AAMC Reporter: February 2006

Medical Schools Use Different Approaches to Geriatrics Education

By Anne Blank, Special to the Reporter

When a newly graduated physician from the University of Arkansas for Medical Sciences (UAMS) first noticed changes in his grandmother's behavior, he recognized the symptoms of Alzheimer's disease and quickly got her the medical care that she needed. Surprisingly, his specialty is not geriatrics but pediatrics.

Cathy Powers, M.D., associate professor of geriatrics and head of the education division in the Donald W. Reynolds Department of Geriatrics at UAMS, tells this story to illustrate the success of a geriatrics program that she helped initiate.

"We know that out of our class of 150 medical students, we're not going to get 150 geriatricians," Powers said. "We stress to students who are going into different specialties how geriatrics will impact them."

With the first group of baby boomers approaching age 60, the need for qualified physicians trained in geriatrics is more pressing than ever before. An analysis of current trends indicates that during the next 10 years, people ages 55 to 64 will represent the fastest-growing sector of the adult population. By the year 2029, individuals born during the baby-boom years will reach age 65 or older. Between 1950 and 2004, this U.S. population group climbed from 12 million to 36 million people, according to the National Center for Health Statistics, and is expected to continue to increase.

With today's medical advances, America's aging population will live longer after suffering from an acute disease, such as cancer, or be able to cope with a chronic disease, such as diabetes, for much longer than in the past.

The concern is that while the number of elderly people is increasing, the number of physicians going into geriatrics is not growing commensurately. In fact, as of 2002, the American Geriatrics Society identified only 9,000 practicing geriatricians in the United States.

"The main thing is that we've got a burgeoning need for people who are going to be able to put the problems of the elderly all together in a package, to be able to treat the whole person, and that we are desperately short of geriatricians in this country who can do that type of care," said Powers.

In continuing efforts to address this shortage of physicians trained in geriatrics, the AAMC joined forces with the John A. Hartford Foundation in 2000 to distribute to 40 medical schools more than $5 million earmarked for geriatrics training and education. In the six years since the Hartford grants were awarded, M. Brownell Anderson, senior associate vice president in the AAMC's Division of Medical Education, has noticed a definite increase among medical school graduates both in the level of exposure to and comfort with geriatrics, as indicated by their responses to the AAMC's annual Graduation Questionnaire.

"Our goal has been to ensure that students, regardless of the field that they are choosing, recognize that there are different approaches that must be taken with a mature patient, with an aging patient," Anderson said. "There are different social needs, there are different physical needs, there are different things that you have to think about in taking care of them that you may not if you're just approaching everybody like a healthy 35-year-old adult."

Clerkships

The geriatrics clerkship at UAMS is one of only a few programs in the country that are solely dedicated to geriatrics training at the medical school level. The month-long program, which started seven years ago with funding from the Donald W. Reynolds Foundation, is designed to teach students how to treat and manage all of the concomitant medical conditions that may affect elderly patients. As Powers explains, this model is different in that it takes a much more holistic approach than the traditional piecemeal method of treatment.

"The way medical schools are these days, we concentrate mostly on organ systems when a patient is sick," Powers said. "When you're in geriatrics, you really get a chance to concentrate on the entire person."

This model gives students the opportunity to see not only how different diseases interact with one another but also how social, economic, and emotional issues may affect the progression of disease and the success, or failure, of treatment. Students learn how to talk to their elderly patients about such issues as whether they have the money to buy the prescriptions they need and whether they've signed up for the correct Medicare program, Powers said.

Integrated Curriculum

Not all medical schools subscribe to the idea of a dedicated geriatrics clerkship. At the University of Michigan Medical School, the geriatrics curriculum is integrated into the four-year medical school program because the goal was not to increase the number of requirements in an already packed schedule but to reduce this number, said Jeffrey Halter, M.D., professor of internal medicine, chief of the division of geriatric medicine, and director of the Geriatrics Center and Institute of Gerontology. "To add another requirement was somewhat in the face of our own school's look at curriculum reform," Halter said.

Since elderly patients often have chronic diseases, it is imperative that medical students spend more time with these patients than a one-month clerkship can provide, Halter said.

"Having someone come into a long-term care facility and get the two- and three- and four-week exposure, that's a pretty short length of time for someone who's in a process of care that is measured in at least weeks to months," Halter said.

Medical student Raj Kakarla, Rev. Walter Koepsell and Steven Barczi, M.D., at the University of Wisconsin School of Medicine

Likewise, the University of Wisconsin School of Medicine and Public Health has integrated its geriatrics curriculum across the whole four years of medical school. Although the university first started this process in 1992, it wasn't until 1999, with support from a Hartford grant and the AAMC, that the four-year integrated curriculum reached fruition, according to Steven Barczi, M.D., assistant professor at Madison VA Hospital, Geriatric Research Education and Clinical Center, an affiliate of the University of Wisconsin, and director of the university's Geriatric Medicine Fellowship Program and the Diamond Team Geriatric Medical Clinics.

One of the problems with traditional geriatrics training was that students weren't introduced to it early enough, Barczi said. During the first and second years of medical school, students spend most of their time in the classroom buried in books, with just a sampling of what it is like to interact with patients. In contrast, integrated geriatrics programs are not only allowing first- and second-year students to have contact with patients; they are encouraging it through mentoring programs that link students with senior citizens in their school's community.

"They really love that," Barczi said. "Any time they can have a chance to interact with a live body, a patient, rather than with a book in a lecture hall, they really
get enthusiastic."

Powers agrees that there is a need for an integrated approach in geriatrics education, but says that the dedicated clerkship is imperative, as well. The one-month clerkship teaches students how to comprehensively treat the whole patient rather than one particular complication at a time, she said.

"To have a month dedicated to geriatrics gives students an appreciation of all the different problems that a geriatrics patient may have," Powers said. "If a patient is in cardiology, they're focusing on the heart, and not necessarily the attendant diabetes, or the chronic obstructive pulmonary disease, or the multiple other diseases that a lot of the elderly can have."

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