The aging population compels change in medical education. Elder care must be recognized as vital to medical student training.1 The Association of American Medical Colleges and the John A. Hartford Foundation sponsored a consensus conference which resulted in a set of “Minimum Geriatric Competencies for Medical Students.”2 These 26 minimum medical student competencies cluster in eight domains highlighting crucial geriatrics content for medical student education leading to improved care of the elderly. However, geriatric care, and specifically psychosocial aspects of elder care, extends beyond traditional specialty-driven clinical curricula and must be integrated within each specialty’s clinical rotation.
Computer-based learning represents a powerful tool to supplement medical student training3,4 and may be particularly useful in areas that cross traditional boundaries of educational exposure, such as geriatrics.5 We proposed to present concepts of elder care focused on these specific competencies within the context of a neurology rotation using an e-learning module, in conjunction with the didactic presentation of dementia as a clinical problem. We then asked whether presenting these competencies in this hybrid context would result in effective mastery of geriatrics concepts and effect a change in clinical behavior of the students exposed.
Our e-based curriculum e-module titled “Neurology and Dementia: Psychosocial Aspects of Care” was explicitly designed to address geriatrics competencies with a focus on neurology patients. The e-module was offered as a standardized elective experience within the required Neurology M3 clerkship.
An e-learning team composed of a neurologist, a geriatrician, and an education specialist collaborated to create an online curriculum module. The initial step included a needs assessment to identify gap areas between current neurology clerkship content and geriatrics competencies for medical student education. These gap areas formed the core structure for the course e-module content. E-module design incorporated multiple formats and media using the ANGEL e-learning management system as the electronic delivery platform. Content included video segments hyperlinked to explanatory text (home care options, driving) and external resources (advanced directives, community-based resources) concluding with a required quiz and module evaluation. The curriculum mapped to address eight (50%) of the geriatrics competency domains.
The e-module was offered to students on a voluntary, elective basis as an adjunct to their Neurology M3 clerkship materials and was available during the two weeks of their required neurology rotation. Students were informed that the e-module content could improve their patient care and may assist with their end-of-clerkship written examination and OSCE, but that there had been no change in the exam or OSCE content since the inclusion of the e-module in the curriculum.
The end-of-clerkship learner assessment consisted of a multiple-choice examination and an OSCE with two standardized patient (SP) encounters. SPs have previously been shown to be effective in assessing students’ understanding of geriatrics concepts.6 One of the OSCEs required students to assess an SP with dementia and document the encounter by a clinical note. It is only this encounter that is used as the dependent variable. The students’ clinical encounter performance was rated by the trained SP using a 30-item yes/no checklist comprising four categories: history, examination, communication, and empathy/professionalism. History checklist items emphasized self-care, mood, drug use, and possible reversible causes of dementia. The clinical encounter note was independently scored by the first author (AH) in five areas associated with history, physical examination, differential diagnosis, diagnostics, and management, yielding a total of 20 points. For example, notes received points if they contained documentation regarding functional status [e.g., activities of daily living (ADLs) or instrumental activities of daily living (IADLs)] and psychosocial aspects of care (e.g., caregiver stress, neglect and abuse, home safety evaluation, or driving).
The voluntary nature of this study produced two groups. The Geriatrics Group comprised those students who voluntarily completed the e-module, and the Neurology Group was composed of students had chosen not to complete the e-module. The two groups were compared for SP evaluation score, note documentation score, and specific note section scores regarding ADL/IADL function and psychosocial aspects of care. The required written end-of-rotation multiple-choice examination, which did not include questions regarding psychosocial aspects of geriatric or dementia care, was used to determine whether the choice to complete the e-module was related to overall student performance. Written examinations were taken by all students immediately after the two-week neurology rotation.
Because of the clerkship rotation structure, Geriatrics Group student OSCE data were further divided into two subgroups; one subgroup took the OSCE immediately after their rotation (Geriatrics Immediate Group) and the other took the OSCE one month after completing the rotation (Geriatrics Delayed Group). Geriatrics Immediate Group student scores were compared with the Geriatrics Delayed Group student scores on all outcome measures. All scoring/ratings of the exams, notes, and OSCE scores were done by examiners blinded to whether students did or did not complete the online e-module.
To determine the effect of completing the geriatrics e-module (Geriatrics Group, Neurology Only Group) and the impact of OSCE timing (immediate, delayed) on student performance measures, multivariate analyses of variance were conducted using SPSS for Windows version 15.0. IRB approval for human subject research was obtained to conduct this research.
A total of 92 students completed the neurology clerkship rotation between July 1, 2008, and December 23, 2008. The Geriatrics Group comprised the 66 (72%) students who voluntarily completed the computer-based e-module during their two-week rotation on neurology using the ANGEL e-learning management system. The 26 students in the Neurology Only Group (28%) chose not to complete the e-module. Exam scores between the Geriatrics and Neurology Only Groups revealed no significant differences (P = .24). Table 1 shows the students’ mean performance by group.
The Geriatrics Group had a significantly higher performance on the OSCE as evaluated by the SPs (P = .03, effect size = 0.53), and on the overall note score (P = .002, effect size = 0.63) compared with the Neurology Only Group, and documented attention to psychosocial aspects of care (P = .04, effect size = 0.48). Attention to ADL/IADL function (P = .06) showed a trend toward higher performance and has a medium effect size (0.44).
Comparisons between the Geriatrics Immediate Group (n = 36) and Geriatrics Delayed Group (n = 30) revealed no significant differences between groups defined by timing for overall encounter note score, sections within the note (i.e., ADL/IADL evaluation, attention to psychosocial issues), or written examination scores (Table 2). There was a significantly higher SP score in the Delayed Group (P = .04, effect size = 0.53). To ensure that there were no timing effects for the Neurology Only Group, additional analysis revealed no significant differences between the Immediate Group and Delayed Group students among those choosing not to complete the module (data not shown).
Our findings demonstrate the value and efficacy of computer-based learning in presenting the recommended geriatrics competencies to medical students in the context of a third-year neurology clerkship. Our findings are encouraging to educators who may struggle to incorporate these vital geriatrics competencies into a medical student curriculum. One study evaluating inclusion of behavioral and social sciences in medical training identified the challenges of integration of the material in the curriculum, in addition to staffing and space, as the significant barriers.7 We have shown that a computer-based e-module can overcome several of these barriers. The material was well integrated with the clerkship’s didactic learning related to the pathophysiology, clinical presentation, and medical therapies of dementia patients and, thus, was not disjointed from the curriculum. Additionally, after development, an e-module may require updating if subject matter is time-dependent, but can be cost-effective over time because the students can complete it on their own schedule without direct faculty involvement.8
One of the significant criticisms of the development and implementation of computer-based learning is that there are not enough controlled data to assess efficacy.9,10 In this blinded, controlled study, we have demonstrated efficacy of an online module through immediate and delayed assessment of the students’ learning. Students who completed the e-module displayed learning of the topics as assessed in the online quiz and superior and sustained change in clinical behavior in their treatment of and approach to an SP compared with students who did not complete the e-module. This demonstrates strong evidence for the efficacy of computer-based learning in addressing geriatrics competencies in the context of a neurology rotation.
Our study does have some limitations. The study was conducted at a single institution and within a single specialty. Moreover, our outcome was based on a single OSCE case, which is undoubtedly influenced by case specificity. Additionally, we could have some contamination if students in the Geriatrics Group discussed the case with their peers in the Neurology Group. However, both of these biases, if present, would have reduced differences between groups. A randomized design was not used, as students chose whether or not to participate in completion of the e-module. It might be argued that superior students were more likely to take advantage of the e-module’s learning opportunity and would be expected to demonstrate better performance on the OSCE. The written examination scores, however, revealed no differences between the two groups. The psychosocial aspects of geriatric care were not tested on the exam, effectively controlling for baseline student achievement. Second, the furthest time point for subsequent testing was at one month, which, while not optimal for testing long-term learning, does suggest that the e-module’s effect on learning has sustainability.
Interdepartmental collaboration presenting standardized educational content through an online learning platform resulted in effective learning and clinical application of geriatrics competencies. Voluntary completion of a computer-based e-module increased subsequent student evaluation and management of psychosocial aspects of dementia care as measured by a simulated dementia patient OSCE. This change in behavior was sustained for at least one month. Online e-modules provide a useful method for standardized, competency-based education to address topics falling outside of traditional clerkship boundaries.
The authors acknowledge the contributions of Dawn S. Bragg, PhD, and the Office of Educational Services for statistical consultation.
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