and Evaluation Instruments We are using the geriatrics survey instrument developed at UCLA to evaluate our students’ knowledge and attitudes before and after the project We have developed geriatrics-specific stations in the PD course (MS I), the clinical skills appraisal exam (MS II), and the CPX and OSCE exams (MS III). Resources Required A small but dedicated group of faculty has accomplished the development, implementation, and evaluation of the new geriatrics curriculum. This grant has funded a relatively small part of the total faculty time spent on this project. Another grant (Hartford/ADGAP) is funding faculty development for both the geriatrics faculty and the primary care faculty who see geriatric patients and teach our students in the clinics and in SSPP. Requirements to Sustain the Program Faculty time. We will need to find ways to support the faculty time required to maintain this project. We are exploring ways to include a larger number and wider variety of faculty—including primary care physicians and specialists who provide care for geriatric patients as well as community physicians and volunteer physicians—to help teach in the SSPP. This will require an expanded faculty development program. Incorporation into “medical education.” The SSPP is clearly identified as “geriatrics medical education,” and our Program in Geriatrics provides the faculty and the administrative and support staff to administer the program. We are struggling with the choice between maintaining this independence (and the associated control of curricular content and assurance that it will receive the attention we think it deserves) and true integration with “medical education” (with the administrative and financial support that has to offer). Unanticipated Outcomes Challenges “Transitions.” This module was originally planned for MS II but was moved to early in the MS I year because several of our senior partners experienced significant changes (including stroke, suicide) that required immediate attention, discussion, and student-faculty interaction. Third-year clinical clerkships. Our students work in pairs during SSPP in their first two years but often rotate through clinical clerkships at different times and, therefore, see their senior partners individually. Those additional home visits may be a burden to the senior partners. Resident physicians. Our students have positive experiences with older patients and see wonderful examples of physician-patient interactions through our faculty role modeling in the SSPP program. They also observe and participate in many less-than-ideal experiences through exposure to residents on a day-to-day basis. (We need residents’ education too!) The logistics of the MS IV year. The MS IV students participate in a wide variety of clerkships (at UCI and elsewhere), have competing responsibilities, and are more difficult to get together for the small-group discussions. (We are working on computer-based technology to assist with this.) Faculty time. We are exploring ways to collaborate with other faculty—community physicians, primary care physicians, and specialists who provide care for geriatric patients. The increased variety of faculty practice types and experiences will improve the program but will also require expanded faculty development efforts. Diversity. Our initial groups of senior partners have been overwhelmingly Caucasian, English-speaking, and from upper socioeconomic groups. We are actively recruiting a more diverse group of senior partners that will reflect the experiences of the elderly people in our community more accurately. Rewards Collaboration. Because this is a longitudinal curriculum, we have had the opportunity to collaborate with basic science faculty, clerkship and course directors, the directors of the other “content themes,” the medical librarian and her staff, and the distance learning institute—all fantastic resources for our program. Increased visibility. The SSPP program has increased the visibility of the geriatrics program on campus, in the medical center, and in the community. Participation in our student interest group and our elective rotations is increasing. Students call for expert advice when faced with geriatrics learning issues from other courses. Several other departments have approached us to assist them in developing geriatrics curricula for their residency programs. Senior partner recruitment. Our initial concerns that recruitment of senior citizens would be a challenge were unfounded—word has spread and we have more than enough each year. Students. The students are enthusiastic and eager to learn. We all (students, seniors, and faculty) have enjoyed watching the changes in their knowledge and skills as they progress in their education. Other funding opportunities. Our experience with this project has helped us to identify current and projected needs, opportunities to collaborate with other departments, and areas to expand and develop—all important issues in preparing for other funding opportunities. Impact of External Funding Funding from the John A. Hartford Foundation has allowed us to take advantage of the opportunity provided by the timely confluence of UCI's desire for curricular change, growth of the geriatrics program, and an enthusiastic and dedicated cadre of faculty to create a four-year longitudinal geriatrics curriculum for our medical students, gain recognition for the geriatrics program, and position us to pursue other funding opportunities. For further information contact Anne E. Musser, DO, at 〈[email protected]〉.