Johns Hopkins University School of Medicine

Overview of the Geriatrics Curriculum Based on a literature review and a needs assessment of learners, our curricular goal was to foster and/or maintain positive attitudes of our medical students toward geriatric medicine and older persons. The curriculum involved providing students feedback on their attitudes toward older persons and geriatrics; encounters with both chronically ill and healthy older persons; exploration of societal attitudes toward older persons; and skills development in identifying geriatric syndromes, using geriatrics assessment tools, and developing advanced communication skills important in the care of older persons. Curriculum Management and Governance Structure Johns Hopkins University School of Medicine has an educational policy committee (EPC), which serves as its curriculum committee. The vice dean for education chairs this committee. The EPC meets on a monthly basis throughout the academic year, and it serves as the educational policy organ for the School of Medicine. The geriatrics program was incorporated as a distinct curriculum under the EPC structure, and one of the co-investigators on the AAMC grant was given membership status on this committee. Although the curriculum was supported by the educational infrastructure at Johns Hopkins, no new specific curricular time was provided for the geriatrics curriculum. Instead we had an opportunity, with the dean's encouragement, to incorporate geriatrics within existing curricular time. The investigators met with various course directors in the undergraduate curriculum and instituted much of their curriculum in the Physician and Society course, the basic internal medicine inpatient clerkship, and the physiology course. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Theme for the Geriatrics Program One of the major purposes of our curriculum initiative is to expose students to geriatricians early in their training. In doing so, we hypothesize that students would see geriatricians as positive role models who are integral to the milieu of an academic medical center and therefore see geriatric medicine as integral to their training. We also emphasize that the principles we teach in the curriculum are generalizable and should apply to any field of medicine where the students will encounter older adults. Learning Outcomes for the Geriatrics Program The main outcome for the curriculum has focused largely on fostering positive attitudes toward geriatric medicine and older adults. The assessment of this effort has been through the ongoing collection of attitudinal data, using standardized instruments. During the third-year basic medicine clerkship, the learning outcomes also incorporate knowledge and skills areas. Students are exposed to the geriatrics continuum of care and are instructed in high-level communication skills, as well as the assessment of two geriatric syndromes, depression and dementia, using a standardized patient exercise. Special Programs During the third-year Basic Medicine Clerkship, students participate in a two-hour standardized patient exercise. In an initial encounter, eight students are given the opportunity to interview an elderly woman with early-onset dementia and depression. During a subsequent visit in the same session, the students interview the patient along with her daughter. The goals of the session include diagnosis of depression and dementia, atypical presentation of disease, incorporating the use of standardized screening instruments in the clinical setting, assessment of basic activities of daily living and instrumental activities of daily living, and three-way communication skills. Resulting Pedagogical Changes During the Year 1 Physician and Society course, students are asked to complete a survey, using standardized instruments, about their attitudes toward geriatrics medicine and older adults. That information is then reported to them in a two-hour large-group session, with an opportunity for discussion. They then hear an older patient's story about his experiences in the medical system and learn how the attitudes of his health care providers both positively and negatively affected his care. In addition, in the first year, two of the authors present a clinical correlation during the endocrinology section of the physiology course. Here students are exposed to the variety of ways in which hypothyroidism can present in an older person and, perhaps more important, how that diagnosis affects major geriatric syndromes such as decreased physical function. They are also exposed to the atypical ways in which common diseases may present in older adults, illustrating the heterogeneity of this population. Building on the first-year experience in the Physician and Society course, in the second year the students have a one-hour didactic large-group session followed by a one-hour facilitated small-group discussion focused on describing and demonstrating the way society views older persons. This session incorporates examples from the popular media, including films and television shows and ads. Students’ Clinical Experiences in Geriatrics During the third-year basic medicine clerkship, the students have, apart from the standardized patient exercises, three hours of instruction in groups of eight with an attending geriatrician. The sessions involve descriptions and tours of the components in the continuum of geriatric care. Students go on a house call visit with an attending geriatrics physician, and they visit a nursing home, PACE site (i.e., Program of All-inclusive Care for the Elderly site), subacute unit, and rehabilitation unit. In addition, attending physicians in geriatrics constitute approximately 40% of the attending physicians in the inpatient services at Johns Hopkins Bayview Medical Center, one of the medicine clerkship sites through which two thirds of students rotate. The Program’s Assessment and Evaluation Instruments Ongoing evaluation of student attitudes toward older people continues on an annual basis. We are developing and analyzing both cross-sectional and longitudinal data related to this issue, which was the primary goal of the curriculum. Preliminary analysis suggests that the curriculum is having a positive impact on student attitudes. Resources Required Faculty time to develop and teach the curricular interventions Standardized patients and the staff to train them Support for data collection and analysis Requirements to Sustain the Program Continued funding to support the standardized patient programs Continued support from the leadership of the Physician and Society and physiology courses. Faculty time to teach and evaluate the curriculum Unanticipated Outcomes The most significant unanticipated outcome of this work is that two of the co-investigators, by virtue of becoming better known within the educational milieu at Johns Hopkins, were appointed directors of the basic medicine clerkship at The Johns Hopkins University School of Medicine. Impact of External Funding Geriatrics clearly has a higher profile in the educational mission at the level of the School of Medicine. The students in the undergraduate curriculum, especially in Years One and Two, have exposure to geriatricians; this had never been the case before. Overall, we believe the curriculum will meet its educational objectives and enhance the geriatrics experience for the Johns Hopkins University medical students. For more information, contact G. Michael Harper, MD, at 〈email protected〉.