University of Massachusetts Medical School.

Abstract

Overview of the Geriatrics Curriculum The geriatrics curriculum at the University of Massachusetts Medical School (UMMS) is designed to enhance students’ knowledge of and commitment to caring for the elderly through a continuity-based, multidisciplinary curriculum, longitudinally integrated across all four years of medical school. The undergraduate curriculum offers 196 hours of geriatrics curricular content, with 31 of those hours being required of all medical students (see Table 1).TABLE 1: Integrated Longitudinal Curriculum in GeriatricsCurriculum Management and Governance Structure The curriculum management structure and educational program governance are tightly integrated into the organizational framework of the Hartford Grant through a variety of mechanisms (see Figure 1).FIGURE 1.: Organizational Chart 2003First and foremost, the Educational Policy Committee (EPC), which governs educational policy for the medical school, actively participated in the development and implementation of the grant, with the EPC's chair serving on the grant's executive committee and selected curriculum committee members serving on the multidisciplinary steering committee. Representation from curriculum committees was drawn from the directors of the courses and clerkships that held a major role in geriatrics teaching, such as the medicine clerkship, interclerkship program, and introductory clinical skills course. The grant was housed in the Office of Medical Education (OME) under the direction of the vice dean, who also served as grant principle investigator (PI) and Executive Committee member. This provided access to the resources housed in the OME, including standardized patients, faculty development and technology support, and research and evaluation services. The grant structure also included representation from the Department of Medicine's Geriatrics Division, with the interim division director serving as grant co-PI and member of the Executive Committee. Other institutional stakeholders in geriatrics teaching included the Graduate School of Nursing, which was also represented through membership on the steering committee. Finally, reflecting the strong base of geriatrics resources in our local community, a network of community-based geriatrics resources was integrated into the grant with representation on the multidisciplinary steering committee. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change At the time of the Hartford Grant our school was not involved in curricular change. Themes for the Geriatrics Program Normal and successful aging Evidence-driven, population-based practices Health promotion Continuity-based educational experiences Ethical dimensions in geriatrics Interdisciplinary models and community-based resources Family-centered model in geriatrics These seven themes constitute the common unifying elements for integrating the learning objectives of the American Geriatrics Society longitudinally across all four years. These themes also reinforce the educational principles that have been applied in the development and implementation of the new and/or enhanced components of the expanded geriatrics curriculum. Learning Outcomes for the Geriatrics Program The medical school graduate will be exposed to the following geriatrics content: Basic science content related to aging, focused on normal processes: Normal aging: anatomy, histology, and biochemical processes Pathology: normal and abnormal aging by organ system Pharmacology: aging-related changes and relevance to therapeutic decision making Core skills in geriatrics assessment. Geriatrics-specific communication and physical assessment skills, focused on normal and successful aging: Mental status and cognitive assessment Decision-making ability Functional assessment Mobility assessment Risk factor assessment and preventive counseling Activities of daily living (ADLs), independent living assessment Demographics and epidemiology, focusing on evidence-driven, population-based practices, including health care disparities in diverse elder populations: Cultural diversity trends as seen in elder populations Disparities in health care outcomes among elder populations Disease prevention, focusing on health promotion: Risk-factor assessment and preventive counseling Primary, secondary, and tertiary prevention in elder populations Common clinical geriatric conditions, focusing on continuity-based educational experiences relating to chronic conditions: Geriatric-specific syndromes Common conditions in geriatric populations End-of-life care focusing on the ethical dimensions in geriatrics: End-of-life-care decision making Pain management Euthanasia, assisted suicide Health care rationing and resource allocation: long-term care or medical/surgical interventions such as transplantation Health care delivery systems and financing focused on interdisciplinary models and community-based resources: Health care resources, such as community service agencies, elder home care, assisted living, and rehabilitation and extended/skilled nursing facilities Health care delivery models, such as community-based services, interdisciplinary team care management, and managed care models Federally and state funded programs and policies, such as Medicare and Medicaid Psychosocial issues in geriatrics, using a family-centered model: Elder abuse and neglect Impact of elder care and aging issues on the family Support and resources assisting elders and their families with common issues of aging Psychosocial issues in aging: sexuality, grief and bereavement, response to illness, and adaptation to environmental changes Special Programs Seniors/mentors programs As part of the Physician, Patient and Society course, all first-year medical students and their faculty small-group facilitators spend an afternoon at the local senior center learning about pharmaceutical issues facing elders in the U.S. health care system. Seniors are recruited to participate as small-group co-facilitators (“senior educators”) and provide students with real-world life experiences such as interacting with providers, accessing care, and managing rising costs associated with the purchase of insurance and medications. Based on the success of this model, there is an interest in expanding student and senior interactions into longitudinal educational experiences. Community partnerships The cornerstone of the UMMS geriatrics curriculum is our strong group of partnerships with the network of local elder service community agencies. Over the course of their training, all students will interact with elders on-site at the Worcester Senior Center as well as at one of five assisted living facilities. Additionally, students are given the option to enroll in educational experiences that are based at such diverse community agencies as Home Health and Hospice Care, Age Center of Worcester, Jewish Family Services, Elder Services Plan, and Elder Services of Worcester. Also, with clinical oversight provided by a geriatrics nurse practitioner, first- and second-year students who are members of the Geriatrics Student Interest Group volunteer their services at the local YMCA, where they conduct health screenings for hypertension, hearing loss, osteoporosis, and memory impairment. Geriatric standardized patients A “geriatrics OSCE (objective structured clinical examination)” station has been incorporated into the end of third-year assessment (EOTYA.) The EOTYA is a seven-station clinical skills assessment required for all students at the end of Year Three. The “confused elder” case involves a triadic interview with an elder patient in his seventies or eighties who presents with a deterioration in his mental status. The patient is brought to his doctor's office by his wife. Both standardized patients (SPs) are interviewed by the student examiner, who must elicit a history and perform an appropriate physical exam. Following the interview (typically 15 minutes), the SP scores the student's performance on a case-specific history content and physical exam checklist. The communication skills of the examiner are assessed according to a 24-item interview rating scale. Faculty development As part of the geriatrics interclerkship course, a two-hour faculty development session is offered to all participating faculty. The interclerkship's faculty is composed of 15 geriatrics health providers, (physicians and geriatrics nurse practitioners from the community) and 15 staff members from the assisted living sites participating in the program. Effective teaching methods for small-group facilitation are emphasized in the session. In support of the fourth-year mini-selective for “Elder Care in the Home,” a 1.5-hour faculty development session is provided to home health nurses who participate as teachers during the course. Student interest group Five students who participated in the first-year geriatrics community clerkship founded the Geriatrics Student Interest Group in 2001. The co-PI of the UMMC Hartford Grant provides faculty guidance to the group's membership of 12 core students. Creation of geriatrics community volunteer opportunities, opportunities for “shadowing” geriatric providers, establishment of an American Geriatrics Society student chapter, participation in well-elder screenings at the local YMCA, and establishment of a geriatrics lunchtime speaker series are among the activities in which the students are involved. Palliative care and end-of-life courses An elective course entitled Caring for the Seriously Ill is offered to first- and second-year medical students. During this seven-week elective students are given multiple opportunities to explore, practice, reflect on, and discuss how physicians might best promote excellence in end-of-life care. The course format is a one-hour lecture followed by faculty-facilitated small-group discussions. Students are paired with a terminally ill patient and their family throughout the course. Resulting Pedagogical Changes A number of pedagogical changes (shown in Table 1) have occurred in the geriatrics curriculum as a result of curricular initiatives spearheaded by the Hartford Grant. The Medical School has worked closely with the Graduate School of Nursing in the development and implementation of two new courses: the Geriatrics Interclerkship and the Geriatrics Miniselective. Nursing faculty participate as course directors, and nursing students are enrolled in both courses. As part of the first-year Physician, Patient and Society course, a required session is conducted off-site at the local senior center where volunteer “senior educators” co-facilitate small groups with UMMS faculty A one-day geriatrics interclerkship is now required of all third-year medical students. Didactic sessions are combined with off-site visits to area assisted living facilities where students informally interact with elders and conduct a life history and functional assessment. Faculty co-facilitate student small-group discussions with assisted living staff. A small-group case-based problem-solving exercise was introduced into the second year pharmacology course; geriatric providers and pharmacists co-facilitate students’ small-group discussions. A triadic interview with an elderly standardized patient and his wife was introduced into the assessment at the end of the third year as one of seven OSCE stations assessing students’ clinical and communication skills. Community agencies working with the elderly provided a foundation for a number of elective educational experiences, including the first-year Geriatrics Community Clerkship; health screenings of elders at the local YMCA by interested first- and second-year medical students; and a fourth-year elective concentrating on home care in which students conduct home visits to geriatrics patients with both home health nurses and physicians. A new continuity geriatrics experience was introduced in the third-year medicine clerkship. As part of this required exercise, students conduct a minimum of two visits with an elderly patient (in their home, follow-up doctor's visit, rehabilitation facility, etc) after initially caring for the patient in the acute care hospital setting. Application of Computer Technology There is a need to catalogue the geriatrics content that is taught throughout the four years of undergraduate medical education and make this information easily accessible to students and faculty. A Web site is under development that will showcase geriatrics as one of a number of longitudinal curriculum themes. These longitudinal themes are defined as critical curriculum content that is not offered through a discrete course but instead has been integrated into existing courses and/or electives. The Web site will feature resources and tools that have been developed to support geriatrics curricula such as case studies, videos of geriatrics interviews, links to community elder service agencies, upcoming special events related to seniors, learning objectives for geriatrics course content, and external related Web resources. Students’ Clinical Geriatric Experiences in Geriatrics First-year geriatrics community clerkship: Students who elect this clerkship spend one afternoon “shadowing” a geriatrician providing care to elders in a hospital-based practice, nursing home, assisted living facility, or an elder's home. Third-year medicine clerkship: All third-year medical students care for elders during this 12-week rotation. After selection of an elder patient cared for in the hospital, the students are required to spend two subsequent visits with that patient in the home, in a rehabilitation or other interim care facility, or at follow-up medical appointments. Third-year geriatrics interclerkship: All third-year medical students and participating graduate nursing students spend an afternoon at an assisted living site and conduct a life history and functional assessment during a one-on-one interview with an elder. Geriatrics clinical practitioners and assisted living staff co-facilitate small-group discussions of the students’ experiences. Fourth-year geriatrics miniselective: Medical and nursing students who elect this one-week course spend three mornings with home health nurses and one afternoon with geriatricians providing care to elders in their homes. Fourth-year geriatrics elective: Students can elect to spend one month with a geriatrician and provide care to elders in a variety of clinical settings. The Program’s Assessment and Evaluation Instruments A triadic interview with a geriatric patient and his wife was created for inclusion in the assessment at the end of the third year. This OSCE case serves as an assessment of each student's clinical and interviewing skills in the area of elder care. A written survey instrument has been developed to evaluate elder patients’ experiences and satisfaction as participants in the geriatrics interclerkship. A written survey instrument was developed to assess the experience of home health nurses as trainers of medical students and graduate-level nurses in the geriatrics mini-selective. During the medicine clerkship, students are required to submit a written assessment of their continuity experience with a geriatric patient, and this assignment will contribute to the overall assessment of students completing this clerkship. Resources Required Matching funds were received from the medical school to augment Hartford Foundation support during the two years of programming. These funds supported administrative infrastructure, including dedicated staff time and standard operating costs for the administration of the geriatrics educational program; faculty development expertise to provide training to interested practitioners and educators; special events such as the annual Geriatrics Teaching Day, Geriatrics Teachers Appreciation lunch, and Community Elder Service Agency recognition breakfast; and limited salary offset for participating geriatrics educators. To better prepare UMMS students, residents, and practicing physicians in caring for the elderly, the medical school also funded eight small educational grants designed to enhance curriculum and faculty development efforts devoted to geriatrics education. With faculty guidance, the Geriatrics Student Interest Group received a stipend from the Pfizer Foundation for students’ work conducting memory screenings at the local senior center. These funds are earmarked for future activities sponsored by the Geriatrics Student Interest Group. Non-monetary support for the development of an enhanced geriatrics educational program was extensive and included significant in-kind support from numerous groups: Partner institutions Fallon Clinic St. Vincent Hospital at Worcester Medical Center UMass Memorial Health Care Meyers Primary Care Institute Medical school departments and programs Department of Medicine Department of Family Medicine and Community Health Office of Medical Education Office of Community Programs Educational Policy Committee Community Faculty Development Center Center for Health Policy and Research Community agencies UMass Memorial Home Health and Hospice Care Fallon Elder Service Plan Age Center of Worcester Worcester Senior Center Jewish Family Services Community Health Link Elder Services of Worcester Notre Dame du Lac Assisted Living Eisenberg Assisted Living Christopher Heights Assisted Living Tatnuck Park Assisted Living Briarwood Assisted Living Shrewsbury Crossing Assisted Living Requirements to Sustain the Program Funds to support the project's administrative infrastructure are required to ensure continued maintenance and growth of the geriatrics educational program. An ongoing administrative system would support the coordination of the UMMS geriatrics executive and multidisciplinary committees as well as coordination of the network of community agencies and the interdepartmental faculty, staff, and resources contributing to the geriatrics educational program. Continued endorsement and advocacy by the Educational Policy Committee and vice dean for undergraduate medical education are required to strengthen geriatrics training of medical students. Centralized administrative support housed in the Office of Medical Education is needed to maintain high visibility of geriatrics educational programming and to use unique resources available through the office such as faculty development, research, evaluation, and educational computing expertise. Continued recruitment by the new Division of Geriatrics of additional clinical educators to teach geriatrics is essential. Unanticipated Outcomes Individuals in both the basic sciences and clinical specialties with interest and expertise in geriatrics forged new alliances and collaborations across courses and departments. One community leader who represented the network of community elder service agencies to the Hartford Steering Committee received a faculty appointment and provided leadership in the first-year geriatrics community clerkship. This same community leader received an honorary doctorate at the 2003 medical school commencement for her commitment to geriatrics education and service to the community. Impact of External Funding An infrastructure was created through the Office of Medical Education to support multidisciplinary approaches to developing, integrating, and implementing geriatrics curricula. A steering committee consisting of representatives from the medical school, community, and partner institutions was also formed, enabling UMMS to expand its geriatrics educational resource base. A geriatrician appointed as co-PI of the grant assumed a leadership role in the school-wide effort to enhance geriatrics training and facilitated the recruitment of new geriatrician educators. The Hartford Grant helped mobilize medical school clinicians, educators, and researchers to work collaboratively to identify additional external and internal resources required to build a geriatrics program. Although not ultimately funded, a Donald W. Reynolds Foundation grant proposal was submitted for competitive review. The Division of Geriatrics in the Department of Medicine was established contemporaneously with the Hartford Grant. The curricular programs established by the grant have reinforced and defined the educational mission of the newly formed division and stimulated the recruitment of new geriatrics faculty educators. The medical school has recognized and formally acknowledged teachers of geriatrics throughout the community with an annual appreciation event. A community leaders’ breakfast was also instituted to recognize the significant contributions made by the community agencies as partners in the development and provision of rich educational experiences for UMMS students. For more information, contact Michele Pugnaire, MD, at 〈[email protected]〉.