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Not the same old, same old

Lindsay Kalter , Special to AAMCNews
January 18, 2019

10,000 Americans turn 65 every day. Geriatricians are in increasingly short supply. So medical schools have begun teaching all students how to care for an aging population. Tackling ageism is a big part of it.

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Students try to button coats
Students at the Charles E. Schmidt College of Medicine at Florida Atlantic University (FAU) in aging sensitivity training.

Lena Vaynberg Eder recalls one of her biggest “aha!” moments in medical school. While wearing blurred glasses and cumbersome leather gloves and with cotton balls in her ears, she and her fellow students at the Charles E. Schmidt College of Medicine at Florida Atlantic University (FAU) were charged with performing just a few tasks: counting out pills and buttoning their lab coats.

The simple movements were nearly impossible.

At the time, Vaynberg Eder was enrolled in aging sensitivity training, where students learn first-hand how it feels to experience some of the limitations of hearing loss, vision impairment, and arthritis. During the exercise, she felt — for the first time — that she could begin to really understand older patients.

And two years later, during her residency, that exercise paid off. During her primary care clinic at Duke University Medical Center, she understood the plight of an 87-year-old patient who wasn’t taking his medication. His arthritis made it difficult to open his pill bottles, and he couldn’t see well enough to read the instructions.

“It led to us experimenting with ways of reducing the number of his medications, and we gave him special prescriptions for bigger pill boxes that are more user-friendly,” says Vaynberg Eder. “The sensitivity training was really eye-opening for me. It’s stayed with me to this day.”

With one in five Americans projected to be 65 or older by 2030 and fewer physicians going into geriatrics, more medical schools have added curricula to address this growing wave of older patients.

“The principles of geriatric medicine are just good medicine.”

Mandi Sehgal, MD
Geriatrics Curriculum Thread at FAU

New physicians, no matter their specialty, are likely to care for elderly patients, says Mandi Sehgal, MD, director of the Geriatrics Curriculum Thread at FAU.  And in the future this will be increasingly important because fewer new physicians are choosing geriatric medicine: The AAMC’s 2018 Physician Specialty Data Report found that the number of first-year residents and fellows studying geriatrics declined 14.3% between 2012 and 2017.

“Even pediatricians will,” Sehgal says. “Sometimes people will bring grandchildren to the office and that pediatrician may see that the grandparent might be a fall risk or may see signs of cognitive impairment. It applies across the spectrum.”

“Most diseases occur in people over 65”

FAU is one of the medical schools putting geriatrics front and center. The college of medicine hired the former President of the American Geriatrics Society, Joseph Ouslander, MD, to develop and direct the geriatrics program, and the school weaves geriatrics education into almost every single one of its classes, says Sehgal.

For example, a neuroscience and behavior course includes an entire section on dementia, and staff and caregivers are brought in from the local memory and wellness center.

“The principles of geriatric medicine are just good medicine,” Sehgal says.

R. Sean Morrison, MD, agrees. The Ellen and Howard C. Katz professor and chair for the Brookdale department of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai is leading the effort there to get its students up to speed on aging and the physiology of aging, not by requiring a separate class or curriculum, but by incorporating the care of older adults into all preclinical experiences, Morrison says. Students are required to make house calls and spend time in ambulatory care practices where patients skew older.

There is also a two-year course called “Art and Science of Medicine,” generally taught by geriatricians. Though it is not specifically labeled as a geriatric course, it touches on many issues faced by older adults, like surrogate decision making and autonomy.

The approach is a “stealth geriatrics” model, according to Rainier Soriano, MD, co-director of curriculum at the Icahn School of Medicine. “We’ve always focused on teaching geriatrics without letting students know they’re learning about it,” he says. “If you teach too much of one topic, interest wanes.”

Over the last several years, Mayo Clinic College of Medicine campuses have developed an online geriatric curriculum with 26 cases that test competencies including medication management, palliative care, and the ability to engage in self-care. The program has had 85,000 case completions to date, says Amit A. Shah, MD, associate dean for faculty affairs at Mayo Clinic Alix School of Medicine in Scottsdale, Arizona, who was editor-in-chief of the curriculum from 2010 to 2017.

“Because the number of geriatricians is so small, it’s just really hard to make all of that learning happen,” Shah says. “We need to ensure everyone practicing medicine has knowledge of geriatric medicine.”

Fighting the last acceptable “ism”

Maria Minor, a second-year medical student at Weill Cornell Medicine in New York City, remembers the man in his 90s who shuffled into her classroom with a walker. She assumed his mental state would match his physical condition and that he may have some cognitive decline.

But the man — who turned out to be a former literature professor and writer — quickly proved her wrong.

“He was cracking jokes and didn’t miss a beat, especially when we got nervous asking him difficult questions about incontinence and sexual function,” Minor says. “I was very humbled.”

Minor met the man as part of the curriculum at Weill Cornell designed to dispel harmful myths about the elderly, a type of program that’s becoming more prevalent at medical schools across the country.

A November 2018 Yale School of Public Health study found that ageism against people 60 and older was to blame for more than 17 million cases of the eight most expensive illnesses, costing roughly $63 billion a year. The study found that stereotypes about age lead to greater cardiovascular stress, causing serious events such as stroke or heart attack. This is in addition to the cost of chronic conditions generally experienced by older patients.

Schools are getting more creative with their curricula when it comes to combating ageism. The Weill Cornell program includes a play that juxtaposes an ageist interaction with an appropriate one.

In one scene, an older woman comes to the emergency department with chest pains, accompanied by her daughter. The doctors ignore the patient, speaking only to her daughter, and take a very brief medical history.

In another scene, an older woman seeks help for the same symptoms, only this time the doctors get a full life review and psycho-social history. The doctors discover she was recently widowed and is experiencing an episode of depression.

After the play, medical students are given the opportunity to interview older patients.

“You need to make sure students basically like older patients. See them as individuals worthy of love and care.”

Amit A. Shah, MD
Mayo Clinic Alix School of Medicine

“They love getting to know an older person, and by doing that, so many stereotypes are erased,” says Ron Adelman, MD, professor of geriatrics and gerontology and co-chief of the division of geriatrics at Weill Cornell. “We live in an ageist society and medicine mirrors our society.”

Indeed, ageism is “the last acceptable ‘ism,’” says the Mayo Clinic’s Shah, and for many new doctors, it begins in medical school.

“They get through their first two years without any required geriatric experience, and they have an overwhelming experience with a complex older patient during their internal medicine rotations,” Shah says. “People want to run in the opposite direction.”

This is why all successful programs must have an empathy component as well as basic education about the risks for older patients, Shah says. Two years ago, Mayo's Arizona campus kicked off its Senior Sage Program, which pairs first-year medical students with seniors. The students meet with their mentors several times over their four years in medical school to discuss topics related to aging and health.

“You need to make sure students basically like older patients,” Shah says. “See them as individuals worthy of love and care.”

It’s that piece — the process of humanizing older people — that is most important in fighting ageism, says Tracey Gendron, MD, assistant professor and interim chair of the department of gerontology in the College of Health Professions at Virginia Commonwealth University.

Five years ago, Gendron developed a senior mentoring program for first-year students. Two or three students are paired up with one mentor from an assisted living center or the local lifelong learning institute, where people over 50 can take classes for free. Students gather with their mentors a total of three times throughout the year.

Students are directed to ask certain questions like “What are the best and worst experiences you’ve had with doctors?” and “Tell me about your quality of life.”

“What I found was that there were some relationships that developed so beautifully that they kept in touch,” Gendron says. “We want to move away from ‘This is a patient in front of me’ to ‘This is a person.’”

And training students how to properly treat patients over 65, both from a physiological and a psychological standpoint, will only become more important over time, says Weill Cornell’s Adelman.

“There are 10,000 Americans turning 65 every day,” Adelman says. “This is the future.”

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