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AAMC Files Brief Supporting U-Michigan Admissions Policy AAMC Panel Defining Physician Roles Within Bioterrorism Education Innovations in Medical Education: "Teaching - and Learning - Through Collaboration" Wanted: More Anatomy Instructors Viewpoint: Avoiding Faculty Burnout A Word from the President "A Day in the Life of a Medical Student"
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Respecting Their Elders: Hartford Grants Initiate Unique Learning Experiences in GeriatricsThree years ago, the John A. Hartford Foundation, based in New York City, granted the AAMC $2.6 million over four years to help enhance the gerontology and geriatric curricula at U.S. medical schools. In 2000 and 2002, the AAMC awarded two-year grants of $100,000 to 40 medical schools. AAMC staff received proposals from 76 of 125 medical schools for the first round of grants. The Hartford Foundation initially asked the AAMC to coordinate a program with 20 schools, but when the response to the first request for proposals was so great, the foundation came forward and doubled the amount of money and suggested that it be used to fund 40 medical schools. The institutions were required to use the funding to develop an integrated geriatrics curriculum spanning the four years of undergraduate medical school training and to provide materials developed through the program to the AAMC for dissemination. The goals of the project are to encourage more students to consider a career in geriatric medicine and, equally important, to give medical students exposure to aging patients and their particular needs. How they do that is up to them, and several schools have approached the challenge with much creativity and insight. When the Hartford Foundation began developing the grant program, it planned to give $1 million to each of four medical schools. But when it approached the AAMC to administer the grants, staff suggested the money might be more effective if it was spread across more schools in smaller amounts, acting as seed money to launch many more initiatives. "This program has shown that schools can do a lot with a little," says M. Brownell "Brownie" Anderson, project director and senior associate vice president in the AAMC's Division of Medical Education. "We have seen medical schools go beyond academics, reaching out to seniors through community involvement - health fairs at malls, exercise programs… Seniors consider themselves important contributors to the education of physicians. The money from the Hartford Foundation has demonstrated what a powerful influence external funding can have on the attention given to a topic or program in medical school." The goal, Anderson says, is to expose students to the unique issues faced by the aging patients - physical, economic, and social - that they may encounter in their practice, whether they choose to specialize in surgery, psychiatry, internal medicine, or geriatrics. Even pediatricians may encounter a grandparent who is the primary caregiver for a child; everyone needs to be able to recognize and care for the needs of the aging patient, she adds. Pairing with 'senior mentors'
"The idea behind it is that students will learn about the processes of normal aging; they are not simply focused on disease," says Louise Arnold, Ph.D., associate dean for medical education at Missouri-Kansas City, who co-directs the program along with Harry S. Jonas, M.D. "They learn firsthand the challenges and the triumphs people face in growing old." In the three years since the program's inception, Dr. Arnold has seen a "substantial attitude shift" among students as a result of the mentoring program. "We know from our research that students come in with all the negative stereotypes about aging that characterize our society - old people are slow, poor, sedentary, in poor health, etc. Over the course of the program, their attitudes become markedly more positive. We believe that as physicians they will be mindful of the lessons their mentors teach them." Students also learn the critical skill of treating the whole patient. First- and second-year students in the B.A./M.D. program work through a number of vignettes related to aging, meeting in small groups overseen by a community physician who cares for older patients. One vignette introduces an older woman who is facing some nutritional concerns. She needs to alter her diet, but is having trouble coping with the changes. "Students get into basic concepts about nutrition for the elderly, but they go well beyond biological considerations," says Dr. Arnold. "They go on to learn that the patient now lives alone, but was once regarded as the best cook in her family. Now that role is unavailable to her; she has lost her sense of self. Students learn to integrate that element into the patient's care as well." They finish the project by writing reflective essays about their experience, along with a scholarly presentation gauged from the literature on aging and a performance-based assessment using a standardized older patient. From aging to 'saging'
The Ohio State University College of Medicine also has a senior mentoring program - "From Aging to Saging" - that spans all four years of the undergraduate curriculum. The core program matches each first-year student with an elderly resident in the community and they learn from each other throughout the duration of medical school. Students follow a longitudinal, Web-based curriculum that often closely mirrors the experiences of their aging partner. "Over the four years the partners will accumulate some health issues, so for the student it becomes a problem-based learning approach," says Bonnie Kantor, Sc.D., director of OSU's Office of Geriatrics and Gerontology. She explains that whatever students are learning in curriculum - osteoporosis, for example - they are interacting directly with their partner about those issues as well. As partners experience health problems, the student can access that part of the curriculum in real time. "If a partner seems to be growing confused, the student will go to the Web-based curriculum to learn about dementia and related conditions, even to the level of conducting evaluations of their partner's living arrangements," Dr. Kantor explains. "If a partner dies, or loses a loved one or close friend, the student is given access to our end-of-life curriculum at that point. It will have the most meaning for them right then." She adds that by the end of the four years, "Most will have completed this unit, because older people are surrounded by loss issues." Programs like the partnerships offered by Missouri and Ohio ensure that gerontology skills and experiences are built into every level of the curriculum. "Our goal is not to turn out geriatricians," Kantor notes. "We want every graduate to be able to care effectively for the elderly citizens of Ohio. That is why it's a part of virtually every course, in much the same way that ethics is integrated into our teaching. It shouldn't be an add-on." In pharmacology class, for example, Ohio State medical students track and log their partners' prescribed medications, even researching the retail costs of the drugs at several pharmacies. Students undertake a complete pharmaco-dynamic review of one of their partners' drugs, and discuss their findings in small group sessions. "Having a real-world case really makes the basic science curriculum come alive for students," Kantor asserts. Even pediatrics has an appropriate place for concepts in geriatrics. Both the Missouri and Ohio partnership programs include sessions dealing with issues faced by grandparents raising grandchildren - an increasingly common scenario practicing physicians will encounter. At the Medical College of Wisconsin (MCW), another Hartford Grant recipient, geriatrics studies are linked to a clinical case in which the patient "ages" through the four-year curriculum, according to Edmund H. Duthie Jr., M.D., professor of medicine and chief of geriatrics and gerontology at MCW. "The concept in our school is to teach geriatrics in the context of existing courses," he explains. "In the first year, each student is introduced to a fictional patient who is on the 'young' side of elderly, fit and functional, but with some early problems like atherosclerosis, diabetes, and mild hypertension. That patient's experiences are integrated into the first-year coursework. The next year, the patient 'ages' and the problems he develops are worked into the pathology curriculum. The patient ages further during the third and fourth years, and his more serious medical issues feed the students' clinical learning." Throughout, students focus on interdisciplinary approaches to care, engaging medicine as well as physical therapy, exercise, nutrition, podiatry, and clinical pharmacology. "In this way, geriatrics becomes a system of care, not simply the medicine of the elderly," says Dr. Duthie. Geriatrics lends itself well to full integration, he believes, "because as a relative newcomer on the block, it doesn't have a 'home.'" He compares it to the study of genetics, another discipline that crosses every boundary. At MCW, as at many other medical schools, "there is a big push to integrate genetics into the curriculum, and our new geriatrics initiatives may prove to be a prototype for teaching it and other cross-disciplinary subjects like nutrition," he says. Sowing seeds of innovation
Several of the schools have found that programs initiated with Hartford support have bloomed into curriculum centerpieces that continue to attract support from other funding organizations. "We have forged some real changes as a result of this grant and the new emphasis our school has placed on geriatric medicine," says Dr. Arnold. "For example, now we are part of a consortium of schools providing CME in geriatrics to physicians in the community. We also have a named chair in geriatrics at one of our affiliated hospitals. We continue to identify funding opportunities to expand what we're doing. We're particularly interested in doing more in the area of [graduate medical education]." At the MCW, where the curriculum committee was headed by a basic scientist at the time of the AAMC-Hartford grant application, "The money supported the time of our opinion leaders as they thought about how geriatrics can bring medicine and science together," says Dr. Duthie. "The Hartford funding stimulated some very constructive conversations. We are very appreciative of the Foundation and the AAMC for giving us something to build on." Indeed, MCW received additional funding from the Donald W. Reynolds Foundation to evolve the paper cases into a series of CD-ROM-based virtual patients for faculty to incorporate into their teaching. Each CD contains case materials ranging from two-minute video clips to radiographic images and genetic history, all used for teaching concepts in geriatrics. "Why didn't we have this focus before?" asks Dr. Duthie. "There was no flag to rally around. The grants gave us that. Developing the AAMC-Hartford proposal was a big motivator. Suddenly, the talking was over and it was time to make a commitment." Dr. Kantor agrees that an integrated geriatrics curriculum has become a necessity, not a choice. "We have crowded curricula just like everyone else does. But this is so important, it has to be central to our teachings." "The enthusiasm and commitment that the medical school faculty bring to this project is overwhelming and exciting. I wish everyone could attend one of our grantees' meetings to experience the tangible energy in the room," the AAMC's Anderson says. "The schools, the deans, and the faculty deserve enormous credit for providing models for all medical schools as they develop a focus on geriatric medicine, and we are grateful to the Hartford Foundation for their foresight in supporting this initiative." By Martha Frase-Blunt
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