University of California, San Francisco, School of Medicine (2004)

Overview of the Geriatrics Curriculum The University of California, San Francisco, School of Medicine (UCSF) began implementation of a new medical school curriculum in fall 2001; the first class of students taught entirely in the new curriculum will graduate in 2005. The curriculum redesign sought to energize the educational experience for medical students by emphasizing case-based, learner-centered educational methods, multidisciplinary integration of subjects, and limited lecture time. The structure of the new curriculum is shown below in an outline style in Figure 1.FIGURE 1. Curriculum StructureThe Essential Core, during the first two years, consists of nine sequential blocks, each an interdisciplinary course organized around central themes or systems. Most blocks are about eight weeks long. Foundations of Patient Care (FPC) runs longitudinally with all the other blocks for both years. The Essential Core provides meaningful opportunities for active and collaborative learning. The curriculum also fosters each student's professional stake in learning. Students are responsible for small-group preparation and attendance. Evaluations of courses and faculty are also part of their professional commitment. The block courses are (in chronological order): Prologue: An introduction to essential anatomy, physiology, biochemistry, molecular and cell biology, epidemiology, social and behavioral science, and pharmacology. Foundations of Patient Care: A block that spans the entire Essential Core, covering clinical skills, professional development, and clinical reasoning. For geriatrics content, in Year One, students learn about special aspects of the history and physical of the older patient, are introduced to the concept of geriatrics assessment and function, and interview an older patient in a small group. The students also have a section on Medicare and Medicaid. Beginning in 2004, a clinical reasoning component of FPC will feature geriatrics clinical decision making. In the second year, there is an extensive module on death and dying. Organ Systems: An integrated approach to investigating the cardiovascular, pulmonary, and renal systems. For geriatrics content, various themes of age-related diseases are incorporated into the course. Clinical Interlude: A three-day immersion in the hospital setting that provides students their first inpatient experience. Cancer: An in-depth and innovative look at the pathology and therapy of major human cancers, and a broad exploration of relevant disciplines, including epidemiology, genetics, hematology, culture, behavioral sciences, ethics, and complementary and alternative medicine. For geriatrics content, the students receive a two-hour lecture on cancer in older people, including special aspects of epidemiology, presentation, cancer screening decisions, and clinical decision making in older adults. Brain, Mind, and Behavior: A comprehensive overview of general principles in neuroscience, neurology, and psychiatry. For geriatrics content, information about dementia and the mental status exam are taught in this course. Infection, Inflammation, and Immunity: This is the first block of the second year, covering microbiology, immunology, and infectious disease, as well as public and international health issues. Metabolism and Nutrition: An investigation of the gastrointestinal system, endocrinology, and metabolic issues, with additional emphasis on prevention of disorders in these areas and on counseling for nutritional health. Life Cycle: A study of the human developmental sequence, considering special topics in childhood and adolescent medicine, men's and women's health, and aging. For geriatrics content, Life Cycle anchors the geriatrics curriculum in the Essential Core. Geriatrics sessions focus on the following topics: Demography and social context of aging (one-hour lecture) Biology of aging (one-hour lecture) Physiology of aging (one-hour lecture) Drug use in elders and geriatric pharmacology (one-hour lecture and two-hour case-based small-group session) Late life events and psychology (one-hour lecture) Common ethical issues in late life (two-hour case-based small group) Geriatric syndromes and failure to thrive (one-hour lecture) Advance directive and resuscitation orders (one-hour lecture) Principles of long-term care (one-hour lecture) Principles of rehabilitation (one-hour lecture) Health aging and longevity (one-hour interview of an older person) Integration and Consolidation: The final step of the Essential Core, which enables students to review and integrate concepts through case-based study. This block also reinforces differential diagnosis skills and provides a structure to prepare and review for the board exam. Curriculum Management and Governance Structure Figure 2 shows the UCSF School of Medicine Organizational Chart for Medical Education. Decisions about the curriculum decisions are the purview of the Committee on Curriculum and Educational Policy (CCEP), which reports to the School of Medicine Faculty Council. The Faculty council meets monthly and the dean attends these meetings. Under the CCEP are the other curricular committees.FIGURE 2. Organization of Curriculum CommitteesTHE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The new curriculum that was unfurled at UCSF in the fall of 2001 followed three years of intensive planning at annual educational retreats and countless smaller planning committee meetings. Geriatrics representatives were present at many of the planning meetings, a geriatrics advisory group to the new curriculum was formed, and geriatrics was considered one of the themes that would be woven throughout the new curriculum. The AAMC/Hartford grant came at the perfect time to allow geriatrics faculty to participate in the intensive planning process for curricular change. Theme for the Geriatrics Program Older people are diverse physiologically, socially, and psychologically. Patient preferences, life expectancy, and comorbidities should be considered in developing treatment plans collaboratively with patients. Health professionals should use evidence from the literature, not preconceived notions, to determine if a disease, diagnosis, or treatment is different for older adults than for other populations. Functional assessment is an important component of the evaluation of older patients. Special Programs In collaboration with the schools of nursing, dentistry, social and behavioral sciences, and physical therapy, we have developed a series of Web-based modules in geriatrics and gerontology. The modules are the Demography and Epidemiology of Aging, the Biology and Physiology of Aging, Assessment of the Older Patient, and Need and Access Across the Spectrum of Care. The modules are almost complete and will be universally accessible at 〈http://ucsfagrc.org〉 within the next few months. Geriatrics OSCEs We have developed two geriatrics OSCEs (objective standardized clinical examinations), one on a functional screening tool and another on administration of a Mini Mental Status Exam. These were piloted for students at the end of their second year. In addition, we have a clinical practice examination (CPX) administered to all fourth-year UCSF students, one station of which is a geriatrics station. SAGE Program SAGE, the “students and great elders” program, was designed as a first-year course to introduce students to relatively healthy older adults who live in the community. The course was designed to explore a variety of issues in normal aging through a monthly meeting with the elder and in class lectures and small groups. The major disappointment of the AAMC/Hartford Project was that the SAGE program was not made a required course. It was offered as an elective but did not have enough participants to continue. The reasons for the failure are thought to be a very full curriculum and a high number of popular electives in competition with SAGE. We are happy to share our curriculum with other schools, if they wish to use it. Resulting Pedagogical Changes UCSF has undergone significant pedagogical changes since the curricular change in 2001: Lectures are limited to no more than two hours per day. Material previously taught in lecture format is now taught in small-group, interactive, and problem-based learning-type formats. Computer-assisted and multimedia instructional technologies have been introduced into the Essential Core Curriculum and some clinical rotations. Simulated patients are now used to give students experience and feedback in interviewing and physical exam skills throughout the four years of medical school education. Application of Computer Technology Computer technology has been incorporated into the geriatrics component of the curriculum in the form of five Web-based geriatric teaching modules: Demography and Epidemiology of Aging Biology and Physiology of Aging Socio-Cultural and Psychological Aspects of Aging Assessment of the Geriatric Patient Health Care Policies The modules are meant to be supplemental to class materials and are geared toward all health professional students at UCSF: medical, nursing, physical therapy, pharmacy, and dentistry. Modules 1-3 are targeted toward preclinical students, module 4 is targeted toward clinical students, and module 5 is targeted toward either level. The modules are available at 〈http://ucsfagrc.org/content.html〉. Students’ Clinical Experiences in Geriatrics The Clinical Core, the third year, includes the required clinical clerkships of the UCSF medical program. The Clinical Core runs for 54 weeks. It is composed of six eight-week-long clerkship periods, including psychiatry/neurology, pediatrics, obstetrics/gynecology/women's health, medicine, surgery/anesthesiology, and family and community medicine. Family and community medicine anchors the geriatrics clinical experience. Each student is expected to do at least one home visit, and most are to older patients. Linked to the home visit experience are two didactic sessions – one on the home visit and one on geriatrics assessment tools. After the home visit, students write up the experience using standardized home assessment and participate in a group debriefing session with a faculty member who has geriatrics expertise. The third year also includes the Longitudinal Clinical Experience, which runs concurrently with the clerkships, meeting for half a day each week and giving students exposure to an outpatient clinical setting in a field of their choice. Geriatrics clinical sites are among the choices, and some students have selected geriatrics longitudinal experiences. Geriatrics objectives have been incorporated into the third-year medicine clerkship, and geriatrics content is included on the medicine final examination. One activity that has been piloted but is not yet implemented is to ask third-year medical students to do one case write-up of an older person reviewed with a geriatrician during their medicine rotation. We hope to have sufficient faculty at all three hospitals to integrate this into the medicine clerkship during the 2004-05 academic year. Three week-long intersessions punctuate the clerkship rotations. Intersessions enable students to meet and exchange thoughts about their recent clinical experiences, further refine critical thinking skills, and explore more fully medical ethics, health systems, medical sciences, and evidenced-based medicine. Although geriatrics per se is not included in the intersessions, many of the ethics sessions involve geriatric cases and important geriatrics concepts (e.g., components of competence and decision making capacity), and many are facilitated by members of the geriatrics faculty. Advanced Studies, in the fourth year, encompasses elective rotations, research, and specific fields of inquiry that make up the fourth year of the medical program. Advanced Studies prepares students for postgraduate study and provides opportunities for international health, scholarly work, and senior clinical rotations. Students may select an area of concentration in order to develop expertise in a field that informs the kind of physicians they would like to be and to join communities of common interest (other than those in their specialty). Areas include health policy, community medicine, humanities, international and public health, and medical education. UCSF made a very conscious decision to have few requirements in the fourth year, and so it was logistically impractical to require geriatrics content in the fourth year. Because the fourth year is based on offering a rich variety of electives, a decision was made to develop attractive electives rich in geriatrics content. Two electives have been developed so far. One is The Perioperative Care Clerkship for Future Primary Care Doctors and Surgeons, a one-month rotation that follows patients from preoperative evaluation, through surgery, to postoperative care and discharge planning. Perioperative delirium and discharge planning are core learning modules in the clerkship. The other clerkship is called Caring for Patients in the Palliative Care and Long-Term Care Settings; it is jointly run by general internal medicine and geriatrics faculty. This one-month rotation gives students exposure to end-of-life care in institutional and noninstitutional settings, as well as an introduction to institutional long-term care. This rotation was piloted last winter, was well reviewed, and will continue to be offered. The Program’s Assessment and Evaluation Instruments We are using instruments developed by the UCLA Division of Geriatrics (see the UCLA report in this supplement) for cross-site evaluation. The instruments include a geriatrics attitude and knowledge survey consisting of eight true-and-false items adapted from Palmore's Facts on Aging Quiz (Palmore EB. Facts on Aging Quiz, 2nd ed. New York: Springer, 1998), 15-case-based multiple-choice items on medical assessment and management (Reuben B, Lee M et al. Development and validation of a geriatrics knowledge test for primary care residents. J Gen Intern Med, 1997;12:450–2), and a 14-item Likert-typed attitude scale (Reuben DB, Lee M, et al. Development and validation of a geriatrics attitudes scale for primary care residents. (J Am Geriatr Soc, 46:1425–30, 1998.). The California Consortium for the Assessment of Clinical Performance has developed three geriatric standardized patient (SP) cases for use in a clinical performance examination for senior medical students. The cases include an SP script, a videotape for SP training, and scoring checklists for history taking, physical examination, information sharing, and clinical courtesy for each case along with a standard checklist for patient/physician interaction. Requirements to Sustain the Program UCSF has been able to continue the geriatrics components of the curriculum by continued funding through the California State Agency for Geriatric Research Centers (AGRC) program, which provides limited support for geriatrics education at the University of California, and interjecting geriatrics into already established courses with funding – foundations of patient care, life cycle, and family and community medicine. Unanticipated Outcomes Some of the unanticipated outcomes have included having a geriatrics presence at various leadership committees, including the Academy of Medical Educators Educational Innovations Committee and the Teaching Scholars Program, and closer geriatrics working relationships with teachers of end-of-life care, health care policy, clinical medicine, foundations of patient care, family medicine, anesthesia, and hospital medicine. Impact of External Funding The impact of the external funding cannot be overemphasized. The presence of funding allowed us to buy geriatrics faculty time in order to be present at planning meetings for the new curriculum, which we believe allowed geriatrics to develop a relatively well-planned presence in the new UCSF curriculum. We believe that the timing of this grant to coincide with a period of curriculum reform was key to that success. For more information, contact C. Bree Johnston, MD, MPH, at 〈[email protected]〉.