University of Wisconsin Medical School.

Abstract

Overview of the Geriatrics Curriculum The University of Wisconsin Medical School (UWMS) recognizes the need to prepare physicians to address the needs of an aging nation. It aims to educate all of its 600 medical students in the skills and knowledge essential for competent and compassionate care of older persons. The development of the UWMS geriatrics and gerontology curriculum has been an iterative process dating back to 1993. At that time, a geriatrics education committee was tasked to review options for an integrated four-year curriculum in geriatrics. Initial curriculum additions occurred in 1994 within the introduction to clinical medicine course, the medicine clerkship, and a fourth-year elective. In 1998, a new patient, doctor, and society course was initiated as a four-semester, sequenced course in Years One and Two, with five major components, including patient–doctor communication, clinical skills, evidence-based medicine, health and society, and a community-based primary-care clinical experience. This course served as a venue for new geriatrics instruction at its inception and subsequently played a pivotal role in a number of the Hartford grant innovations. In 1998, the UWMS articulated a revised mission and new vision statement. This strategic planning process identified six priority areas for resource allocation to guide the research and education direction over the next five years. Aging and geriatrics medicine represented one of these foci to support the medical school's vision for the 21st century. This decision was based on the relevance, impact, national recognition, and recent successes of UWMS geriatrics programs. The objectives of the strategic priority for aging dictate that students be trained in core aspects of geriatrics and gerontology (including basic biological processes, clinical care, demographic trends, and the economic, psychological, and social components of aging) to deliver the highest standard of care for older persons. In 1999, a review of geriatrics content across the four-year curriculum demonstrated that medical students received approximately 20 hours of formal didactic and small- group instruction in geriatrics. Concurrently, the Association of American Medical Colleges (AAMC) Graduation Questionnaire revealed that 43% of UWMS graduates sought increased training in geriatrics and long-term care. In the context of the new strategic plan, these events provided impetus to initiate geriatrics curriculum enhancement. This effort was bolstered by support from the AAMC and Hartford Foundation through its geriatrics education enhancement grant from 2000 through 2002. Collaborative efforts by UWMS geriatricians, internists, and family medicine educators have produced a number of new curricular enhancements since 1998. These are indicated in Figure 1. These additions or revisions have increased student contact hours for geriatrics content by two- to three-fold, depending upon the student's involvement in extracurricular activities such as the geriatrics interest group (described below).FIGURE 1. Geriatrics Education Enhancements, 1998-2003Curriculum Management and Governance Structure The current UWMS organization for curriculum management includes the dean of the medical school, the senior associate dean for academic affairs, the associate dean for curriculum, and the Educational Policy Council (EPC). In 1999, an associate dean for curriculum was appointed to develop and implement a more competency-based curriculum, plan for future interdisciplinary education in the health sciences, and facilitate more case-based and active, independent learning within the curriculum. The EPC is responsible for curriculum planning and educational policy for undergraduate, graduate, and medical student education within the framework established by the medical school faculty. The EPC implements educational policies and evaluates the effectiveness of the educational programs, including continuing curricular review and new course approval. Geriatrics educators and course/clerkship directors at the UWMS elected to not create a new geriatrics course or clerkship within an already heavily programmed curriculum. Rather, educators identified courses or clerkships across Years One to Four that were relevant to senior care, and that were receptive to emphasizing these principles in existing materials and clinical encounters. Changes were enacted by enlisting ongoing participation and buy-in from these course and clerkship directors and by introducing approaches that were novel and attractive to students. The senior associate dean for academic affairs and the associate dean for curriculum supported all of these changes. Evaluative processes were linked to all changes to refine this curriculum development even more. In this way, the AAMC/Hartford grant was used as a catalyst to reinvigorate the geriatrics content in the medical school curriculum while also using existing resources. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change A new structured, cohesive curriculum that extended across Years One through Four was introduced in 1994. This curriculum included the Generalist Partners Program, a mentoring effort between community-based physicians and UW medical students that extends across four semesters in Years One and Two. The curriculum emphasized active learning, integration of basic and clinic sciences, and exposure for all students to generalist principles. This focus on generalist principles afforded expansion of geriatrics principles into this matrix. From 1996 through 1998, the medical school developed and implemented a model for allocating resources in alignment with its mission and strategic goals. This model, called mission-aligned management and allocation, resulted in a redirection of resources that had an impact on curricular planning. In 1997, the UWMS started a series of curricular initiatives that emphasized self-directed learning and problem solving in small groups, as well as integration of information technology. The nationally acclaimed Generalists Partners Program was adapted for even greater patient-focused learning in primary care. At the time of the Hartford geriatrics curriculum grant, the medical school was in the process of further curricular revisions toward a more competency-based curriculum with an enhanced component of active, independent learning. The ongoing curricular change served more as a catalyst than as an obstacle to successful integration of the geriatrics curricula. Geriatrics educators worked with the associate dean for curriculum and several curriculum subcommittees to develop and begin implementation of geriatrics-specific competencies for the four-year curriculum. Nevertheless, during this time of transition, some course and clerkship directors were cautious about proceeding with new initiatives. Theme for the Geriatrics Program One of the strengths of this program is its utility in incorporating modifications to existing course material, rather than inserting new material. Additional themes include developing peer student leaders in geriatrics, employing simple education technology in enhancements, and working toward a competency-based curriculum. An integrated, interdisciplinary team approach was emphasized whenever possible. Because caring for frail older adults can produce positive and negative emotional responses, many of the initiatives prompted students to reflect on their personal experiences and feelings. Learning Outcomes for the Geriatrics Curriculum Undergraduate activities related to medical education aim to offer sufficient training for students to master the following competencies in geriatrics: Recognize how the normal process of aging is distinct from features of age-related illness. Identify psychosocial and economic risk factors for older adults that predispose them to illness and loss of function. Perform the basic components of a geriatrics assessment. Recommend age-appropriate preventive care for older adults. Demonstrate basic approaches in screening for and managing common geriatric syndromes/illnesses as well as frailty. Adjust treatment strategies based on physiologic and pharmacologic changes that occur in older adults. The measurement of specific learning outcomes occurs at the time of the year-end performance and skills assessment (YEPSA). Other surrogate endpoints include performance on the geriatrics objective structured clinical exams (OSCEs) during the medicine clerkship, subjective appraisal of knowledge and skills during clinical rotations, and results of the AAMC Graduation Questionnaire subsection on geriatrics and gerontology. Although the survey question format changed from 1999 through 2002, there has been an increase in students who learned about the health care needs of the elderly—from 57% to 85% in the past three years. Special Programs Seniors/mentor program In 2002, 24 students were partnered one-on-one with older adults residing in an independent living or assisted living facility in the community. In 2003 and 2004, over 40 students per year sought out this selective. This one-semester experience is part of an ongoing multiyear pilot in the patient, doctor, and society course at the UWMS. Known as the Student–Senior Partners Program, its primary goals are to improve medical education by better preparing medical students to address the needs of their older-adult patients. A secondary goal of this program is to provide a positive experience for the older-adult partners. In Year Three of a six-year plan, the future goal is to expand this experience to the entire first-year class and extend it to two semesters. Medical students attend an introductory session at an older-adult living facility, two one-on-one home visits with the older adult, a physician's appointment serving as a patient's advocate, and a small-group session led by a geriatrician. Specific student objectives include: Refine skills in interviewing and eliciting social and life histories. Increase knowledge of the systems of care and health services with which older patients interact. Identify physician–older patient communication styles and barriers and develop interviewing and other skills that enhance communication between the two. Participate in a physician–patient interaction from the perspective of the patient, rather than the doctor, by serving as “interpreter” or advocate at a doctor's appointment. Serve as a patient advocate by assisting in medication review and creation of a medication chart for prescribed medications, vitamins, and health supplements. Recognize how specific health, social, and cultural concerns of older adults affect their attitudes toward, and compliance with, their physicians’ instructions. The older-adult partners are able to take pride in serving as mentors to medical school students as a way to help future physicians treat older persons more effectively. They also enjoy friendly visits with young people and get more out of doctor visits because of the students’ help. Community partnerships The UWMS has been a leader in community-based ambulatory-care education with nearly 100 training sites throughout the state (as detailed in Figure 2.). These sites represent 5 distinct programs and involve family medicine, pediatrics, internal medicine and general surgery practitioners. They encompass rural, mid-size towns and urban settings providing exposure to the scope of practice settings. This partnership with generalists creates an ideal milieu for students to work with older adults and gain exposure to health-care teams that focus on elder care.FIGURE 2. The Wisconsin Clinical CampusThe diversity of practices, ranging from rural to urban settings, gives students an opportunity to learn about community care and managed care of older adults. The preceptorship program is a network of 33 community primary-care sites distributed throughout the state. Students spend eight weeks in this required fourth-year experience. Within the framework of this program, many students are exposed to both clinic-based and nursing home care for a growing segment of older adults within a primarily rural population. These experiences are more difficult to quantify and are not uniform experiences for all of the students. Geriatrics standardized patients/simulations Although standardized patients are utilized within certain areas of the UWMS curriculum to educate students, they have not yet been incorporated into the geriatrics education component; however, they are used for assessment purposes. Standardized patients are used twice within the present curriculum to assess student skills and knowledge in geriatrics. The third-year medicine clerkship has used OSCEs with geriatrics content for a number of years. Medical students must pass a comprehensive clinical skills exam at the end of their third year. A geriatrics OSCE exam station was introduced to evaluate students skills based on the geriatrics curriculum innovations. Faculty development programs for the geriatrics curriculum The UWMS has a rich tradition of providing instruction on teaching and education administration. The medical education development and leadership (MEDAL) courses are year-long programs whereby junior faculty and fellows meet monthly for four-hour workshops. To extend the breadth of effective geriatrics educators, geriatrics fellows and junior faculty regularly participate in these programs. Student interest groups In addition to expansion of the geriatrics curriculum content, resources from the Hartford grant were used to enhance medical students’ interest in geriatrics medicine as well. In 2001, several highly motivated students, with the assistance of the Hartford grant program director, initiated a geriatrics interest group (GIG) sponsored by the American Geriatrics Society (AGS). This student-run group is also supported by a grant from the University of Wisconsin Department of Medicine Section of Geriatrics. The GIG has developed a series of extracurricular noontime lectures and enlists the participation of medical students in various geriatrics-related community services. These include health fairs that promote awareness of Alzheimer's disease, advance directives, immunizations, and safety measures to prevent falls. Students participate in friendly home visits with the local Meals-on-Wheels chapter. Student leaders’ interests are fostered with attendance at the annual meeting of the AGS, and during quarterly meetings with geriatrics faculty members. Palliative-care and end-of-life (EOL) courses A substantial number of new palliative-care and EOL curricular initiatives have been implemented in the past three to four years at the UWMS. These activities have occurred through the work of several oncologists and pharmacologists at the UWMS comprehensive cancer center. Within the past two years, geriatrics and oncology have collaborated, resulting in an National Cancer Institute-funded cancer and aging program grant and an even stronger palliative-care focus. As part of the oncology course in Year Two, there is a lecture on palliative care as it relates to cancer, with application to noncancer diagnoses. Instruction in pain management is well addressed in the pharmacology course. Students engage with palliative-care consult teams at all of the affiliated hospitals in Years Three and Four. While at the Department of Veterans Affairs (VA) hospital, they participate in a monthly palliative-care morning report. During the medicine clerkship at the UWMS hospital, students participate in small-group sessions with palliative-care faculty. A full day in the third year is dedicated to breaking bad news and dealing with ethical issues of care near the end of life. This is facilitated jointly by oncology, psychiatry, ethics, and geriatrics personnel. Students have the option to choose a fourth-year elective at a local hospice organization and in UWMS oncology clinics. Resulting Pedagogical Changes The medical school's curriculum has de-emphasized a heavy reliance on lectures and a predominantly knowledge-based-objective testing format for student evaluation. All courses now have applied learning activities, and the emphasis on problem solving and evidence-based decision making has increased significantly. Interdisciplinary courses, especially in the clinical venues, were initiated in 1990, and these experiences are now a significant part of the medical student curriculum, especially in clinical venues. Topic areas, such as geriatrics and aging, ethics, and principles of epidemiology are woven into existing courses rather than creating multiple new small topics courses. The pedagogical approaches chosen for the new geriatrics curriculum were shaped by these changes and also supported them. Through this recent curricular reform, specific grant initiatives have demonstrated that we have made the shift to a more interactive, problem-based approach. Previously, the geriatric case in the medicine clerkship was presented as a didactic session. With revision of these cases to PowerPoint, a more interactive, case-based approach was employed. At the Milwaukee site, teaching stations have been devised that provide a small-group emphasis as common geriatric syndromes are reviewed via case discussion. Application of Computer Technology The Alzheimer's case conference primer presents didactic material in an appealing Web site format. This preconference preparation is intended to enhance as well as increase the quality of the time students spend interacting with participants in the actual case conference session. The geriatric cases for the third-year medicine clerkship have been updated and reorganized into a standardized educational design, and they are now being disseminated in an easily transportable and teachable PowerPoint format to four different clerkship sites across the state. Students’ Clinical Experiences in Geriatrics Clinical geriatrics experiences exist for UWMS students spanning all four years and multiple training sites. Geriatrics, internal medicine, and family medicine faculty members with certificates of added qualification in geriatrics care for seniors throughout the UWMS system. This care occurs in primary-care clinics, hospitals, nursing homes, and home settings. Students have a chance to see both the primary-care and specialty-care aspects of this discipline portrayed in three distinct geriatrics clinical programs at UWMS-Madison, the UWMS-Milwaukee campus, and the Marshfield Clinic. Unfortunately, these experiences are not uniform across the medical school class at present. In Years One and Two, many medical students are paired with preceptors with an interest or training in geriatrics within the Generalist Partners Program. This includes clinic mentoring for three half-days per semester for four semesters. The student–senior partners program introduces students to patient–physician communication issues and care issues relevant to older persons. Within Year Three, 12 students per year rotate on the UWMS hospital inpatient geriatrics unit during their medicine clerkships. Students may be exposed to the geriatrics and palliative-care consult teams on most any third-year inpatient experience. The primary-care clerkship places students into the geriatric clinic sites in Milwaukee and at the Madison ElderCare Partnership site, where they receive mentoring and hear a series of interactive lectures on geriatrics topics. A small number of third-year students enroll in the one-month geriatrics elective in Madison. For fourth-year students, geriatrics medicine electives exist in Madison, Milwaukee, and Marshfield. The elective rotation in Madison educates four to six students per year. This experience exposes students to the rich blend of specialty clinics, primary care, long-term care, and home care that exists between the Madison VA Geriatrics Research, Education, and Clinical Center (GRECC) and the UW geriatrics section. The students also attend many GRECC-sponsored conferences and seminars relevant to geriatrics and geriatric psychiatry. A distinct geriatrics psychiatry elective is also available at the Madison VA. The Program’s Assessment and Evaluation Instruments The entire geriatrics curriculum is evaluated within the context of ongoing curriculum review (student ratings of courses and faculty, focus groups, and end-of-year surveys). The Medical School instituted a comprehensive clinical skills exam in 1998. The YEPSA is required of all students at the end of their third year, and they must successfully pass all stations in order to graduate. Students are informed of the competencies that may be tested in the YEPSA when they begin their third-year clinical rotations. Subsequently, all students on the medicine clerkship receive a 1.5-hour seminar that reviews two geriatric cases. This topic is consistent throughout the year and provides content for the YEPSA case. This examination uses ten OSCE stations for skills assessment, selected from the third-year competencies. It is noteworthy that UWMS clinical departments administer the stations and the geriatrics OSCE is one of only three nondepartmental programs represented. Students must demonstrate proficiency in selected geriatrics competencies. This links curricular initiatives with geriatrics competencies and student proficiency prior to graduation and provides a powerful incentive for students to learn core topics in geriatrics and gerontology because this content is “on the test.” Resources Required The dean's office, the academic affairs staff, and the EPC of the Medical School supported the new geriatrics longitudinal curriculum. Specifically, administrative staff supported the standardized patient program, the OSCE, and the YEPSA exams, to process evaluations and to coordinate learning experiences within the patient, doctor, and society course. The UW Department of Medicine Section of Geriatrics and the Madison VA GRECC play pivotal roles in supporting faculty salaries to participate in teaching, programming, and administration of education activities. The GRECC also provided space and administrative support for most of these initiatives. Requirements to Sustain the Program Mission-aligned management and allocation funds: Consistent with its strategic priorities, the UWMS has developed a highly successful mechanism, called “MAMA funds,” to support the educational and academic activities of its faculty members. This mechanism rewards faculty members involved in medical education and training that are in alignment with the medical school's areas of emphasis. In 2001, approximately 17% of the UWMS Department of Medicine budget was supported by MAMA funds from the medical school. Similarly, the Section of Geriatrics received more than $126,000 from the Department of Medicine as reimbursement for the various educational and scholarly activities of its faculty. The allocation of MAMA funds for each faculty member is based on a complex formula that takes into account time spent for various educational activities, such as lectures for students, residents, and continuing medical education, mentorship, group discussions, clinic and research project supervision, and publications. Since the initial Hartford support, MAMA funds are playing a pivotal role in providing salary support for key personnel to continue their curriculum-related activities. Madison GRECC recruitment: At this writing, the Madison GRECC is recruiting an associate director for education and evaluation. These efforts targets advanced-degree candidates with an acknowledged reputation and background in medical education. Additionally, the appointed individual will have a track record of educational activities in geriatrics medicine and demonstrated excellence in aging research. It is anticipated that this official will play an important role in perpetuating the educational activities of the geriatrics curriculum. Support for this position will be provided by the GRECC. Health Sciences Library: The UW Health Sciences Library will play a critical role in ensuring continued success of this program. The library has extensive resources in information technology and will provide all the resources necessary to maintain the “virtual course” in geriatrics beyond the initial period of funding. Additionally, the library will continue to provide information resources essential for evidence-based education. Endowment funds: The UWMS is the recipient of funds from a significantly increased gift and grant program. There are plans to hire at least two additional staff members to support educational activities at both the medical school and residency levels. It is expected that the enhanced infrastructure will support the geriatrics educational activities of the present proposal beyond its initial period of support. Research grants: We anticipate that extramural funds will be one of the major resources to sustain the program, including pursuit of funding through the Reynolds Foundation. The UWMS has a solid track record of receiving federal and nonfederal grants in the field of medical education. There are currently a number of active federal grants at UWMS related to faculty development and training and to medical education. In addition, the university has several demonstration grants from the Health Research and Services Administration. The Wisconsin Area Health Education Centers (AHECs) will be working in close collaboration with educators on further curriculum enhancements. The Wisconsin Geriatrics Education Center, based in Milwaukee, has already provided funding to perpetuate the student–senior partnership program. Discussions have begun regarding future support via AHECs for the rural physician component of the project. Therefore, overall, we are confident that we will be successful in receiving extramural support for this geriatrics education program. Unanticipated Outcomes Clearly, curricular changes have occurred and geriatrics visibility has increased within the curriculum office of the UWMS. Several geriatrics faculty members have adjusted their academic pursuits from a clinical or research focus to a more concerted commitment to geriatrics education. Collaborations between geriatrics faculty and information systems and computer technology personnel will foster future projects following the grant. Participation by geriatrics faculty in medical school programming and committees has increased. Geriatricians at different clinical sites (Madison, Milwaukee) renewed relationships and now plan to work together on other extramural efforts. The positive interactions between grant personnel and course directors fostered interest in pursuing further course innovations distinct from the grant. Impact of External Funding The external funding from the AAMC/Hartford Foundation was a critical and essential component in implementing the geriatrics program. Although a number of favorable factors were in place (such as curricular reform and strategic planning), it is doubtful that this initiative would have succeeded without the focused support for development that these grant funds provided. The funds were critical in supporting targeted release time for faculty and specific staff support for the geriatrics curriculum as it was developed. They were the catalyst that allowed the curriculum development and implementation, and they also allowed the medical school to provide ongoing support for the curriculum once it was established and running smoothly. For further information, contact Steven Barczi, MD, at 〈[email protected]〉.