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Academic Medicine:
The Reports

University of Louisville School of Medicine

O'Brien, James MD; Greenberg, Ruth PhD

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Overview of the Geriatrics Curriculum

The overall goal of the integrated geriatrics curriculum is to prepare undergraduate medical students to diagnose, treat, and interact with senior adults, and with their families and caregivers, in ways that communicate expertise, understanding, and respect for their personal, physical, cultural, psychological, and social conditions. In addition, we wanted to create an educational program in geriatrics that emphasizes progressive acquisition of knowledge, skills, and attitudes. Finally, we wanted this new geriatrics curriculum to affect all students and all four years of the undergraduate program.

The geriatrics curriculum begins with healthy, normal aging processes; in Year Two, students learn about abnormal and unhealthy aging and the complex bio-psychosocial issues facing senior adults. Years Three and Four emphasize applying geriatrics knowledge to direct patient care in a variety of clinical settings. Educational activities are developed to maximize the use of standardized patients, human patient simulators, and interactive educational experiences. The Interdisciplinary Committee on Geriatrics Education (ICGE) was created and continues to meet, coordinating the development and evaluation of this new component of the educational program. Learning objectives have been drafted, and the ICGE continues to seek “homes” for these objectives.

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Curriculum Management and Governance Structure

Curriculum oversight consists of three entities: the Educational Policy Committee, the Educational Administrative Committee, and the Program Advisory Council (see Figure 1).

Figure 1
Figure 1
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The Educational Policy Committee, which consists of both elected and appointed members, is responsible for the design and management of a coherent, coordinated curriculum, including recommending curricular goals, determining means to fulfill these goals, evaluating how well the curriculum meets its goals, and recommending changes and innovative improvements

The Educational Administrative Committee (dean, vice dean, student affairs dean, associate dean for curriculum, and senior associate for educational affairs) serves as“chair” for all interdisciplinary courses and advocate for Educational Policy Council (EPC) recommendations.

The Program Advisory Council (created in December 2003), a 36-member, high-level “think tank,” focuses on long-term planning and oversight of the educational program.

The ICGE provides oversight and guidance in the development of a new, integrated, innovative geriatrics curriculum.

Since all components of the new geriatrics curriculum have been integrated into existing courses and clerkships, they did not require approval from the EPC. However, the project coordinator serves on the EAC and PAC (Educational Administrative Committee and Program Advisory Council), and is ex-officio on the EPC. In these roles, she continues to seek opportunities to educate members of these high-level groups about the need for geriatrics education and the progress of the ICGE.

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THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM

Institutional Involvement in Curricular Change

The School of Medicine has been involved in curriculum reform since July 2000, when the dean created the Curriculum Objectives Task Force and charged it with developing program objectives for the undergraduate program.

The document, entitled Educational Objectives for the Undergraduate Medical Education Program, was completed and approved; this document identifies ten themes and more than 80 objectives for the program.

Currently, courses and clerkships are creating learning objectives that reflect and support these program objectives. The dean has also identified four goals for the curriculum reform movement:

1. Course and clerkship objectives that reflect program learning objectives

2. Increased small-group and self-directed active learning experiences

3. Closer integration between clinical sciences and basic sciences

4. Innovative use of technology to enhance student learning

The EPC, EAC, and PAC all play a role in supporting these goals and encouraging courses and clerkships to develop educational activities that support these goals. For example, the EPC has incorporated questions about these goals into its annual structured interview process (a component of the program evaluation system) and has asked for examples of how courses and clerkships support these goals.

Another important outcome of the curriculum reform initiative is the multimillion dollar Alumni Center for Medical Education, which was constructed to support innovative clinical education and assessment programs. This center now houses a state-of-the-art patient simulation center and standardized patient clinic.

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Theme for the Geriatrics Program

The geriatrics curriculum we are developing emphasizes active, interactive learning experiences. Thus, we have tried to create learning opportunities that draw upon one or more of the following approaches: Standardized patients, computer-driven human patient simulators, computer-based instruction, experiential learning with geriatric patients, and face-to-face activities with geriatric patients.

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Learning Outcomes for the Geriatrics Program

The geriatrics learning objectives focus on 12 themes: (1) stereotypes of aging; (2) communication/compassionate care; (3) demography/epidemiology; (4) normal aging; (5) abnormal aging;(6) psychosocial issues/mental health; (7) prevention; (8) ethical issues; (9) health care financing/economics; (10) assessment, diagnosis, and treatment; (11) cultural aspects of aging, including belief systems and spirituality; and (12) end-of-life care/palliative care.

To illustrate, these are the learning objectives developed for the ethical issues theme.

Upon graduation, students will be able to

identify the major ethical issues related to care of aged persons within their cultural context (e.g., identify ways that Asian Americans prefer to deal with the dying process);

list the steps involved in conducting a family meeting at which goals of care, withdrawal of care, advanced directives, and other end-of-life issues for a geriatric patient are discussed;

define “palliative care” and “euthanasia”;

discuss the clinical settings involving geriatric patients where difficult distinctions between palliative care and euthanasia might be experienced;

discuss the pharmacologic and practical clinical principles of pain management in the geriatric patient, with special attention to the use of opiates; and

discuss the phrase “Capacity to make medical decisions” from the legal and medical perspectives as it relates to geriatric patients.

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Special Programs

The integrated geriatrics initiative continues to serve as a model for interdisciplinary and interprofessional curriculum development and implementation. The ICGE has been successful in placing new geriatrics experiences into many courses and clerkships.

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Standardized patients and simulators

Encounters with geriatric standardized patients occur in the clinical practice sciences course (Year Two, geriatric history taking; sexual history) and the primary care clerkship (Year Three, hypertension)

In addition, such patients are used routinely in the clinical practice sciences course for encounters that do not focus exclusively on geriatrics learning objectives—for example, history and physical skills laboratories (Year One).

Experiences with human patient simulators (computer-driven mannequins) occur in basic science courses—for example, physiology (Year One, cardiac ischemia, peripheral circulation, cardiac function) and pharmacology (Year Two, uptake and distribution of inhaled anesthetics).

Experiences with human patient simulators occur in clerkships—for example, the perioperative medicine clerkship (Year Four, in which approximately half the simulation cases are geriatric patients; students also spend one day at a veterans hospital focused on geriatrics and complete a hemodynamic change form, which they compare with the same form for a young patient.

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Case conferences

There are five interdisciplinary case conferences with a geriatrics focus (Year One, osteoporosis case, rotator-cuff injuries, and basic patient interviewing of 75-year-old; Year Two, dementia case and depression case).

There is a two-hour geriatrics preceptorship in clinical practice sciences (Year Two), in which students spend four hours at an assisted living facility practicing interviewing skills.

There is the Geriatrics Day “miniconference” in the clinical practice sciences course (Year Two). (For more information, see the Appendix and check the Web site at 〈www.louisville.edu/medschool/curr/geriatrics_day.htm〉.)

There is a second-year elective designed and offered in collaboration with the School of Nursing (the geriatric caregiver support program).

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Student interest group

A geriatrics student interest group was created to encourage and support students interested in geriatrics training.

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Telemedicine geriatric consultation

This program is used for the rural sites program, housed in the family medicine component of the primary care clerkship. This provides opportunities for students to participate in and present geriatrics case conferences at two Kentucky sites (Glasgow and Madisonville) Kentucky.

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Resulting Pedagogical Changes

Created a new second-year elective

Increased use of standardized patient program and human patient simulators

Created a student-run special interest group

Developed a model for “special topics” days (e.g., Geriatrics Day)

Created computer-based instructional module for the geriatric history and physical examination.

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Application of Computer Technology

How to conduct a mini–mental status exam is now available online.

Use of Personal Digital Assistants (PDAs) to access drug identification information (Geriatrics Day—see 〈www.louisville.edu/medschool/curr/geriatrics〉).

Geriatrics instruction via telemedicine incorporated into geriatrics training in the primary care clerkship

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Students’ Clinical Experiences in Geriatrics

Students have exposure to geriatric patients in all required clerkships, with the exception of pediatrics, because senior adults make up much of the patient population at all inpatient and many ambulatory sites in the surgery, psychiatry, perioperative medicine, primary care, obstetrics–gynecology, and neurology clerkships.

In addition to exposure to geriatric patients at the clinical sites, students are exposed to geriatric standardized patients in the primary care and surgery clerkships.

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The Program’s Assessment and Evaluation Instruments

Standardized-patient encounters are evaluated using checklists.

Simulation experiences are evaluated using quiz and multiple-choice questions on high-stakes exams.

Didactic content is evaluated in high-stakes exams.

Geriatrics Day is evaluated using a student feedback survey and quiz.

Student satisfaction with geriatrics exposure is measured in the AAMC Graduation Questionnaire.

The ICGE reviews progress of the geriatrics curriculum initiative semi-annually.

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Resources Required

Project coordinator and principal investigator effort (central administration)

ICGE member effort (home departments)

Standardized patient and simulation center operating, training, and teaching expenses (central administration)

Geriatrics Day funding (Department of Family and Geriatric Medicine)

Support program elective for geriatrics caregiver: Faculty salary (Department of Family and Geriatric Medicine)

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Requirements to Sustain the Program

We anticipate that additional geriatrics activities will be integrated into the curriculum, for example, a long-term geriatrics experience and the development of a “continuum” geriatrics family. To achieve these expansion goals, the following resources will be needed:

Maintaining a vital, active ICGE

Continuing central administration funding for the standardized patient and patient simulation activities

Keeping geriatrics on the “high-priority” list at the EPC, EAC, and PAC levels

Developing partnerships with community agencies and organizations

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Unanticipated Outcomes

Interdisciplinary collaboration: The geriatrics initiative brought together faculty from different rotations, courses, and units (one of the ICGE members is with the School of Nursing), as well as staff from community organizations (one of the ICGE members is with ElderServe)

A new model for curriculum development: Our work building the geriatrics curriculum provides a successful model for building an integrated curriculum and for demonstrating that new topics can be introduced into the curriculum by adding more time or taking away existing content

Affirmation that the standardized patients and human patient simulators offer innovative educational opportunities

Presentations at regional (Southern GEA) and national meetings (AAMC) with other schools in the AAMC Hartford initiative

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Impact of External Funding

Enhanced geriatrics education at the undergraduate level

Enhanced recognition for the medical school, in particular the standardized patient program and patient simulation center

Helped us become part of a national network of individuals interested in and involved with geriatrics education

Allowed us to legitimize geriatrics in the curriculum and opened the door for the pursuit of additional funding

For further information, contact Ruth Greenberg, PhD, at 〈rgreenberg@louisville.edu〉.

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APPENDIX
Geriatrics Day: Creating a “Mini-Conference” to Teach Students About Geriatrics
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Background

As a AAMC Hartford Grant recipient, the University of Louisville School of Medicine focused on integrating geriatrics learning experiences into the undergraduate medical education program that would reflect our commitment to active, interactive, and innovative approaches to teaching students about geriatrics. One successful strategy was Geriatrics Day, a half-day program held on April 2, 2003, that engaged students in various activities that supported our program goals.

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The Model

Our vision for Geriatrics Day was to adapt the model for a professional conference and design a “mini-conference” that would teach students about healthy and unhealthy aging and expose them to the diverse issues that senior adults face as they age. Geriatrics Day was a half-day program planned and delivered collaboratively by the Office of Curriculum Development and Evaluation (OCDE), the Clinical Practice Sciences (CPS) course (our two-year long introduction to medicine course), the second- year pharmacology course, the standardized patient program (SPP), and faculty and residents from geriatrics housed in the Departments of Family and Geriatric Medicine. Students were required to attend Geriatrics Day and received credit in the CPS course for participating. The OCDE coordinated all of the logistics for the program while the content experts and the CPS course director developed the various components of the program.

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The Program

The Geriatrics Day program contained three major components: a keynote speaker, six geriatric “work stations,” and an “exhibit hall” where students could meet representatives from local organizations and agencies that provide services to seniors and view posters submitted by their classmates on “The Mystery of Aging.” Geriatricians, fellows, residents, and students from the Geriatrics Special Interest Group (SIG) were recruited to provide assistance.

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The Schedule

Geriatrics Day began at 8 am with a continental breakfast (funded by the Department of Family and Geriatric Medicine), followed by a keynote address, “Healthy Aging,” delivered by the Chair of the Department of Family and Geriatric Medicine. In addition to the didactic instruction, the speaker showed students several video clips of local senior adults who remained active and involved in their families and communities. Following the keynote, a geriatrician introduced students to a working older adult man, who discussed his routines of daily living and provided students with an excellent example of successful aging.

From 9:15–11:15 am, students rotated through four pre-assigned geriatric workstations (20 minutes per station) and the exhibit hall. A geriatrician, fellow, or resident facilitated each work station and involved students actively in some aspect of geriatrics; students received worksheets that identified the tasks assigned for each work station and the exhibit hall:

Pillbox Challenge. Students interviewed senior adult standardized patients about their medications, some of which the standardized patient could not identify, then used a portable digital assistant to identify adverse effects, drug interactions, appropriate use, and cost; students then completed a worksheet of medications and instructions for the standardized patient.

Photo Home Safety Assessment. Students examined photos of a home, identified safety issues, and recommended solutions.

Screening Issues in the Elderly. Students discussed four cases and recommended appropriate health maintenance and screening interventions for each case.

Photo Diagnosis. Students examined approximately ten case vignettes with photos and identified a diagnosis for each case.

Prescription Drug Coverage for the Elderly. In small groups, students discussed and developed four viable options for providing and funding prescriptions for the elderly, including benefits, problems, and implementation barriers for each option.

Geriatric Ambulatory Assessment. Students examined a senior adult standardized patient, performed the “get up and go” test and the mini mental status exam, and received feedback from the standardized patient.

Exhibit Hall. Students visited with representatives from local agencies and identified specific services provided for the elderly; students also had time to examine the Mystery of Aging posters.

From 11:30 to noon, students re-convened to complete a quiz and program evaluation. Students also participated in a brief game of Geopardy, which mimicked the television show using an audience response system (each student used a console to respond to geriatrics questions; the results were instantly calculated and displayed on a large screen).

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Outcomes

Overall, Geriatrics Day was a huge success. Student evaluations indicated that the information presented would be helpful to them as physicians and that the “conference-like” format enhanced the way they learned. Their scores on the post-program quiz were high, suggesting that the geriatrics content was mastered, at least for the short term. Faculty, fellows, and residents who participated were enthusiastic about the results and expressed a willingness to participate again if the program were repeated. Community agency representatives appreciated the opportunity to meet students.

The second annual Geriatrics Day program was held on March 31, 2004. The geriatric workstation activities and the community agency tasks were revised in response to evaluation results. For example, clinical vignette cases were written with input from the community agency staff; students answered questions about these clinical vignettes using information they gathered from the various community agency representatives in the exhibit hall. We also secured new, larger space for the event to create smoother transitions as students moved from one Geriatrics Day area to another. However, the mini-conference model we developed to teach geriatrics remained relatively unchanged. We anticipate that this model will be adopted for other “special topics” programs. The Clinical Practice Sciences course is currently considering such a program on asthma in the 2004–05 academic year. Cited Here...

© 2004 Association of American Medical Colleges

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