University of Missouri–Columbia School of Medicine

Overview of the Geriatrics Curriculum Medical Students’ Training The University of Missouri (MU)–Columbia School of Medicine is located in a state with one of the largest concentrations of rural elderly residents. The recently organized Center of Excellence on Aging at MU brings together resources from the Schools of Medicine, Nursing, and Health Professions. The curriculum at the University of Missouri is recognized for its successful problem-based learning (PBL) approach to teaching medical students. During the first two years, students learn through small-group discussions of clinical cases, thus integrating the basic sciences and clinical reasoning. This basic science/PBL component of the curriculum offers an ideal opportunity to include basic science foundations and the clinical aspects of geriatrics medicine. The introduction to patient care (IPC) is the other curricular component in the first two years. IPC is the foundation for clinical training. Students learn the fundamentals of history taking and physical examination, psychosocial aspects of medicine, clinical epidemiology, and selecting and interpreting diagnostic tests. This is also an ideal time to include the unique aspects of history taking and physical examination of elderly patients. Also included are the psychosocial aspects of aging, end-of-life issues, and death and dying. The AAMC/Hartford initiative has allowed us to initiate several very successful preclinical and clinical activities for our students. During the course of our grant, we created six additional PBL cases. The Senior Teacher Education Partnership (STEP) is an innovative program linking first-year medical students with elderly patients in the community. Students and STEP partners attend group educational sessions led by program faculty and arrange, on their own, social activities, physician office visits, and even exercise dates. This program received the Catalyst Institute's national award for excellence and innovation in 2002 and was recently recognized as a model program for education in geriatric medicine (Adams D. Gray days ahead. Am Med News. Feb 10, 2003:10, 11). Using the first cohort of STEP and interested students from the existing family medicine and internal medicine interest groups, we have started a geriatrics interest group. During the required third-year clerkship in family medicine, students participate in two cases to explore issues of geriatric polypharmacy, falls, depression, dementia, multidisciplinary management, and health-care financing. Also during the clerkship, some students work with geriatricians in an ambulatory setting. During the AAMC/Hartford project, we implemented the acute care for the elderly (ACE) curriculum for third-year students on the internal medicine clerkship. Students complete an online module on geriatric assessment and then apply three instruments to an elder for whom they are caring on the inpatient service. Students on each of the other required rotations encounter older patients, but the explicit curricular elements are few. In 2001, we tested a pilot program of one full day of EPEC (Education for Physicians on End-of-Life Care) with 11 fourth-year medical students. This spring, we conducted mandatory EPEC training for the entire third-year class. Among the rural experiences available to our students is the rural training track, which includes 12 to 15 students in each third-year class who have special interests in rural health care. This program was first organized in partnership with our federally funded Area Health Education Center (AHEC) and now operates with state support. For six months in the third year, students complete required rotations in rural communities and retain a continuity primary-care practice. Since up to half of the visits in these practices may be from elderly people, this experience enables students to care for patients across settings of care and specialty services, much like a real primary-care physician in office practice. Residency Program We have built a modest program in geriatrics medicine for the family-practice residency program. There is a monthly presentation, during the residents’ didactic afternoon, on a core geriatrics topic, such as falls, delirium, or depression in older adults. A required month-long rotation includes experiences in the multidisciplinary geriatrics clinic, adult day care, home care, and nursing home care. Each resident also has a two-year longitudinal experience in a community nursing home under the supervision of attending physicians and nurse practitioners. The residency program has two rural family-practice centers, and residents participate in home and nursing home care in rural communities. Regarding end-of-life care, we use parts of the EPEC curriculum and a short community-based hospice experience. Our residents in internal medicine have a one-month rotation at the adjacent Department of Veterans Affairs (VA) hospital, where they spend time in the geriatrics clinic, on the GEM (geriatric evaluation and management) and nursing home units, and with the home-based primary-care team. Fellowship Training We developed a geriatrics medicine fellowship program in 1993 to educate academic geriatricians with special interests in the needs of rural communities. Three of our fellowship graduates have joined our own faculty, and one is on the faculty of the University of Virginia. The geriatrics medicine fellowship is a part of the academic family medicine fellowship that began in 1979. All fellows take coursework in epidemiology, research design, biostatistics, and the health-care system. Fellows who complete the two-year curriculum receive a master of science degree. We have weekly seminars in geriatrics medicine that include core clinical topics, a geriatrics journal club, and monthly end-of-life care conferences. Finally, we host a monthly campus-wide team for interdisciplinary research seminar, which is open to students, residents, and faculty members. Continuing Education and External Relationships MU has an accredited Office of Continuing Education and Extension for the Health Professions, which has attracted more than 4,000 primary-care physician registrants to its programs during the last five years. In 1990, funded by a health of the public grant from the Pew Charitable Trusts and the Rockefeller Foundation, our geriatricians created an alliance with a group of rural primary-care physicians providing care for the frail elderly. Among the enduring products of this relationship was the Physicians Advisory Committee to the Division of Aging (State of Missouri), an annual conference, the Long-Term Links newsletter, and the founding of the Missouri Association of Long-Term Care Physicians (MALTCP). Each year, at the Caring for the Frail Elderly conference, a multidisciplinary group of 150 to 200 health-care professionals gathers for a two-day meeting to address long-term care practice. Long-Term Links has a requested circulation of over 600 long-term care physicians, nurses, and administrators from across Missouri. MALTCP is a multidisciplinary group of professionals from around the state who are committed to improving the quality of care in nursing homes. Curriculum Management and Governance Structure The medical student curriculum is a partnership between the curriculum board and the dean's office. The curriculum board is a nine-member group of elected faculty members who oversee the medical student curriculum. Students representing each medical student class are ex-officio members. The board oversees the development and maintenance of a comprehensive list of outcome goals or competencies for graduates of the School of Medicine (SOM); establishes explicit learning objectives consistent with the goals to be used to define the appropriate content of courses and to design the evaluation process; makes recommendations about curriculum content, methods of instruction, and evaluation to faculty members who plan individual blocks and courses; provides an annual report to the dean and the faculty; serves as an advocacy group for the faculty members in their roles as teachers; promotes faculty development; and approves the academic calendar. Within the dean's office, the Office of Medical Education (OME) oversees the curriculum (see Figure 1). Under the leadership of the senior associate dean for education and faculty development, OME consists of the associate dean for curriculum, associate dean for student programs, assistant dean for graduate medical education, the director of evaluation, the financial aid officer, and the admissions coordinator.FIGURE 1. Office of Medical Education Organizational ChartThe geriatrics curriculum was incorporated with full OME support. Dr. Michael Hosokawa, associate dean for curriculum, was co-principal investigator (PI) on the Hartford/AAMC project. This summer, the University of Missouri–Columbia School of Medicine was selected by the Donald W. Reynolds Foundation to receive a four-year, $1.9 million geriatrics training grant. This funding is enabling us to build upon and enhance the geriatrics education efforts begun with the Hartford/AAMC grant and is further evidence of OME's commitment to geriatrics education. The geriatrics education programs are multidisciplinary, cut across departments, and have the full support of the dean's office. THE AAMC/HARTFORD GERIATRICS CURRICULUM PROGRAM Institutional Involvement in Curricular Change In 1993, the SOM implemented the PBL approach, which provides opportunities for integrating a broad range of topics into the case discussions and for incorporating the basic concepts of geriatrics medicine and gerontology. Over 60 cases are in use in the preclinical curriculum at any given time, and the number with a focus on geriatrics could be substantially increased. The flexibility of the PBL curriculum is a tremendous asset in introducing new concepts. Theme for the Geriatrics Program During the AAMC/Hartford grant, we reviewed the literature, performed a self-study, and had discussions with key geriatrics medicine faculty as well as subspecialist faculty physicians who care for older patients. During this time of self-assessment, we developed ten principles of geriatric care that will guide our educational initiatives. These concepts (see List 1) are meant to assist us as we share our vision with learners and colleagues at all levels.LIST 1. Ten Principles of Geriatrics Care Learning Outcomes for the Geriatrics Curriculum We have not developed formal learning outcomes, but we are developing informal ones in accordance with an institutional commitment entitled MU 2020. These outcomes include that each of our graduates is able to deliver effective patient-centered care, honest, with high ethical standards, knowledgeable in biomedical sciences, evidence-based practice, and societal and cultural issues, able to think critically and solve problems, able to communicate and collaborate with patients and other members of the health-care team, and committed to improving quality and safety and to lifelong learning and information mastery. Special Programs Senior mentor program We have formed a partnership with senior citizens in our community that promotes geriatrics in the first and second years of medical education and addresses the problem of stereotyping the geriatric population. The STEP program matches medical students with seniors for two years or more, providing the former with the opportunity to know healthy, active senior citizens and breaking down the stereotypes students may have (e.g., that most elderly patients are frail and in poor health). As a result of this program, students have reported changes in their understanding of patients’ experiences. Senior volunteers were recruited from a senior membership program associated with MU Health Care. The dean's office played a vital role in validating the STEP program, informing students about the program through OME's online newsletter, an e-mail campaign, the annual student activities fair, a poster on the M-1 bulletin board, and brochures. The outcomes of the program have surpassed expectations. The program's success has earned it a national award. Most important, our experience highlights the importance of exposure to healthy older people in implementing positive attitude changes among medical students. Based on student interviews, we believe STEP will make a difference in the way medical students will practice medicine. A gift from the family of Robert M. Heyssel, MD, provides support for this program and ensures its continuation. Community partnerships MU's School of Medicine has strong ties to partnerships that provide valuable educational experiences: A network of community-based primary-care teaching practices Affiliated nursing homes and assisted living facilities (attending over 200 patients) A multidisciplinary comprehensive geriatric assessment clinic An ACE model of care on the inpatient internal medicine and family medicine services An eldercare Center (adult day care) run by the School of Health Professions Senior Care, a community-based, care-coordination program (a home-health agency based in the School of Nursing) A source of relevant information on geriatric medicine through our successful continuing education programs and our links to professional organizations of physicians caring for the elderly Faculty development programs for the geriatrics curriculum Although our AAMC/Hartford project did not specifically address faculty development, we have a long history of providing continuing education in geriatrics through the Caring for the Frail Elderly conference and the Long-Term Links newsletter. Student interest groups With the Hartford/AAMC funding, the SOM established a geriatrics interest group (GIG). Palliative care and end-of-life courses In 2002, EPEC classes were offered to the M4 class. In 2003, mandatory EPEC training for all M3's took place on March 28. Resulting Pedagogical Changes There were six new PBL cases for the first two years of medical school (one new dementia case, two congestive heart failure cases, two stroke cases, and one Parkinson's case). The STEP program has been enormously successful in linking our students with seniors in the community. We are happy to report that STEP has become an integral M1 experience that will continue beyond the grant. The GIG was established, and we are happy to report that this group will continue and expand in years to come. We have incorporated geriatrics into the third-year curriculum, including the ACE program in internal medicine. This program is up and running and has become fully incorporated into the third-year curriculum. Application of Computer Technology The OME promotes openness to changes in technology. We see our students as information interpreters and focus on their integrative and evaluative skills. Computer technology plays a major role. We use Web-based instruction and integrate Web-based searching exercises into our PBL curriculum. This type of instructional tool is used in clerkships and other rotations. Of particular note is the ACE tool kit developed for use during the internal medicine clerkship. This tool kit uses Web-based instruction to teach students the value of geriatrics assessment; how to improve their communication skills with patients, families, and other caregivers; and how to appreciate fully the multidisciplinary team approach to patient care. Students’ Clinical Experiences in Geriatrics These experiences begin with the first year in the ambulatory-care experience. This is a shadowing experience for first-year students. When possible, students with an interest in geriatric care (such as those enrolled in the STEP program or the GIG group) are assigned to the faculty geriatricians for this experience. During the third year of the curriculum, the clerkships in family medicine and internal medicine are expanding the geriatrics training that the students receive. Family physicians with certificates of added qualifications in geriatrics are key members of this project. The clerkship director for internal medicine is also a key member of the project. She has developed a new segment of the internal medicine clerkship curriculum, and has also developed a tool kit (mentioned above) for students to use during their internal medicine clerkship. The Program’s Assessment and Evaluation Instruments In our OME, we use evaluation to determine whether each student is acquiring the appropriate knowledge, skills, values, attitudes, and behaviors to function as a competent physician. Evaluation also provides useful feedback to students about their progress. Results of formal evaluations are used by the faculty to judge the progress of students and are used by individual students for self-improvement. The first year of the medical school curriculum consists of four nine-week blocks. Each block has two components: basic science/problem-based learning (Bsci/PBL) and IPC (introduction to patient care). Each student receives a grade for both components. All examinations occur during the ninth week of each block. There are no midblock exams or quizzes. Evaluation of PBL group performance is a continuous process that takes place during the eight weeks of PBL small-group meetings. Evaluation tools and programs are being developed to support continuous improvement of the curriculum. Resources Required There is substantial support for geriatrics training at our school. For example, the PI receives dean's office support to lead geriatrics academic programs. In addition, federal grants from the Health Resources Services Administration (HRSA) are currently supporting family medicine residency efforts in geriatrics, and another grant helps to support research infrastructure development. Current HRSA grants provide partial support for the academic training of our geriatric medicine fellows. MU's continuing education activities, such as the Caring for the Frail Elderly conference and the Long-Term Links newsletter, have been self-supporting through fees for the conference and unrestricted educational grants that will help further proposal goals. Geriatrics research/education has just been named as one of four major endowment efforts by the dean of the School of Medicine, along with cardiovascular disease, cancer, and child health. A $10 million endowment is targeted for geriatrics. In recent months, a donor referred to OME has created an endowment to help support the STEP program. All of this reflects the institutional recognition of, and commitment to, advancing training programs in the care of the elderly. The senior associate dean for education and faculty development is proud of the progress we have made in the way we deliver and teach care of the elderly. She backs our efforts to continue development of a geriatrics program of the size and scope necessary to deal with Missouri's aging population. Requirements to Sustain the Program Continued OME support, along with a new grant award by the Reynolds Foundation, will allow us to continue to maintain and improve the work we have started. Unanticipated Outcomes Recognition and funding from the Reynolds Foundation The extraordinary success, recognition, and continued funding of our STEP program Interest at the dean's level to make geriatrics and its endowment priority efforts Impact of External Funding External funding is allowing us to extend and expand the innovations developed under the AAMC/Hartford grant through new PBL cases, expansion of the STEP program, enlarging the GIG group, enhancing IM acute care of elderly experience, and developing a home-care curriculum for third-year students. For further information, contact Steven C. Zweig, MD, MSPH, at 〈[email protected]〉.