Wayne State University School of Medicine (2004)

Overview of the Geriatrics Curriculum Wayne State University School of Medicine (WSUSOM) has a traditional curriculum that consists of basic science courses in Medical School Year 1 (M1) and M2 and clinical learning in M3 and M4. We have introduced important new curricular topics as vertically integrated curricular (VIC) themes: focused content integrated into existing required courses and clerkships across the four years of medical school. The VIC, Geriatrics and Gerontology Curriculum (GGC), is integrated across the four years of undergraduate medical education—see List 1.LIST 1. Geriatrics Curriculum for Medical School Years 1–4, Wayne State University School of Medicine, 2003–04In M1 and M2, the basic science correlates of aging include the physiology, neurology, nutrition, and neuropsychiatry of normal aging. A geriatrician provides clinical correlation lectures on normal and pathological aging in pulmonary and pharmacology. The biopsychosocial aspects of healthy aging are emphasized in a new longitudinal course, Clinical Medicine (CM). In this course, healthy aging and common conditions in aging, including memory loss and functionality, are explored in physician-led, case-based, small-group sessions. Standardized patients (SPs) and computer-based reading and exercises support the small- group learning. An additional experience in CM requires that students interview a geriatric patient in a primary care physician's office practice using the Health Related Quality of Life Measure questionnaire (see 〈http://www.cdc.gov/nccdphp/hrqol/pdfs/hrqolm2000.pdf〉). The geriatrics curriculum also includes age-related pathobiology and psychiatric conditions; interactions of pharmacology and aging, and social risks associated with aging, including end-of-life issues. During the clinical years, M3 and M4, students’ geriatric experiences include didactics on prevention activities and elder abuse, an interview with a hospice patient about end-of-life issues; required discussion about advanced care planning with a patient using a durable power of attorney for healthcare form; and use of life-cycle-specific cases in the family medicine clerkship. Curriculum Management and Governance Structure The School of Medicine is managed both democratically and centrally. The democratic management consists of a Curriculum Committee appointed by the elected faculty senate plus voting student members from each medical school class. The associate dean for academic and student programs, who also has a central staff for implementing curricular innovation, evaluation, research, and contracts, chairs the Curriculum Committee. The geriatrics program was incorporated the same way that all of our VIC themes are implemented. Before we applied for the Hartford Grant, a team of faculty and academic administrators made a formal proposal to the Curriculum Committee. Once approved, the proposal was then submitted. Once we received the grant we began creating new curricular elements and implementing them incrementally. To ensure that our geriatrics theme is sustained, we have set up a permanent advisory group to the Curriculum Committee consisting of a wide range of stakeholders including geriatricians, gerontologists, educators, patients, a nursing home operator, geriatrics clinical nurse specialists, students, and community outreach specialist. This kind of process is also used to help sustain our other themes. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change Our school has engaged in a continuous quality improvement process for medical education that we describe as “radical-incrementalism,” making small, meaningful changes gradually so that over time the small changes constitute major revision with minor disruption. We continuously look at the curriculum, using a variety of metrics, and strategically focus on issues that we feel are basic (radical). We then implement these changes using the tactics of incrementalism, preserving what is good about what we already have as we constantly move forward. The process of radical incrementalism provides excellent opportunities for curriculum change, as this model is always open to new ideas, teaching methods, and instructional innovations. Using this approach, we have been able to introduce and implement new focus areas for students without requiring major changes. An important outcome of the curricular strategy of radical incrementalism has been the creation of a positive learning environment in which faculty look forward to interdisciplinary collaboration. The key to successful curricular change is institutionalization, which means that these changes become “hard-wired” in a forward-moving curriculum. As with any other part of the curriculum, these new elements may be altered in the future, but we have selected topics and issues that are meaningful and that must be a part of a modern updated curriculum for medical students. Curricular change provided a tremendous opportunity for incorporating new geriatrics content as well as coordination of existing curriculum. As a result of earlier UME-21 funding, (Health Resources and Services Administration) we created an interdisciplinary M3 clerkship, the continuity clinic clerkship (CCC). Administrative support for the CCC and concomitant interdisciplinary collaboration provided a foundation for the development of a new clinical course, CM, mentioned earlier. This course includes Web-based experiences, lectures, and case-based, small-group sessions, several of which also include SPs. The intent of the course was to increase clinical exposure and training in M1 and M2. Previous stand-alone “orphan” courses that were clinically relevant were integrated into this new interdisciplinary course. The AAMC/Hartford geriatrics and gerontology grant began as we were designing this new course. The timeliness of the grant allowed us to incorporate many of the geriatrics learning objectives into the curriculum as part of the CM course. The course co-directors are also the directors for the family medicine and CC clerkships in M3, and the medical educator on the AAMC/Hartford grant is also the medical educator for the CM course. The involvement of these and other faculty contributed to a seamless integration of geriatrics curriculum throughout undergraduate medical education. Another important factor in the success of incorporating geriatrics content into the curriculum is that the project director of the AAMC/Hartford grant is the associate dean for academic and student programs and is also the architect of the radical incrementalism approach. Theme for the Geriatrics Program Two themes have guided the development of our curriculum: “Healthy Aging” and “End of Life” (EOL) care. Our new curricular components emphasize healthy aging through modeling by SPs, challenges to commonly held myths, and emphasis on health promotion and health maintenance with the older patient. The EOL curriculum has been enhanced by laddering of learning across the four years. Students learn about EOL in M1 and M2, interview EOL patients in M3, and assist with advance planning in M4. Learning Outcomes for the Geriatrics Program The learning outcomes are derived from the learning objectives that we proposed in our grant application and include the following new and enhanced curriculum: Acquire a basic, introductory knowledge of and an appreciation of the complexities involved in the diagnosis and management of common geriatric conditions in the elderly patient. Physiology lecture and lab includes biology of normal aging (M1). The Clinical Nutrition course includes nutritional needs of the elderly (M1). Introduction to elements of the geriatric assessment includes memory assessment tools and family experience with Alzheimer's disease in CM (M1). Students learn basic concepts of the aging immune system (M2). Students learn basic pathophysiology and clinical presentation of common conditions in geriatric patients (M2). Students understand common drug interactions, pharmacokinetics, and pharmacodynamics in the elderly patient (M2). Acquire a familiarity with current literature regarding conditions associated with aging and suggested prevention activities and resource information for adverse health outcomes and general wellness promotion. Students learn current overview information and recommended prevention activities and are provided with resource information for dementia, delirium, inappropriate medication prescribing, incontinence, falls, osteoporosis, sleep disorders, pain, elder abuse and neglect, substance abuse, sexuality, and home safety (M1). Students learn to organize and administer a set of instruments to assess differences in mental functioning, physical functioning, and quality of life of the senior through student practice with the Mini Mental State Exam, the Geriatric Depression Scale (short form), and functional status assessment (Activities of Daily Living and Instrumental Activities of Daily Living) (M1). Learn skills of effective communication and advocacy through planned experiences that focus on the effect of nonmedical variables (family, socioeconomic resources, community resources and access issues, etc.) on health outcomes among the elderly. Students interview elderly SPs in CM small groups with physician oversight, using a case that focuses specifically on the role of the family (M1). During four CM site visits to the community-based offices of primary care physicians, students interview an elderly patient using the Health Related Quality of Life Measure (M1). Develop attitudes that contribute to an appreciation of the aging process as a normal part of the life cycle through which most elderly patients can move without major problems and a commitment to improve the quality of life and mental and physical functioning of older persons. Students complete a 50-question web-based aging quiz (Woolf L, The Aging Quiz, 〈http://www.webster.edu/∼woolflm/myth.html〉) that tests common myths about aging and provides correct information after the question is answered. Elderly patients who participate in small-group case presentations, the objective structured clinical examination (OSCE), and the CM site visits all represent the healthy, well-functioning elderly. Students learn about decision making at the end of life, advanced directives, competent patient decision-making, and competency legal issues in lecture (M2), in small-group case discussions (M2), and by helping a patient complete advance planning directives (M3). In the family medicine clerkship, students discuss end-of-life issues with hospice patients during a home visit and participate in interdisciplinary team patient management meetings at a hospice center. The experiences are shared in a debriefing session with a palliative care physician. Special Programs Community partnerships We have partnered with St. Patrick Senior Center for student advocacy, senior citizen residencies (Brush Park, Hannah House) for planned student-senior interviews, nursing homes (Presbyterian Village), and community-based primary care physicians (clinical medicine site visits and continuity clinic clerkship). Geriatrics standardized patient/simulations We have trained and use SPs in our case-based, small-group sessions entitled “The Aging Patient and Geriatric Assessment” and use SPs as elderly patients in the OSCEs in M1 and M3. Faculty development programs for geriatrics curriculum We do not have a formal faculty development program in geriatrics at the SOM. However, there has been tremendous informal faculty development with our 24 clinical medicine small-group physician instructors through the new geriatrics cases (including the EOL cases) developed with the assistance of the AAMC/Hartford geriatrics grant and through the dissemination of the requirement for the geriatrics interview in the site visits to community-based physicians (256 students in each class). Our theme of healthy aging has contributed to the enhancement and development of new curriculum by faculty in psychiatry, family medicine, and internal medicine who otherwise might not have emphasized this part of the life cycle. In addition, we have partnered on this grant with the Institute of Gerontology. The Institute hosts the Colloquium and Professional Development Series with weekly seminars that are open to WSUSOM faculty. For example, one of the recent seminars was “Keys to Unlocking the Health Beliefs of African-American Elders: You Don't Know What You Don't Know,” by Toni Flowers, RN, of the Michigan Peer Review Organization. Student interest groups There are two student interest groups that focus on the elderly. The Senior Citizen Outreach Group provides basic screening and health promotion services to the St. Patrick Senior Center members on Saturday mornings. In addition to taking blood pressures, they developed a “key chain” project in which a list of current medications is attached to a key chain. A new interest group this year that calls itself the Death and Dying Interest Group works with the Hospice of Michigan. Members complete a three-hour training seminar and after additional training, they will shadow a hospice physician and volunteer at the Hospice of Michigan for one year. Palliative care and end-of-life courses We have developed a strong palliative care component to the geriatrics curriculum that is integrated across years M1-M3. End-of-life topics are well represented in the curriculum in required courses. Components have been described in the text above. Resulting Pedagogical Changes We define pedagogy as creating an environment that allows learning to thrive. One of the major changes we made to create a thriving learning environment was to increase and encourage interdepartmental collaboration for curriculum development and implementation. This approach revitalized interest in teaching, even as the increased emphasis on clinical income-generating activities would have seemed to discourage an interest in teaching. The bond that unites the faculty from different clinical and basic science departments is an interest in providing clinical learning in the medical school curriculum. For example, the School of Medicine has encouraged the development of “clinical correlations” in basic science topics. Physician faculty are asked to provide clinical relevance in the basic science courses. One of the co-investigators on this grant provides three clinical correlation lectures in basic science courses on the aging patient. At the same time that the basic science courses integrate clinical relevance, the new CM course arranges the case-based sessions to correlate with the current basic sciences topics. For example, the unit on “The Uncomfortable Arm” (eliciting an occupational/environmental exposure history in a patient with carpal tunnel syndrome) occurs concurrently with upper limb dissection in anatomy. An important outcome of this evolving collaboration and interest in teaching is an elaborated focus on students’ learning. The CM course evolved from an earlier course (Introduction to the Patient) in which attendance at lectures was voluntary. In the interdisciplinary planning meetings for the new CM, we agreed to raise the bar for students’ performance by requiring mandatory attendance at all small-group sessions and lectures. Small-group evaluations of students now include assessment of advance preparation. Because many of the small-group sessions occur in physician offices away from the medical school, all students are required to wear white coats to small group to emphasize professional behavior. These changes are justified as preliminary training for the skills and attitudes needed to be successful during residency training. The effect of these new requirements has been to energize both the students and small- group faculty, who in the past tried to motivate unprepared students. Based on feedback from faculty and students’ evaluations, the improved small-group dynamics contribute to an enhanced and energized learning environment. Several clinical teaching faculty have said that the CM small-group sessions are the high points of their week. An additional positive outcome of this improved learning environment has been that we now have several new faculty who have volunteered to be small-group instructors for next year. A surplus of volunteer faculty is a new experience for us! Another important change was the inclusion of SPs in the small-group sessions. During the geriatrics session, students practice using the Mini Mental State Examination and the Geriatric Depression Scale with the SP to evaluate an older patient who presents with memory loss. Students were very positive in their evaluation of the use of SPs in this session. We have increased our use of Web-based exercises, and all course materials are posted onto the course management program, Blackboard. The use of interactive Web modules is an evolving process. This year is the first that students could use streaming video without difficulty and we began using pocket personal computers (PCs) to log in attendance during CM. We anticipate an increased use of Hartford Foundation-sponsored Web-based resources as the pocket PC program is more fully integrated into the curriculum. The increased use of Web-based resources will grow as faculty members become more familiar with Web-based programs and our information technology support for the School of Medicine improves. Application of Computer Technology The entire CM course is available on-line on Blackboard, a course management program sponsored by the university. Pocket PCs are used to document attendance in CM. Because of the clinical relevance of the course, attendance is mandatory. Students complete the “Aging Quiz,” in Blackboard, as a required assignment. This quiz challenges common myths about the elderly. After selecting their response, students can access the correct answer. The intent of the quiz is to further enhance positive attitudes toward the geriatric patient. Key links are provided for additional information. The WSUSOM is refining the use of a pocket PC program in clinical years to document similarity of clinical experiences across different sites. Once this program is established (2004–2005), we will be able to add additional Web-based components to the clinical geriatrics curriculum. Students’ Clinical Experiences in Geriatrics Clinical Medicine (M1) Interview geriatric SPs Interview geriatric patients during primary care site visits Interview geriatric SPs for OSCE Physical Diagnosis (M2) Interview elderly nursing home residents Clerkships (M3) Family medicine visit and interview with hospice patient CCC: Plan advanced directive with a patient; evaluate community resources in a clinical learning exercise Obstetrics and gynecology: Small-group discussion of potential stigmatization of elderly patients Rotations (M4) Emergency medicine: Students participate in evaluation of elderly patients treated for fall-related injuries Extracurricular and electives: (1) The Senior Citizen Outreach Program, and (2) the Death and Dying Group The Program’s Assessment and Evaluation Instruments An M1 Geriatric OSCE was created to evaluate the ability of students to assess an elderly patient's functional status through assessment of Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). We incorporated trained SPs for the geriatrics case-based interview sessions in CM. In addition to the students’ interviewing experience, the SP also was trained to provide feedback to the students on their performances. Web-based resources were used to evaluate students’ learning on geriatrics topics, including use of the Aging Quiz. Student experiences and insights are elicited in a hospice debriefing session after students visit and interview a hospice patient. Four palliative care physicians rotate supervision of these sessions, and each has commented on the transforming effect that students describe recounting their interview experience. For example, one student wrote, “I couldn't get over that this person who was dying was talking with me and laughing and encouraging me to do well in medical school. They should be thinking about themselves.” Questions on geriatrics topics have been added to the clinical medicine and continuity clinic clerkship written examinations. The program-level evaluation was assessed by the successful development and integration of the curricular components of our geriatrics program into the undergraduate medical education program, as well as determining the effectiveness of the curricular components through the student-level evaluation. The student-level evaluation was conducted through three primary mechanisms. First, for the didactics related to our current geriatrics curriculum and new curricular components during M1-M3, students are assessed through traditional classroom examinations. Second, at the end of M1 and M3, OSCEs were conducted. Third, to determine the effectiveness of the advocacy program on students’ attitudes toward caring for elderly patients, a randomized pre-test/post-test control group design was applied using M1 medical students. of the M1 students received the advocacy program and geriatrics the other received the groups of students were the Aging to the advocacy program and following the program The aging a factor The of the was to determine the student advocacy program would students’ attitudes toward the elderly. was that at the end of the group will increased positive attitudes about geriatric patients, as to the control of that there was a increase in positive attitudes toward senior patients by all students, with a increase in the group to the these differences were not An involved a small of students who very high on positive attitudes toward the elderly on the this their high but most of this group was also involved in activities with Resources resources not by Hartford were used to implement the geriatrics curriculum. 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