Research Letter

SIR—Learning about ageing and the appropriate management of older patients is important for all doctors. Those >65 years comprise between 15 and 18% of admissions to UK Emergency Departments [1, 2] and two-thirds of acute hospital inpatients in England and Wales and 36% of acute admissions are >65 [3]. However, recent changes to postgraduate medical training within the UK [4–6] have resulted in a more streamlined training programme, with the British Geriatrics Society (BGS) stating ‘it cannot be assumed that doctors will have further education in Geriatric Medicine after graduation’ [7]. This places increased onus on the quality of undergraduate education, yet previous research has suggested undergraduate teaching in geriatrics to be in decline [8]. This assertion was based upon examination of trends in the number of discrete academic units and modules in the specialty but did not examine what was actually taught to undergraduates [9]. This study set out to evaluate what medical undergraduates in the UK are taught about ageing and geriatric medicine and how this teaching is delivered. The study took place in 2008. We validated the current BGS curriculum for undergraduates by mapping it to the 2003 version of Tomorrow’s Doctors [10], which provides national guidance for the teaching of UK medical undergraduates [11]. An electronic questionnaire was developed, in which outcomes from Tomorrow’s Doctors were used as topic headings, with relevant learning outcomes from the BGS curriculum listed beneath. For each outcome, we asked whether and how it was taught and examined, the disciplines involved in teaching and the amount of time devoted to teaching. Only teaching delivered to all students was included. Topics taught to sub-groups of students or as part of a student-selected component were not recorded. A free text box was provided at the bottom of every page for clarification. The deans of all 31 UK medical schools were approached by both email and letter, asking them to nominate a respondent who would have a comprehensive overview of ageing as delivered across the undergraduate curriculum. Where direct approaches were unsuccessful, members of the BGS Education and Training Committee, comprising representatives from every UK postgraduate deanery, were asked to identify colleagues within their local medical school who could provide a response. The electronic survey was then sent to all nominated respondents. Telephone and face-to-face support was offered if necessary. Once responses were collated, a copy was sent to each participating school for them to verify, augment or comment on. Three medical schools declined to participate at outset, one only taught preclinical medicine and two had a policy not to respond to surveys. Invitations and instructions on how to complete the electronic questionnaire were therefore sent to 28 schools. Responses were received from 18/28 (64%) schools. One of these responded only in vague terms despite requests to be more specific, stating that their problem-based curriculum covered most of the learning objectives specified. Thus, responses from 17/30 (57%) of the UK medical schools teaching a full 5-year course were analysed. Fourteen respondents were geriatricians: 12 consultants (10 academic; two clinical) and two registrars (one academic; one clinical). Only three were non-geriatricians (vice deans or course directors). The numbers of schools teaching and examining each learning outcome are outlined in Table 1. Learning outcomes taught and assessed Learning outcomes taught and assessed Teaching was subdivided according to formal methods (lectures/seminars/tutorials/small group teaching/formal ward teaching/Computer Aided Learning (CAL)) and informal (library, book-based and informal ward teaching). Results are summarised in Table 2. Formal vs informal teaching Formal vs informal teaching These results show a mixed picture with regard to undergraduate teaching in ageing and geriatric medicine. The common presentations in older patients, the so-called ‘geriatric giants’ [12]—delirium, dementia, stroke, falls, osteoporosis, parkinsonism, polypharmacy and incontinence—were taught in the majority of schools. Ethics was also taught widely. Despite this, only 8 out of 21 learning objectives were taught in all schools and none of them were examined in all schools. Assessment plays a pivotal role in learning. Ramsden [13] stated that, for many students, assessment is the curriculum—students focus their efforts on learning outcomes that they know are assessed. Biggs [14] proposed that students are more motivated if outcomes assessed map closely to those specified in the curriculum and taught during the course (‘curricular alignment’). Thus, the failure to assess core concepts may result in a failure to learn core concepts. Elder abuse was taught formally in only 8/17 schools, despite ‘abuse of the vulnerable patient’ receiving explicit mention in Tomorrow’s Doctors. This is a significant omission given the relevance of elder abuse to clinical practice. A fifth of older people presenting to the emergency department report abuse [15], whilst older people who are abused are 3.1 times more likely to die during a 3-year follow-up period [16]. Pressure ulcers were taught about in 14/17 schools but taught formally in only 7/17 of these and examined in only 9/17. Pressure ulcers have a prevalence of 9.6–11.9% in hospitalised adults in the UK [17] and the annual cost of pressure ulcer care for the National Health Service in 2000 was £1.77 billion [18]. Only 9/17 schools reported teaching in social ageing, 7/17 in cellular ageing and 9/17 in the physiology of ageing. Tomorrow’s Doctors states that, ‘graduates must know about and understand normal and abnormal structure and function, including the natural history of human diseases, the body’s defence mechanisms, disease presentation and responses to illness’ [10]. It would be seen as unacceptable to assert that doctors could effectively manage heart failure without an understanding of cardiac physiology. By analogy, the physiology underpinning the altered pharmacology of later life and the social demography underpinning the funding of healthcare provision in care homes are equally essential. The strengths of this study include the use of an objective questionnaire based upon the national curricula for medical undergraduates, delivered to all UK medical schools, with respondents nominated by deans. We took a number of measures to maximise response rate including using an electronic interface, providing schools with paper copies of the questionnaire on request, and repeated email and formal mail reminders. Despite these measures, our response rate was suboptimal, raising the possibility of response bias. The reasons for the low response rate are not entirely clear—however, informal feedback was that both the amount and detail of information requested made the questionnaire difficult to complete. On contacting schools, we specifically requested that they nominate respondents with an overview of the whole undergraduate course. It is unlikely, given the predominance of geriatricians amongst respondents, that this objective was fully realised. We may have under-recorded tuition in biogerontology and sociogerontology if our respondents did not have an adequate overview of the curriculum to know about these specialties. However, this does not seem to have affected the comprehensiveness of the response in other multidisciplinary areas such as ethics, demographics and service models. Despite these issues, this remains the most comprehensive survey of undergraduate teaching in ageing and geriatric medicine within the UK to date. Those schools which responded did so comprehensively. Even if the non-responding schools were teaching ageing and geriatric medicine perfectly (which seems unlikely), then these findings would still raise significant issues. Since this study, the General Medical Council has published a new version of Tomorrow’s Doctors, which will affect undergraduates commencing studies from 2011 [19]. This revised document continues to support teaching in abuse of vulnerable people, in normal and abnormal structure and function, and in common medical presentations. It, therefore, does not contradict our conclusions. On the basis of these findings, all UK medical schools should examine the degree to which they both teach and examine the learning objectives listed here, with particular attention to topics that tend to be overlooked such as elder abuse and pressure sores, as well as the underlying sciences of biological and social ageing. Since ageing is a global phenomenon, similar exercises could be undertaken in other countries. The ‘geriatric giants’ are widely taught amongst the UK medical schools surveyed, despite recent reductions in the number of academic units in geriatric medicine and discrete modules in the specialty. Learning outcomes in geriatric medicine and ageing are inadequately assessed in UK medical schools — this may have an impact on student learning. Elder abuse is inadequately taught in UK medical schools. Pressure ulcers are inadequately taught in UK medical schools. Social ageing, cellular ageing and the physiology of ageing are inadequately taught in UK medical schools. This leaves students ill-equipped to understand common pathologies in older patients. We would like to acknowledge Prof. Peter Crome, University of Keele; Dr Oliver Corrado, West Yorkshire Foundation School; and Prof. Steven Allen, University of Bournemouth, who all contributed to earlier research work around which this project was based and consulted during development of the research protocol. We would like to acknowledge Charlotte Potter of Help the Aged and Age Concern and the members of the British Geriatrics Society Education and Training Committee for their comments on study design, data analysis and the manuscript. We would also like to acknowledge the following medical schools that participated in the study: Brighton and Sussex University Medical School, Bristol University Medical School, Cambridge University Medical School, Hull York Medical School, Kings College London Medical School, Leicester University Medical School, Oxford University Medical School, Peninsula Medical School, Queen’s University Belfast Medical School, St George’s Medical School, University College London Medical School, University of Aberdeen Medical School, University of Dundee Medical School, University of East Anglia Medical School, University of Edinburgh Medical School, University of Nottingham Medical School and University of Sheffield Medical School. All authors declare that they have no competing interests to declare. This research is a survey of teaching provision against nationally stated guidelines. It was discussed with the Chair of the University of Nottingham Medical School Research Ethics Committee who deemed that no ethical approval was required. This research was supported by the British Geriatrics Society and the British Council on Ageing. Both of these organisations are charitable. Support was in the form of approval to use these organisations’ names and copyrighted logos on survey literature. Both organisations support the decision to submit this article for publication. The members of the British Geriatrics Society Education and Training Committee reviewed and commented on the research protocol and manuscript at several points. No financial support was received from either organisation.