University of North Carolina at Chapel Hill School of Medicine.

Abstract

Overview of the Geriatrics Curriculum In recent years, we have developed and strengthened the geriatrics curriculum through a deliberate process of specifying learning outcomes, identifying existing geriatrics content, designing and implementing new learning activities and resources, and assessing students’ geriatrics-related knowledge, skills, and attitudes. Further, recent changes in the curriculum governance structure ensure ongoing assessment and improvement of the geriatrics curriculum. The geriatrics curriculum now is fully integrated in required courses across all four years of the curriculum, providing a coherent and comprehensive program that prepares students to care effectively and compassionately for older adults. A unique feature of our curriculum is its focus on preparing students to improve the health of the state’s population, which includes a growing number of citizens over the age of 65. Approximately 40% of clinical teaching takes place in communities throughout the state, where students learn about caring for diverse populations in a variety of communities and health care settings. Curriculum Management and Governance Structure (see Figure 1)FIGURE 1. Governance StructureIn January 2002, the Curriculum Management and Policy Committee (CMPC) was established as the central body responsible for curriculum management and governance. The CMPC is chaired by the executive associate dean for medical education, who reports to the dean, and its members are the co-chairs of the three course directors’ committees and the associate deans for admission, student affairs, and educational development. The following committees report to and advise the CMPC and are the avenue by which the geriatrics curriculum has been integrated in the overall curriculum: Three course directors’ committees, one each for the first and second year, and one for the third and fourth years combined, are responsible for overseeing, coordinating, and improving the individual courses and overall curriculum for each year. The co-chairs of these committees are appointed by the executive associate dean for medical education. Each committee is composed of all of the course directors for the respective year(s). Ex-officio members include staff from the Office of Medical Education and student representatives. The director of the Program on Aging, as a second-year course director, is a member of that committee and also attends the first-, third- and fourth-year committee meetings. The Curriculum Advisory Board convenes quarterly to serve as a forum for all constituencies and stakeholders involved with the educational program for the MD degree, to share ideas about the curriculum, and discuss current practice, concerns, and plans. The director of the Program on Aging is a member of this committee. Two additional committees report to the CMPC and have supported the development of the geriatrics curriculum: The Faculty Advisory Committee on Educational Technology advises the executive associate dean for medical education on matters regarding effective selection and use of educational technology and information systems. Much of the computer-assisted geriatrics instruction has been facilitated by this group. The Whitehead Curriculum Committee, an arm of the Whitehead Medical Society (the student government), works to improve individual courses and the overall curriculum and serves as the liaison among students, student government, and the Curriculum Management and Policy Committee. Each year the two second-year students who are elected co-vice presidents for curriculum of the Whitehead Medical Society serve as co-chairs of the committee, which is composed of student representatives from each class, the co-chairs of the course directors’ committees, the executive associate dean for medical education, and the associate deans for student affairs and educational development. Whitehead representatives attend meetings of the course directors’ committees and Curriculum Advisory Board. The new governance structure has permitted organizational and administrative flexibility to manage and coordinate the curriculum and to react to a rapidly changing academic medical center environment to facilitate change if and when it is deemed necessary. The strengthening of the geriatrics curriculum has been and continues to be a critical focus. In addition to the overall curriculum governance structure of the medical school, the Geriatrics Curriculum Committee (GCC), centered in the Program on Aging, serves as a major force in the development of the geriatrics curriculum. The seven-member interdisciplinary GCC, chaired by the director of the Program on Aging, was created to remedy gaps in the geriatrics curriculum. The group’s accomplishments include: development of a comprehensive syllabus outlining geriatrics learning objectives and content that all medical students should master prior to graduation; thiswas done through surveying practicing physicians to determine the skills needed to work effectively with elders in the community and following guidelines from the American Geriatrics Society (“Areas of Basic Competency for the Care of Older Patients for Medical and Osteopathic Schools,” 1998); evaluation of existing geriatrics content and learning activities to assess where and how well these topics are taught in the curriculum; and implementation of educationally sound methods to address geriatrics components that may not be fully incorporated into the medical curriculum. Plans developed by the GCC are shared with the three course directors’ committees and the Curriculum Advisory Board via the Program on Aging representative. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The John A. Hartford Foundation grant received through the AAMC in June 2000 provided the resources that allowed us to strengthen and build the geriatrics curriculum across all four years, expand our outreach to students interested in geriatrics medicine, and document those areas in the curriculum where geriatrics knowledge and skills were inadequate or lacking. Specifically, our goals were to increase (1) the exposure of all students to core geriatrics content to help ensure a sound knowledge base for practice, (2) the number of opportunities for student exposure to older adults to support empathic practice, based upon an appreciation of normal and successful aging as well as its challenges, and (3) educational experiences to engage students in applying their knowledge and skills to solve complex problems in geriatrics medicine. These efforts were well received by faculty and students and resulted in increased visibility throughout the School of Medicine and increased awareness of the importance of geriatric medicine as an inherent component of core competencies. Both before and midway through the grant period, institutional involvement in curriculum change permitted even greater achievements in enhancing the geriatrics program. Prior to this, the Program on Aging had limited opportunities to make formal recommendations regarding medical school curriculum design and content, with virtually no active, authoritative role in the decision-making process. In 1999, the large and unwieldy First- and Second-Year Course Directors’ Committee was divided in two, so that each committee could focus exclusively on a single year’s curriculum. This promoted more intense and focused work on analyzing the curriculum and determining ways to strengthen it. In 2001, the dean appointed the Leadership Task Force on the Outcomes of the Medical School Curriculum, composed of nine department chairs representing both basic and clinical sciences. This committee was charged with describing the core competencies (learning objectives) to be achieved by graduating medical students and with revising the curriculum governance structure to promote efficient and effective decision making. The subsequent establishment of a set of core competencies and the reconfiguration of the governance structure (described above) resulted in major curriculum changes, with significant implications for expanding the depth and breath of geriatrics content throughout the four-year curriculum. The Second-Year Course Directors’ Committee transformed the second-year curriculum from separate courses generated by each department into integrated block courses focusing on organ systems. The committee also established both an introductory and a capstone block to begin and end the year, with each of these blocks using case-based learning with a strong geriatrics focus. Theme for the Geriatrics Curriculum The teaching mission of the Division of Geriatric Medicine and the Program on Aging is to build the capacity of UNC to prepare health care providers at all levels for evidence-based, outcomes-oriented health care for older adults and ultimately, to improve or preserve their level of function and quality of life. The major theme for the geriatrics dimension of the UNC medical school curriculum is twofold, to ensure (1) that the geriatrics curriculum is a recognizable and integral component throughout all four years of the medical curriculum; and (2) that students, faculty, and administrators recognize that the mastery of geriatrics competencies is most effectively achieved within an interdisciplinary system of care delivery that recognizes the interdependence of education; research; primary, subspecialty, and ancillary care; and public policy and regulation. The questions that must be addressed for each curricular activity are “How does this intervention affect the student’s acquisition of identifiable geriatric core competencies?” and “How does this intervention increase the student’s understanding and implementation of interdisciplinary team skills?” An additional theme is the commitment to recognize and encourage those students who have a particular interest in geriatrics and the potential to be leaders in the field, regardless of their subspecialty interest. Learning Outcomes for the Geriatrics Curriculum After completion of the enhanced four-year geriatrics curriculum, students will be able to describe age-related physiological changes, differentiate between normal aging and disease processes, demonstrate the problem-solving ability necessary to provide care to older persons, exhibit the professional qualities of integrity, compassion, thoroughness, responsibility, and commitment to caring for older persons, identify political, financial, and social factors that affect delivery of care, and recognize their own potential and that of their patients for subscribing to aging stereotypes. Special Programs Community partnerships Community partnerships play an essential role in fulfilling the university’s commitment to prepare professionals to meet the health care needs of North Carolina’s citizens. The Program on Aging facilitates student involvement in two partnerships that offer a variety of opportunities for work with older adults across the spectrum of geriatrics issues: The Program on Aging enjoys a strong and longstanding relationship with the North Carolina Area Health Education Centers (AHEC) program, a nationally recognized model for interdisciplinary education and training of health care providers. Several regional AHECs collaborate with us on innovative projects to ensure that there are community clinical training sites with well-qualified preceptors available to teach geriatrics knowledge and clinical skills. The Education for Lifelong Service (ELS) Program provides students with community service opportunities, complemented by a curriculum designed to foster leadership skills in service delivery. ELS has responsibility for the newly established Office of Community Service and sponsors courses on the care of underserved and vulnerable populations, including activities that emphasize services to older adults. Program on Aging representatives participate on the ELS leadership team. Standardized geriatric patients The UNC School of Medicine Standardized Patient (SP) Program, administered by the Office of Educational Development, gives students opportunities to practice communication and diagnostic and examination skills before they encounter patients in the actual clinical setting. In addition, the program provides a mechanism to assess these same skills in a standardized format. The program maintains an active database of SPs, including those who are suitable for presentation of geriatric illnesses and situations. Simulated case presentations using geriatric standardized patients are frequently requested for classroom learning, most notably in the first- and second-year Introduction to Clinical Medicine course, in second- year integrated cases, and as part of the fourth-year Clinical Performance Examination, which students must pass in order to graduate. Faculty development The Office of Educational Development provides several faculty development programs and activities in which geriatrics faculty participate and that help to strengthen the geriatrics curriculum. The Expert Preceptor Program, designed for practitioners in community-based clinical settings, is available in an online, interactive format known as the Expert Preceptor Interactive Curriculum. This is a self-paced program comprising modules that can be used individually as information resources or collectively as a complete curriculum. Each module focuses on a skill related to clinical teaching in the community practice setting or on strategies for teaching contemporary health issues. The Teaching Scholars Program is a year-long series of monthly seminars designed to promote expertise and scholarship in medical education for fellows and faculty. In addition, participants choose a specific area of educational interest to pursue in depth and present their results to colleagues at a symposium at the conclusion of the program. Completion of the program confers recognition as a scholar in medical education, and graduates are targeted for positions of leadership in the curriculum. Each year, ten teaching scholars are chosen from faculty nominated by their department chairs, with at least one participant from the Program on Aging. The Excellence in Teaching Series consists of monthly seminars and workshops focused on innovative approaches that enhance learning and instruction in medical education. These sessions provide a forum for participants to discuss practical approaches that facilitate and maximize student learning. The series is designed for faculty and residents who have responsibility for teaching in the classroom, lab, and/or clinical setting. Consultations on teaching and curriculum development issues are provided for individuals or groups of faculty as needed. Faculty and staff from the Office of Educational Development work closely with the Program on Aging to provide ongoing support for efforts to enhance the geriatrics curriculum. Student interest group The UNC Student Chapter of the American Geriatrics Society is a student-led organization for physicians-in-training who have an interest in geriatrics medicine regardless of intended area of specialty. The group focuses on ways to enhance the visibility of geriatrics issues at the UNC School of Medicine and to provide educational programs on geriatric medicine. For those students specifically interested in careers in geriatrics, the chapter seeks to develop leadership skills in geriatrics medicine by sponsoring interdisciplinary educational programs, encouraging research participation, and creating geriatrics-related community service opportunities. The leaders of this student group have initiated a one-hour orientation to geriatric patient care for first year students prior to their community week experience. (See the discussion of “Students’ Clinical Experiences” below.) Palliative care and end-of-life issues In the first year, the required Medicine and Society course provides multiple opportunities for exploration of the social aspects of aging in our society and in politics, as well as the economic factors affecting geriatrics health care. Students discuss various medical-ethical issues found most often among the elderly, e.g., palliative care and end-of-life decisions. In the second year, up to 20 students may select the seminar entitled The Good Death or the Good Fight: Ethnical, Legal, and Policy Issues in Medical Choices as their required humanities and social sciences seminar. A fourth-year elective course sponsored by the Department of Medicine specifically addresses palliative care and end-of-life issues. Palliative Medicine is a six semester-hour, interdisciplinary course taught by faculty from the Departments of Medicine (including a certified geriatrician) and Psychiatry; the Schools of Social Work, Pharmacy, and Nursing; and the Hospital Chaplaincy Office. Resulting Pedagogical Changes Program on Aging faculty promote the importance of teaching methods that encourage students’ active engagement in learning processes that are both self-directed and collaborative. One approach that has proven particularly effective is a merger of evidence-based and problem-based methods. Students are given a clinical vignette in which a patient presents with symptoms and complaints (a problem-based case). Students work in teams to define the problem and set priorities for self-directed (evidence-based) study. This approach is especially appropriate where students must understand the unique and complex presentation of common illnesses among older adults. Specific curricular enhancements include: The Introduction to Clinical Medicine course for first-year students (ICM-1), which devotes time for more in-depth presentations of topics that traditionally have not been an inherent component of the medical curriculum. When these “special topics” were introduced into the curriculum in 1998, geriatrics medicine was included as a three-hour roundtable discussion. Today, the day-long seminar on aging is a firmly established component of ICM-1. Through the AAMC-Hartford program, we further developed this activity to include a lecture and exercise on ageism and aging stereotypes. Strengthened geriatrics content in the following targeted first- and second-year courses: Psychiatry, Gross Anatomy, Immunology, Cardiovascular System, and Respiratory System. The success of this collaborative effort with individual course directors led to an invitation to participate in the design and implementation of the new second-year integrated curriculum. Other regularly scheduled, geriatrics-specific teaching opportunities for required first- and second-year courses. These include geriatrics assessment interviews with standardized patients, a polypharmacy component for the pharmacy course, a geriatrics problem-based case that addresses end-of-life issues, and geriatrics case exercises; they were developed for use in the new introductory and capstone block courses in the second-year curriculum. An interactive, Web-based geriatrics case exercise for the first-year Introduction to Clinical Medicine (ICM) course, which was developed, integrated, and titled “Meet Mrs. Jefferson.” A problem-based case, “Robert Waters,” was developed for the second-year ICM course. A “patient bank” of geriatric subjects for student interviews for the required first-year Medicine and Society course. Students are assigned two patients to interview in teams (two to three students per team). The assignment required recruitment of a significant number of patient-volunteers. Geriatricians from the Program on Aging assisted with recruitment, providing an additional opportunity to ensure a geriatrics component in course content. Additions of geriatrics content to the third-year family medicine, internal medicine, psychiatry, and obstetrics - gynecology clerkships. (See “Students’ Clinical Experiences in Geriatrics” below.) Expansion of the required fourth-year ambulatory care selective to include two additional primary care geriatrics sites. These two sites are in communities with the fastest growing elderly populations in the state. In addition to the required courses and activities described above, the Program on Aging sponsors the following elective activities: For many years, the Program on Aging has sponsored a popular elective course, known as “Geri-Action,” designed to provide first- and second-year students with hands-on clinical care of older patients in inpatient facilities and ambulatory care clinics, and occasional opportunities for home visits. The Senior House Calls Program extends the “Geri-Action” concept by assigning small groups of students to an experienced geriatrics clinician to make house calls to older patients and to follow patients over an extended period. Interdisciplinary Geriatric Education Consultations provide a forum for students to travel with a master geriatrics clinical team to community-based sites for interdisciplinary consultations with local practitioners regarding complex geriatric patient issues. Students who are based in the community are often actively engaged in preliminary home visits with patients or family members and take responsibility for case presentations and follow-up. Seven other electives on geriatrics are offered through the Departments of Medicine and Family Medicine, including Interdisciplinary Teamwork in Geriatrics, Current Topics in Geriatric Health Care, and Rural and Underserved: An Interdisciplinary Approach to Health. Application of Computer Technology The School of Medicine requires that all first-year medical students purchase a laptop computer (first year) and PDA (second year) that are specifically configured to ensure that all students have equal and ready access to all online resources needed for the medical school curriculum. Each student has a dedicated 1000 MB Ethernet connection at his or her assigned lab desk, and each lecture hall has Internet connectivity as well. Online resources are extensive and begin with the online course syllabi that serve as the starting point for course activities. The first-year pre-clinical informatics course teaches students how to best access and evaluate online information, create research presentations, and build Web pages. The Educational Technology Group provides faculty and staff with consultation, workshops, and access to multimedia equipment for curricular projects. They assist course directors with online syllabi and provide expertise necessary to link computer-based teaching resources to the classroom, the lab, and the clinical setting. This strong electronic learning environment supports our commitment to evidence-based practice and learning, as described above in “Resulting Pedagogical Changes.” Examples of the ways in which technology supports the geriatrics curriculum include use of an online geriatrics case-based exercise in the Introduction to Clinical Medicine course, and providing students with the appropriate online information resources needed to complete the case-based exercises in the introductory and capstone block courses in the second year. Students’ Clinical Experiences in Geriatrics Years One and Two Although the first two years of the medical curriculum focus on helping students acquire a solid foundation in the basic sciences, the Introduction to Clinical Medicine course provides clinical experiences as well. Students are introduced to basic clinical skills on campus in weekly small-group sessions with faculty tutors. In addition, they spend five one-week periods in community-based primary care practices. Students learn the complete physical exam and history-taking in the context of a patient-centered approach to care. Both in the classroom and during their five one-week clinical rotations in the community, students are exposed to the entire spectrum of care, from preventive to end-of-life. The Student Chapter of the American Geriatrics Society has initiated a one-hour precommunity week seminar for first-year students focusing on basic care issues common to older patients. Third-Year Clerkships During the 12-week internal medicine clerkship, at least one of the 12 required patient write-ups must focus on a patient aged 65 or older. During the six-week obstetrics and gynecology clerkship, each student is required to complete two weeks of urogynecology and two weeks of oncology and attend 21 hours of lectures and seminars, two of which address issues often seen in geriatric patients, e.g., gynecologic oncology and urinary incontinence. Students are responsible for five case presentations, one of which must be of a patient age 65 or older. The Geriatric Evaluation and Management (GEM) Unit on the psychiatry inpatient service is one of six rotation options students can choose to meet the psychiatry clerkship requirement. This geriatrics clinical experience is available for six rotation periods during the academic year and can accommodate six students per rotation. Through the GEM, students learn clinical skills in the specialized treatment of psychiatric disorders among geriatric patients. Although geriatrics content during the six-week family medicine clerkship varies significantly among sites, overall at least 20% of patients seen by students are age 65 or older, and lectures on geriatrics issues are offered throughout the rotation period. Fourth Year The required ambulatory care selective has two newly established geriatrics-specific sites where students have clinical preceptors who are certified geriatricians. In the academic year 2003–04, five students received geriatrics clinical training at these sites. Electives provide additional opportunities for fourth-year students to complete clinical geriatric rotations. One is a four-week rotation where the student is assigned to a variety of clinical settings to work one-on-one with certified geriatricians. The second option is a six-month longitudinal rotation where the student works one-on-one with a certified geriatrics preceptor to provide comprehensive evaluations and interventions for specifically assigned patients. In both instances, the students are encouraged to focus on a specific area of interest. The Program’s Assessment and Evaluation Instruments An objective structured clinical examination (OSCE) is used to assess students in the Introduction to Clinical Medicine course, allowing faculty to observe and evaluate how well students perform specific clinical skills and behaviors. Students rotate through a series of patient encounters. For each patient, the student is asked to perform a specific, measurable task and a faculty observer evaluates the student’s performance using a structured assessment tool. Standardized geriatrics patients are included in this assessment. Assessment of geriatrics content that is embedded in the courses and clerkships is accomplished by including appropriate items on the various course-related tests and assessments. In conjunction with the Third and Fourth-Year Course Directors’ Committee, the Office of Educational Development administers the Clinical Performance Examination (CPX), a high-stakes authentic assessment required of all fourth-year students. Designed to reflect patient demographics in North Carolina, the CPX contains a patient sample that reflects personal demographics and medical problems most frequently encountered in primary care practices in this region. Typically, geriatrics cases compose approximately one quarter to one third of the total cases used. The exam matrix is designed to ensure that relationship and communication skills, physical examination skills, history-taking skills, and management and assessment skills are evaluated across 12 to 16 cases. Students receive a performance profile that provides a brief description of each case, pass/fail status for each case, overall exam score (pass/fail), and five skill scores. In conjunction with the CPX, students are given a supplemental written, case-based geriatrics test, developed by the Program on Aging. For both the OSCE and the CPX, the Program on Aging works collaboratively with the Office of Educational Development to ensure that core geriatrics competencies are included in the assessment. Requirements to Sustain the Program As a result of the success we have experienced in bringing geriatrics needs to the forefront, we are now confronted with the pressing need for ongoing dedicated faculty teaching time and significant staff support. To maintain and expand our educational programs in all desired directions, we must engage new faculty geriatricians, as well as others who can add a geriatrics component to the training they offer in their respective domains. The success of the John A. Hartford/AAMC grant has confirmed the need for a coordinated, comprehensive approach to geriatrics education. We must continue to explore new ways to address the needs of learners at different levels, to assess the flood of new research, and to rapidly disseminate new information and methods to our students. Unanticipated Outcomes The recent transformation of the second-year curriculum from discrete departmentally-based courses to integrated organ-system blocks gave us an unexpected opportunity to more fully develop the geriatrics curriculum. The redesign provides an ideal context for incorporating geriatrics-focused case-based learning activities. Because the AAMC-Hartford project already had given new prominence to geriatrics content, we were able to argue successfully for additional case-based geriatrics teaching. The introductory block concludes with a two-day problem-based, evidence-based case using a simulated geriatric patient. The case provided an opportunity to demonstrate how diagnostic information is used in patient care, to emphasize the patient-specific nature of high-quality geriatrics care, and to heighten students’ awareness regarding the urgency of health care issues presented by this rapidly growing segment of the population. The final capstone block focuses on two patient cases, one of which involves an elderly patient. Both cases are designed to integrate multiple aspects of medical care that were addressed in previous organ-based blocks. Students work collaboratively in small groups to explore the patients’ problems, including presentation, diagnosis and treatment strategies, and quality-of-life consequences. The restructuring of the curriculum governance system allowed for more Program on Aging involvement in curriculum planning. Through personalized committee contacts, the Program on Aging continues to receive new and renewed requests from faculty to assist in developing and implementing geriatrics teaching resources and strategies. Impact of External Funding The Program on Aging has achieved an unprecedented level of visibility and credibility within the School of Medicine and throughout all the schools and programs in the UNC Division of Health Affairs. There is a growing, mutually supportive relationship with the Office of Medical Education and with individual course directors, affirming a commitment to ensure that geriatrics content evolves and becomes an integral component of required courses. External funding available between 2000 and 2002 made possible the staff time needed to collaborate with course directors and offer geriatrics-specific classroom and small-group teaching/ learning activities. Over the past two years, these individualized course connections have evolved, and the Program on Aging has representation on all course directors’ committees and actively participates in curriculum design and implementation. The foundation laid by the AAMC-Hartford funding allowed us to compete successfully for additional funding from the Donald W. Reynolds Foundation. Our newly-funded initiative is helping us both further expand the medical student curriculum and also build educational programs for residents, fellows, and faculty, including community-based preceptors. For further information, contact Jan Busby-Whitehead, MD, at 〈[email protected]〉.