Medical College of Wisconsin

Overview of the Geriatrics Curriculum Five longitudinal geriatric patient cases were developed explicitly designed to highlight critical concepts and principles associated with basic science disciplines and clinical specialties. Each case was abstracted from a geriatric patient file and then presented at an invitational case development workshop, composed of basic science and clinical faculty with expertise that was related to the patient case under review. Participants were asked to modify the case to highlight teaching points associated with their respective courses/clerkship topic areas. The final paper cases contain longitudinal history, physical exam findings, laboratory results, and reports from radiology, pathology, and other health-care providers. Each patient “ages” 15 to 25 years to demonstrate the progression of disease and health over time and have specific foci that represent key competency areas in geriatrics applicable to specific disciplines and clinical specialties. The cases focus on the following issues (names used are fictional): Mr. Karl Andrews (ages 65 to 80): Cerebrovas-cular disease, diabetes mellitus, erectile dysfunction, hypertension, interdisciplinary health-care team, obesity, peripheral artery disease, wound healing, and aging Mrs. Esther DuBois (ages 70 to 86): Arthritis, autonomy/decision making, breast cancer, constipation and heartburn, end-of-life care, functional assessment, genetics, pain management, and spirituality Mr. Clarence Malone (ages 70 to 85): Activities of daily living, advance directives, artherosclerotic vascular disease, caregiver stress, cultural diversity, dementia, depression, genetics, medications, pain, and prevention/health maintenance Mrs. Violetta Mitsuko Tang (ages 65 to 80): Alternative medicine, degenerative joint disease, falls, functional assessment, hearing and vision, osteoporosis, thyroid disease, and urinary incontinence Mr. Fred Clifford (ages 83 to 98): Caregiving, dentistry, driving, functional aging, genetics, hearing loss, herpes zoster, high blood pressure, macular degeneration, pneumonia, sexuality, and skin cancer Curriculum Management and Governance Structure The Medical College of Wisconsin (MCW) is a private, freestanding medical school chartered in September 1970, when it separated from Marquette University, and governed by a 34-member board of trustees. The college has a bicameral form of governance with the executive committee of the faculty (e.g., department chairs, center and institute directors) and the faculty council advising the dean and the board on all academic matters, including those relating to the students and faculty. The curriculum and evaluation committee (CEC) is a standing committee of the faculty council and has primary responsibility for the curriculum, with the support of the senior associate dean for academic affairs, the associate dean for curriculum, and the associate dean for educational support and evaluation. The geriatrics project team was led by a senior geriatrician and three positional leaders: the CEC chair (who was previously a basic science course director) and the associate deans for curriculum and evaluation. Project team members had been previously recognized for their expertise in education by induction into MCW's Society of Teaching Scholars. In combination, these leaders were able to link formally and informally with key leaders (e.g., M1-2 course directors, M3 clerkship directors, CEC) who had direct responsibility for medical student education to develop and implement a longitudinal case-based approach. An advisory board of clerkship/course directors and critical departmental representatives helped to counsel the project team on its course of action and progress. The strategy for curriculum change—integration of geriatrics via a longitudinal case-based approach—required no formal actions. In providing instructors with a ready-made but flexible longitudinal case, complete with history, physical examination, and laboratory findings over time, the case file proved to be an efficient and effective teaching resource. The limitation of this strategy is that implementation depends upon the individual instructors and course directors to utilize the material where it is congruent with the objectives and teaching methods. To establish “buy-in” for case adoption, a series of invitational case-writing workshops was held. At each workshop, an abstracted patient record was presented (e.g., longitudinal history, physical exam, laboratory data, and diagnostic images) and participants were asked to modify the case to highlight teaching points associated with their respective courses/clerkship topic areas. The updated case was then circulated to all workshop attendees, along with course/clerkship directors and curriculum committee members, for incorporation into their instruction. The case was also posted on a Web site. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change The third- and fourth-year curriculum was undergoing major revision, but given the decision to create the paper cases as flexible teaching resources applicable across specialties and disciplines, there was minimal impact on the grant program. As additional resources became available via extramural grants, geriatrics educators were positioned to integrate/add to the curriculum as follows: Geriatric standardized patients for teaching and assessment, to be used in the first year medical interviewing course, third-year medicine clerkship OSCE, and the end-of-third year benchmark OSCE A geriatrics track option within the required third-year medicine rotation A fourth-year geriatrics selective centered on in-depth study of the basic science and clinical issues associated with the cases An “integrated grand rounds” featuring basic science and clinical presentations to M1-2 students about one of the cases Theme for the Geriatrics Program Cycles of health/wellness and disease among the aged, including emphasis on prevention/screening and health maintenance Progression of chronic diseases/conditions that commonly occur in elderly patients (e.g., arthritis, cancer, dementia/depression, hearing and vision loss, heart disease, hypertension, osteoporosis, urinary incontinence) An interdisciplinary team–oriented approach to geriatric care Learning Outcomes for the Geriatrics Curriculum The overall goal is to integrate the American Geriatrics Society's basic competencies for the care of older patients (attitudes, knowledge, skills) as a longitudinal thread throughout the medical student curriculum. Specific student learning objectives include: As a health-care provider, demonstrate compassion for well and frail elderly patients. Apply knowledge of normal and successful aging to the care of elderly patients. Use basic science knowledge to explain underlying processes for diseases/conditions that commonly affect elderly patients. Diagnose and provide initial management of common medical conditions that make the care of elderly patients complex, including its social and ethical dimensions. In caring for elderly patients, be cognizant of the family and of issues related to community resources. Special Programs Longitudinal case-based curriculum The ability to leverage AAMC/Hartford funding to secure awards from the Donald W. Reynolds Foundation, the Health Resources and Services Administration (HRSA, Geriatric Education Center and Geriatrics Academic Career Award), the Society of General Internal Medicine/Hartford award, and the Village at Manor Park Foundation has resulted in a number of new geriatrics education initiatives, as well as enhancement of established course offerings. Because the original AAMC/Hartford award focused on developing a series of longitudinal cases to thread through the medical student curriculum (as previously described), the other funded initiatives will not be described. Faculty development programs for geriatrics curriculum The case workshops were considered as a form of faculty development, since basic and clinical science faculty came together to revise and refine the progression of disease for each case patient. During this workshop, the facilitators balanced the need to maintain the integrity of the patient's disease progression while working with instructors from all four years of the curriculum to ensure that the case would highlight their core concepts and principles. The dialogue that occurred as basic science and clinical faculty members articulated their needs enhanced all attendees’ understanding of geriatrics, basic science principles, and clinical assessment and management of disease. This dialogue proved to be a critical outcome of the workshop, providing a unique communications forum for faculty members from an array of disciplines and specialties that otherwise have limited contact. Resulting Pedagogical Changes The longitudinal case-based approach does not require any new pedagogical approaches because of the flexibility built into the case design. Application of Computer Technology Case narratives are available on the Web at (http://〈www.mcw.edu/edserv/GeriatricsEducation/index.htm/〉. With additional funding, cases have now been recreated with video, images, and consultation reports incorporated on CD-ROMs, which are distributed at no charge to all course and clerkship directors and to interested faculty. Students’ Clinical Experiences in Geriatrics Students have an array of clinical experiences related to geriatrics, including the senior mentor program (M1-2's), geriatric standardized patients (M1-M4), and a geriatrics track option in the required M3 medicine clerkship, along with M3 and M4 selective and elective opportunities. As part of the M1-2 clinical continuum, students in all required clinical rotations (except pediatrics) and in the required preceptorship experience are caring for geriatric patients, consistent with the demographics of our state's population (13% of Wisconsin residents are more than 65 years old). The Program’s Assessment and Evaluation Instruments Case monitoring revealed that 57% of required M1-3 courses/clerkships integrated at least one case by June 2002. Items were added to the CEC-required end-of-course evaluations and end-of-rotation evaluations, in order to assess the degree to which students recognized incorporation of geriatrics into the curriculum. Resources Required The primary resources needed to launch and sustain the longitudinal geriatric case approach are time and enthusiasm from the following kinds of individuals: Project team members, to explain and demonstrate how cases can be incorporated into an individual faculty member's teaching to achieve and highlight their specialty/discipline-specific objectives Teaching faculty, who incorporate the cases into their teaching and seek to find complementary resources to support the case (e.g., radiographic images) Staff, to provide case resources and Web site information to faculty and to track case utilization Students, who have supported inclusion of the cases but would like to see them presented in total, rather than in fragments, to support a specific concept/principle (e.g., cholesterol metabolism) Requirements to Sustain the Program The AAMC/Hartford–supported virtual patient cases are relatively cost-free, in that the information is available on both the college Web site and the AAMC/Hartford Web site. Adoption and integration of the cases into the curriculum requires vigilance because faculty members are not aware of and/or have forgotten that the cases are readily available for use in their instructional programs. To address this issue, the CD-ROM–based cases have been demonstrated as they become available in multiple forums (e.g., course/clerkship director meetings, M1-2 basic science grand rounds, M-3 student intersessions) and by original case authors as they make modifications to existing/new courses. Unanticipated Outcomes The geriatrics curriculum activities were highlighted as part of the “special programs or educational innovations” section of our recent LCME accreditation site visit, including the virtual patient CD-ROMs and the senior mentor program. Faculty and educational administrators have cited the longitudinal-case approach as a model for other threaded curriculum themes (e.g., genetics, spinal cord injury). Impact of External Funding The Medical College of Wisconsin has had a sustained funding record in geriatrics education, including funding from the National Institute on Aging (Geriatric Medicine Academic Award) and HRSA (our college is a founding consortium member of the Wisconsin Geriatric Education Center). Although the focus of these activities has been primarily in graduate and continuing geriatrics education, they provided the experience in curriculum change needed to support the AAMC/Hartford program. The AAMC/Hartford award provided a focal point for attention on medical student education in geriatrics across the curriculum, requiring the involvement of basic science and clinical educators, associate deans for curriculum and educational support and evaluation, and the faculty governance committee (curriculum and evaluation) charged with oversight of the medical student education programs. There was also leveraged funding support: Partial support was secured from the college's learning resources fund to support development of video and still images to make our paper patients become virtual ones. MCW was one of the original ten recipients of Donald W. Reynolds Foundation grants for geriatrics education in 2001. This award has supported the conversion of the five paper cases to become virtual patient teaching resources files. Each CD-ROM includes 20 to 30 short video clips of the patient (and family) interacting with the health-care team, including geriatrics nurses and social workers, MDs, occupational and physical therapists, and others. The CD-ROMs also include functional assessment results, histological images, laboratory printouts, radiographic images, and other data associated with patients’ diseases/conditions as they age. Each image is then linked to the associated topic and indexed by common basic and clinical science courses/clerkships, to allow easy faculty access to a virtual patient record. MCW has been a partner in the Wisconsin Geriatric Education Center since 1986, focusing on residency-related geriatrics education initiatives. Building on our successful Reynolds Foundation application (to support recreation of the Hartford core cases into CD-ROM “virtual patients” for teaching), we are now transforming the teaching cases to refocus on assessment of the Accreditation Council for Graduation Medical Education competencies. For further information, contact Edmund Duthie Jr., MD at 〈[email protected]〉.