University of South Carolina School of Medicine.

Abstract

Overview of the Geriatrics Curriculum In 1989, the University of South Carolina School of Medicine (USCSM) began developing a vertical curriculum in geriatrics to sequentially integrate core geriatrics issues and topics into existing courses and clerkships across all four years of the undergraduate curriculum. The American Geriatrics Society’s (AGS’s) core competencies are the themes and learning objectives for the geriatrics vertical curriculum. Since 1998, the AGS-recommended core competencies have been progressively integrated into USCSM’s geriatrics vertical curriculum. Curriculum Management and Governance Structure (See Figure 1)FIGURE 1.: Office of Medical Education In 1988, the Section of Geriatrics was created within the USCSM’s Division of General Internal Medicine. In 1989, the course director for the geriatrics vertical curriculum was appointed with the initial goal of assessing curriculum content. This responsibility was expanded during the ensuing three years to include establishing geriatrics course content. In 1998, specific learning objectives were developed, using the AGS core competencies. In July 2000, a half-time position was created as a result of the Association of American Medical Colleges (AAMC)/John A. Hartford Foundation grants program; a PhD health educator was hired as the associate director for undergraduate geriatrics medical education to assist the director of the Division of Geriatrics with the geriatrics vertical curriculum. In July 2001, with additional funds from the Donald W. Reynolds Foundation grant, this position became full time, with added responsibilities for the geriatrics fellowship program, and the position title was changed to associate director of geriatric medical education. In September 2001, as a result of Reynolds grant funds, a full-time assistant director for geriatrics medical education, a PhD health educator, joined the staff and assisted with the assessment and evaluation of the geriatrics undergraduate curriculum. As of January 2003, this position was upgraded to associate director of resident geriatric medical education. In July 2003, two part-time curriculum consultants (a PhD and an MD geriatrician) joined the Division of Geriatrics to assist in establishing and revising learning objectives for the geriatrics vertical curriculum and in assessing the geriatrics course content. A half-time geriatrics educator (MD geriatrician) was added to the faculty in July 2003 to assist with developing and teaching geriatrics content in the undergraduate and graduate medical education programs. This position will be involved with developing competency-based curricula and their evaluation. The Curriculum Committee provides oversight of the geriatrics vertical curriculum. Through its subcommittees, this committee periodically reviews all courses and clerkships, along with the five vertical curricula at the USCSM (geriatrics, nutrition, medical ethics, substance abuse, and genetics). A half-time curriculum consultant (EdD in curriculum), hired by the Office of Curricular Affairs and Faculty Support, assists in establishing and revising specific, objective, and measurable learning aims for the geriatrics vertical curriculum. The USCSM has made a commitment to geriatrics medical education, as seen by the growth of the division faculty and staff in the past three years and the increase of geriatrics content in all four years of the medical school’s curriculum. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The dean’s office, the Office of Curricular Affairs and Faculty Support, the Curriculum Committee, the Office of Continuing Medical Education, the department chairs, and clerkship directors work in collaboration with the Division of Geriatrics to provide opportunities for incorporating more geriatrics education into the curriculum. Since spring 2001, with AAMC/Hartford funding, the USCSM has provided students a longitudinal experience with community-dwelling older adults, beginning in the spring of the M-I year and extending through all four years. We call these older adults “senior mentors” and the longitudinal experience the Senior Mentor Program. In years one and two, the Senior Mentor Program is integrated into Introduction to Clinical Medicine (ICM) and complements materials presented in the preclinical curriculum. Since January 2001, the following nontraditional training sites have been incorporated into the geriatrics curriculum: patients’ homes, nursing homes, independent congregate living, and assisted living locations. The USCSM is committed to implementing the objectives developed for the School of Medicine from the AGS’s recommended core competencies for caring for older people. Fifty-seven percent of the recommended AGS core competencies in the areas of attitudes and skills are implemented in the Senior Mentor Program alone. As a result of AAMC/Hartford funding, six geriatrics objective-structured clinical examinations (OSCEs), two geriatric cases, and three geriatrics problem-based learning (PBL) modules have been introduced into the curriculum. Since July 2000, the following lectures have been added in the preclinical curriculum where geriatrics content had been insufficient: normal and abnormal signs and symptoms of aging, special senses and aging, skin ulcers, falls, failure to thrive, dementia, nutrition, late adulthood, and introduction to geriatrics. Small-group sessions with geriatricians and pharmacists to analyze the senior mentors’ medications and discuss iatrogenesis have also been added to the curriculum. Since July 2000, the following lectures have been added to the M-III and M-IV curricula: life review, advance care planning/advance directives, palliative-care, comprehensive geriatric assessment, delirium, and geriatric pre-operative assessment. As a result of the Donald W. Reynolds Foundation grant funds, the USCSM has developed an undergraduate end-of-life curriculum and expanded the third-and fourth-year senior mentor curriculum. Theme for the Geriatrics Program High-quality geriatric patient care for the citizens of South Carolina Improved knowledge of normal aging compared to disease Positive effect on students’ attitudes toward caring for elders Student mastery of all geriatrics vertical curriculum objectives Comprehensive geriatrics assessment End-of-life issues, consisting of advance directives, palliative care, and death and dying, including cultural and ethnic sensitivity in these matters Good communication and listening skills/good bedside manner Compassion for older adults and their caregivers Learning Outcomes for the Geriatrics Curriculum During the current academic year, the geriatrics vertical curriculum learning objectives are being refined and examined to ensure that data are available to document the attainment of each objective and that learning objectives have been identified for each relevant curricular component. Additionally, student competencies, student-learning experiences and activities, the location of these experiences and activities in the curriculum, and methods of assessment are being updated for each objective. Upon graduation, all M-IV students will be able to competently perform a comprehensive geriatric assessment. Upon graduation, all USCSM students will be able to discuss end-of-life issues with their patients, including advance directives, palliative care, and death and dying. All graduating USCSM students will have demonstrated good communication and listening skills and will exhibit positive attitudes toward caring for the older adult population. Special Programs Senior Mentor Program Beginning in the spring of the M-I year and extending through all four years, students, mostly in pairs, are assigned either one senior mentor or a couple and then follow the same mentor(s) throughout all four years of their medical school experience. The program has introduced the medical students to a healthy older adult population and has effectively presented the health-care challenges in this population. The Senior Mentor Program, now a permanent part of the USCSM four-year curriculum, has been successful in infusing geriatrics content throughout the four-year undergraduate medical school curriculum. The program integrates classroom material into a clinical setting early in the curriculum. It also has allowed for nontraditional training sites, including older adults’ homes and assisted living locations. The Senior Mentor Program has become a great promotional asset for medical student recruitment by the associate dean for medical education and academic affairs and the Office of Admissions. The medical school has been brought into the homes and hearts of 202 community-dwelling seniors as of February 2004. The seniors enjoy the contact with the medical students, and many valuable personal as well as clinical experiences have resulted. Using a multidisciplinary approach, modules have been developed so that students can learn how their senior mentors function on a daily basis, enabling assessment of the whole person’s health, medical needs, lifestyle, and social and physical environment. The modules were designed to coordinate with other areas of the curriculum where these concepts are being taught, so that students have an opportunity to put them into practice. M-I Modules: During the M-I year, students meet with their senior mentors four times and complete modules that address the physiology of aging, medical-history taking and mental-status examination, and psychological issues involved with growing old, such as intimacy and friendship. At every visit, students check their senior mentors’ blood pressures and write about their findings as well as their thoughts on aging. M-II Modules: In the second year, students meet with their senior mentors six times. Modules include assessing the senior mentors’ diet and developing a behavioral modification plan in the first semester and performing an environmental safety check, a physical examination, and a medication evaluation in the second semester. As with the first year, the modules are coordinated with the curriculum and involve student consultation with nutrition and pharmacology faculty members. These activities introduce students to relationship-centered medical care. M-III/M-IV Modules: In the third and fourth years, students meet with their mentors four times per year. Modules include issues concerning death and dying and advance directives, a life review, and a comprehensive geriatric assessment. The students also accompany their mentors to a physician visit. These assignments focus on communication and the physician–patient relationship. The Senior Mentor Program is evaluated through focus groups with students and mentors, student assignments and papers. Community partnerships As a community-based medical school, the USCSM has extensive partnerships to implement its mission. Those particularly relevant for the geriatrics vertical curriculum are with two affiliated hospitals, Palmetto Health–Richland and the Dorn Veterans Administration Hospital. Palmetto Health–Richland is responsible for multiple postgraduate training programs, including the geriatrics fellowship, the internal medicine residency, the family medicine residency, and all other required specialties for training medical students. The majority of geriatrics faculty is based in and funded through the Geriatric Services Department of Palmetto Health. The support provided to the geriatrics program by Palmetto Health has been critical for training at the residency level and also for medical student education. For example, the Senior Mentor Program recruits mentors from the Richland Senior Primary-Care Practice, and geriatrics faculty based in and funded through this Palmetto Health program are responsible for significant portions of the geriatrics vertical curriculum for medical students at the USCSM. The Dorn Veterans Administration Hospital has become more involved in the geriatrics vertical curriculum with the recent addition of two academic geriatricians. These faculty members, funded through the hospital, are involved in didactics and small-group training for medical students as part of the vertical curriculum in geriatrics. Geriatric standardized patients/simulations These patients are part of the USCSM standardized patient program and managed from the Office of Curricular Affairs and Faculty Support, specifically the Office of Diagnostic Education. Since July 2000, six geriatrics OSCEs, utilizing geriatric standardized patients, have been developed and implemented in four of the six required M-III clerkships. Geriatric standardized patients or senior mentors are utilized in the Senior Mentor Program in ICM-II for the physical examination assignment. The USC School of Social Work is developing an interdisciplinary end-of-life curriculum to be introduced with second-year medical students and social work graduate students in the ICM-II bioethics section. This was implemented in spring 2004. Interdisciplinary case-based modules will utilize standardized patients. Faculty development programs for the geriatrics curriculum In July 2001, the Division of Geriatrics was awarded a $2 million grant from the Donald W. Reynolds Foundation to strengthen physicians’ training in geriatrics. Grant funding has provided USCSM faculty with geriatrics training as follows: The Dean’s Faculty Scholars in Aging Program was implemented, and 26 faculty members representing seven USCSM departments are receiving training in geriatrics. The departments include internal medicine, family and preventive medicine, neuropsychiatry, surgery, emergency medicine, orthopedics, and obstetrics and gynecology. One-on-one interviews with these faculty members have been conducted by the grant’s principal investigator to (1) identify the scholars’ continuing geriatrics and instructional technology education needs, (2) develop individual geriatrics-specific professional development plans, (3) monitor scholars’ participation in geriatrics education and training activities, and (4) provide support and mentoring related to geriatric patient care. Regular monthly meetings are held with the Dean’s Faculty Scholars and their workgroups. Three Dean’s Faculty Scholars (two general internists and one family practitioner) have elected to pursue geriatrics fellowship training. Although all three had a preexisting interest in geriatrics, the commitment to complete a fellowship program is attributable to the Dean’s Faculty Scholars Program. All intend to continue in academics as clinician educators in their primary disciplines. Two three-day geriatrics educational workshops and one full-day workshop were held for the Dean’s Faculty Scholars, covering such topics as Clinical Glidepaths®, screening recommendations for diverse older adult populations, and the Stanford-based Geriatrics in Primary Care modules. In April 2003, the Division of Geriatrics, in collaboration with the school’s Department of Pharmacology, Physiology, and Neuroscience, co-hosted “Estrogen and the Aging Brain,” a presentation by a faculty member from the Medical University of South Carolina Center on Aging. From July 2001 to February 2004, 42 noon conferences on geriatrics have been offered on a variety of topics, including sexuality and aging, peripheral vascular disease and management, geriatric patients with vertigo, adverse drug reactions in older adults, Alzheimer’s disease, cultural issues in end-of-life care, and older adults and driving. These conferences are offered to the Dean’s Faculty Scholars, the Division of Geriatrics faculty and staff, internal medicine residents, and other health care personnel in the fields of geriatrics and gerontology. Since July 2001, five Dean’s Faculty Scholars have attended the UCLA Intensive Course in Geriatrics Medicine. In January 2003, two scholars (one from surgery and one from internal medicine) attended the National Residency End-of-Life Care Train-the-Trainer Conference, sponsored by the Robert Wood Johnson Foundation. Later in 2003, during the third Annual General Surgery Update, the Dean’s Faculty Scholar from general surgery conducted three sessions on hospice, geriatric delirium, and end-of-life issues. One of the internist Dean’s Faculty Scholars attended training on educating physicians in end-of-life care and has applied that training in teaching medical students and residents. In June 2003, a Dean’s Faculty Scholar from the Department of Neuropsychiatry attended the 15th Annual U.S. Geriatric and Long-Term Care Congress meeting in San Francisco. Practical clinical and socioeconomic developments in geriatrics were presented. In May 2002, the Division of Geriatrics held the first interdepartmental grand round lecture, “Managing Pain: Is this Pain or Just a Scam?” Since then a total of five geriatrics interdepartmental grand round lectures have been held as of February 2004. Each scholar is developing at least one geriatrics educational module for his or her department’s undergraduate M-III/M-IV or resident curriculum. Student interest groups The AGS student chapter, supervised by the associate director of geriatric medical education, was reestablished in 2001. The average number of meetings held per year is five; average student attendance is 25 students, with 83 being the highest. Topics are selected by the students and have included dementia, the Senior Mentor Program, death and dying, Parkinson’s disease, neurological disease, and “Why geriatrics?” Palliative care and end-of-life courses Introduction to Clinical Medicine-I In August 2003, a death and dying module was introduced around the dissection experience in gross anatomy for ICM-I students. This session focused on the student’s own personal experience with death, including cultural or religious taboos and rituals surrounding death in the context of the gross-anatomy laboratory. Essay reflections and small-group discussions allowed for a diverse learning environment. Introduction to Clinical Medicine-II A PBL case on end-of-life issues will be instituted in spring 2005. An interdisciplinary end-of-life curriculum was introduced to medical and social work students during the spring 2004 bioethics section of ICM-II. This will include case-based modules utilizing standardized patients. M-III/M-IV In July 2003, the “End-of-Life Care Module, a Hospice Experience” was implemented for M-III students during their psychiatry clerkships. Students are trained as hospice volunteers and have an eight-week longitudinal experience visiting with an assigned hospice patient. Since July 2000, end-of-life didactic sessions have been implemented on life review, palliative care, and advance care planning/advance directives. M-III students visit a long-term care facility during their family medicine clerkship rotations, at which time end-of-life issues are addressed. Resulting Pedagogical Changes Geriatrics material previously taught in lectures is now taught in more experiential and independent learning formats. Since fall 2000, the USCSM has provided a longitudinal experience in which students, mostly paired, follow and interview the same community-dwelling senior over four years, in the home and clinical settings, for a total of 17 required visits. M-III students during their psychiatry clerkships are trained as hospice volunteers and follow the same patients as a hospice volunteers for eight weeks. Geriatrics PBL cases and case-based learning modules have been added to the curriculum. Interdisciplinary end-of-life team training with USC graduate social work students and USCSM second-year medical students, utilizing standardized patients was implemented spring of 2004. Geriatrics OSCEs have been introduced into the assessment/evaluation process. The Dean’s Faculty Scholars in Aging Program has been established for training the trainers (physicians) in geriatrics. The Division of Geriatrics is responsible for the training. Twenty-six of these scholars from seven disciplines (internal medicine, family medicine, surgery, neuropsychiatry, obstetrics and gynecology, orthopedics, and emergency medicine) are involved in faculty training and in improving geriatrics medical education at USCSM. The Curriculum Committee and the Office of Curricular Affairs and Faculty Support have prepared faculty members and students for these pedagogic changes in the medical school curriculum. Application of Computer Technology Students enrolled at the USCSM are required to have laptop computers that meet specifications from the Office of Computer and Communications Resources. Most course-related instructional material on geriatrics is in a computerized format. Medical students perform their senior mentors’ nutritional analyses and medication analyses on the computer, using appropriate software. Clinical geriatrics case materials (patient demographic data, laboratory data, skin and retinal images, X-rays, biopsy and autopsy microscopic images, and other information) have been loaded on the computers for all PBL learning cases that have been developed. GeriatricWeb, an Internet digital library of links to peer-reviewed geriatrics resources for the education of medical students, residents, fellows, and health care professionals, became available to students in February 2004. Students’ Clinical Experiences in Geriatrics Longitudinal clinical experiences with geriatrics related to the Senior Mentor Program are outlined above and begin in the M-I year. In the summer between the M-I and M-II years, an eight-week experience that combines research with clinical experiences is available for students. Predictably, students have ongoing experiences with older adults as part of their M-III clerkship rotations. However, as a result of the Dean’s Faculty Scholars program and the educational interventions in the residency programs outlined above, students now have faculty and residents who are trained in geriatrics. Students on the required M-IV internal medicine clerkship may elect to spend four weeks at one of the geriatrics training sites, and a four-week elective in geriatrics is available for M-IV students. The Program’s Assessment and Evaluation Instruments Prior to 2000, students did not receive individual surveys assessing their attitudes and knowledge on geriatrics. Beginning with the class of 2004, student knowledge and attitudes have been evaluated annually. The classes of 2004 and 2005 complete three self-administered surveys each year, the Palmore Facts on Aging Quiz (Palmore EB. The Facts on Aging Quiz. New York: Springer, 1988:11–13) for measuring knowledge, the Maxwell-Sullivan scales (Maxwell AJ, Sullivan N. Attitudes toward the geriatric patient among family practice residents. J Am Geriatr Soc. 1980;28(8):341–5), and the Rosencrantz Aging Semantic Differential (ASD) survey (Rosencranz HA, McNevin TE. A factor analysis of attitudes toward the aged. Gerontologist. 1969;9:55–9) for measuring attitudes toward aging. Beginning with the class of 2006, all students will annually complete the UCLA Geriatrics Curriculum’s self-administered survey instrument to assess attitudes and knowledge level related to several core competencies in geriatrics. Since July 2000, the following geriatrics OSCEs have been implemented: dementia (neuropsychiatry), perimenopausal issues (gynecology), urinary incontinence (gynecology), confusion (internal medicine), comprehensive geriatrics assessment (internal medicine), and nonspecific presentation of disease (surgery). Since March 2002, focus groups have been held yearly to assess the impact of the Senior Mentor Program on the students’ attitudes toward aging and to explore mentor and student perceptions of the program. Trained moderators used a seven-item interview guide, and the groups were audiotaped. Tapes were transcribed into NVivo® software for coding and analysis. Resources Required The USCSM supported the Division Director’s efforts to establish the Vertical Curriculum in Geriatrics, to participate in the Education Committee of the AGS, and to provide time to write multiple grants. Further, the Office of Curricular Affairs and Faculty Support was particularly helpful in the implementation of the Senior Mentor Program, grants planning and the overall evaluation of the Senior Mentor Program. The dean of USCSM has made available $100,000 annually to geriatrics since the commencement of the Reynolds Foundation grant in July 2001. Contributions for geriatrics have been received from affiliated hospitals, including the Palmetto Health–Richland and the Dorn Veterans Administration Hospital. These contributions have included funding for geriatrics personnel, administrative support, equipment, and office space. Ongoing support on the part of the senior vice president for research and education and the vice president for education has been important for the implementation of the curricular changes in the residency training programs. The Donald W. Reynolds Foundation granted $2 million to USCSM over four years (July 2001 to July 2005) to strengthen physicians’ training in geriatrics. This funding has enhanced the geriatrics component of the undergraduate curriculum in multiple ways, including expansion of the Senior Mentor Program and training of faculty and residents, who then incorporate geriatrics principles into medical student education. The Arthur P. Gold Foundation awarded $24,788 (March 2003 to April 2004) to the USCSM to teach a “Brief Clinical Life Review” to third-year medical students as a component of the Senior Mentor Program and to evaluate this educational experience. The American Medical Student Association awarded funds and a summer internship to one of USCSM’s first-year medical students to enhance the university’s end-of-life and ethnic diversity curriculum. The student developed a culturally sensitive death and dying module around the cadaver-dissecting experience and implemented it in the gross anatomy course for ICM-I students in the fall 2003 semester. The National Library of Medicine awarded $76,000 in October 2002 to create an Internet digital library of links to peer-reviewed geriatrics resources for use in older patient clinical care and in the education of health-care professionals at various levels of their training or careers. Requirements to Sustain the Program The vertical curriculum in geriatrics is a permanent, required component of the USCSM curriculum. The innovations developed under the AAMC/Hartford and Reynolds programs will continue in the vertical curriculum. Faculty trained through these grants will continue to provide geriatrics education. The Senior Mentor Program is now a permanent program in the undergraduate USCSM curriculum. Support for two half-time PhD positions after Reynolds funding expires will be provided by the USCSM. Support from affiliated hospitals for salaries of geriatricians, as well as for office and administrative support, will continue. Unanticipated Outcomes The enthusiasm generated from senior volunteers in the Senior Mentor Program has created a great demand and a long waiting list of Columbia-area senior citizens to become senior mentors. The program also has become a great promotional asset for medical student recruitment, through the associate dean for medical education and academic affairs and the Office of Admissions. The Senior Mentor Program has received regional and national attention. The South Carolina Hospital Association selected the program as a “Geriatrics Best Practice.” An article on the program was published in Parade Magazine in December 2003, and the program was featured as an “Eye on America” segment on CBS Evening News with Dan Rather on February 5, 2004. Leveraging the good will generated by the program has allowed for further development of geriatrics. USCSM’s AGS student chapter (the geriatrics student interest group) has become so popular that voluntary attendance has been as high as 83 students for luncheon meetings. As a result of their geriatrics exposure, rising second-year medical students are requesting summer student clerkships in geriatrics. The Division of Geriatrics was able to support six rising M-II students in summer 2002 geriatrics clerkships. Other professional health-related colleges and schools in the university system are asking to work in closer collaboration with the USCSM. The School of Social Work is now working in tandem with the USCSM in developing interdisciplinary end-of-life training with graduate social work students and medical school students. Impact of External Funding The infusion of grant funds has greatly enhanced the visibility of geriatrics training and education at the School of Medicine and its affiliated institutions. Geriatrics has been infused into the following departments and/or clerkships: internal medicine, family and preventive medicine, psychiatry, surgery, obstetrics and gynecology, orthopedics and emergency medicine, with the training of 26 faculty members from these seven departments resulting in more geriatrics content and training in their curricula and clerkships. The dean of the USCSM has made a financial commitment to sustain geriatrics education with additional financial support after grant funds expire. Every graduating USCSM medical student, beginning with the class of 2004, will have a geriatrics longitudinal experience. The geriatrics educational programs and physician-education training models developed as a result of external funding have helped to establish USCSM as an up-and-coming leader in geriatrics medical education as part of community-based medical education. For further information, contact Ellen Roberts, PhD, MPH, at 〈[email protected]〉.