Gerontology & Geriatrics Education
ISSN: 0270-1960 (Print) 1545-3847 (Online) Journal homepage: http://www.tandfonline.com/loi/wgge20
A Problem-Based Learning Curriculum in Geriatrics for Medical Students Mamata Yanamadala, Victoria S. Kaprielian, Colleen O’Connor Grochowski, Tiffany Reed & Mitchell Tod Heflin To cite this article: Mamata Yanamadala, Victoria S. Kaprielian, Colleen O’Connor Grochowski, Tiffany Reed & Mitchell Tod Heflin (2016): A Problem-Based Learning Curriculum in Geriatrics for Medical Students, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2016.1152268 To link to this article: http://dx.doi.org/10.1080/02701960.2016.1152268
Accepted author version posted online: 24 Feb 2016.
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Date: 25 February 2016, At: 05:18
A Problem-Based Learning Curriculum in Geriatrics for Medical Students Mamata Yanamadala
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Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Family Medicine and Faculty Development and Medical Education, Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina, USA Colleen O’Connor Grochowski
Tiffany Reed
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Curricular Affairs, Duke University School of Medicine, Durham, North Carolina, USA
Mitchell Tod Heflin
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Piedmont Senior Care, Cone Health Medical Group, Greensboro, NC, USA
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Department of Medicine, Duke University School of Medicine, Durham, NC, USA Address correspondence to Mamata Yanamadala, Department of Medicine, Duke University School of Medicine, Box 3003, Durham, NC, 27710. Email: [email protected]
Abstract
A geriatrics curriculum delivered to medical students was evaluated in this study. Students were instructed to review real patient cases, interviewed patients and caregivers, identified community resources to address problems, and present a final care plan. Authors evaluated the course feedback and final care plans submitted by students for evidence of learning in geriatric competencies. Students rated the efficacy of the course on a 5-point Likert scale as 3.70 for developing clinical reasoning skills and 3.69 for interdisciplinary teamwork skills. Assessment of an older adult with medical illness was rated as 3.87 and ability to perform mobility and functional assessment as 3.85. Reviews of written final care plans provided evidence of student learning across several different geriatric competencies such as falls, medication management, cognitive and behavior disorders and self-care capacity. Assessment of the curriculum demonstrated that medical students achieved in-depth learning across multiple geriatric competencies through contact with real cases.
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Victoria S. Kaprielian
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KEYWORDS: curriculum, geriatrics, medical students
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Introduction
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among all physicians.1 Older adults currently make up about 12% of the US population, yet account for 26% of all physician office visits and 35% of all hospital stays. Effective care of this
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growing population requires knowledge and skills in the management of complex medical and psychosocial problems. In response, the IOM report recommends that all primary care and
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subspecialty physicians receive enhanced training in geriatrics. Unfortunately, deficiencies exist in preparation of medical students to care for geriatric patients in the United States.2 As a result,
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students graduate with inadequate knowledge and skills in the care of older adults and, furthermore, may perceive geriatrics as a less valuable medical specialty and undesirable career option.3-5
Over the last decade, grant-funded initiatives have targeted these deficiencies. Educators in geriatrics have applied novel strategies for medical student training, including senior mentor programs, community partnerships, and standardized patients.4 In order to provide consistent
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The Institute of Medicine (IOM) has identified a critical need to expand geriatrics competence
expectations for these efforts, a national taskforce published a set of minimum competencies in care of older adults for graduating medical students in 2009.6 Significant efforts are underway to
disseminate the competencies, but, to date, few models describing and evaluating experiences in medical schools to teach these competencies have been published.7
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Multiple barriers exist to effective instruction in geriatrics, including shortage of faculty and student time and funding.
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Teaching geriatric competencies is also uniquely challenging for
educators due to the complexity and multiplicity of medical, psychosocial and functional issues.
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This complexity demands further development of effective and efficient curricula in geriatrics for medical students. Problem-based learning, particularly in examination of real cases, presents
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teamwork issues so critical to geriatrics.12 In this article we describe a week-long problem based learning experience in geriatrics delivered to second-year medical students and its relative
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METHOD
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effectiveness in promoting learning geriatric competencies.
Curriculum development.
Interventions that include contact with older adults in a variety of settings have the highest success rates over time in increasing positive attitudes of medical students towards geriatric patients.13
In addition, problem-based learning (PBL) in medical school positively affects
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an educational strategy proven to enhance learning, particularly around psychosocial and
physician competencies essential to the care of older adults, including appreciation of social and ethical aspects of health care, communication skills, and self-directed learning.12
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Review of the existing curriculum for medical students revealed opportunities to increase medical student interaction with geriatric patients. A subsequent curriculum revision led to the creation of a series of one-week intersessions between the standard clinical clerkships. These
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weeklong experiences addressed key topics spanning multiple medical specialties, including Geriatrics. Geriatrics faculty met regularly with the course director and administrators over a six
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clinical experiences on selected core issues on care of older adults, including falls, cognitive
Curriculum description.
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impairment, polypharmacy and caregiver stress.
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This week-long course titled “Clinical Core on Aging” was delivered to second year medical students after completion of their first clinical clerkship. Learning objectives included the
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following:
By the end of the week, students will be able to: 1.
Analyze the case of an older adult suffering from one of four core problems (falls,
polypharmacy, caregiver stress, or cognitive impairment) for root causes and contributing factors;
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month period to plan the curriculum. Given limited time, faculty elected to focus didactics and
2.
Cite evidence on the epidemiology of the problem, common contributing factors, and
methods of prevention; 3.
Describe community resources available to prevent or manage this core problem;
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4.
Propose specific recommendations at the patient and system level for improving care in
this area; and Demonstrate teamwork skills.
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5.
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We aimed to use a PBL strategy to teach teamwork, clinical reasoning, and care planning. PBL is
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groups and independent study.14 This method encourages learners to use critical thinking and problem solving skills as they apply content knowledge to real world problems and issues.
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During the week, students worked in teams of five on a project with a real patient affected by one or more of four core problems, including falls, cognitive decline, caregiver stress and
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polypharmacy. Faculty reviewed and identified core issues for each case. “Polypharmacy” cases included not only those with multiple medications but also those with potentially
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inappropriate medications. Faculty and fellows recruited case patients by contacting primary providers in different settings including nursing homes, assisted living, independent living, community dwelling, and hospital. Course faculty aimed to achieve an even distribution of types of patient problems and locations of care among the student teams in order to optimize the value of discussions at the end of the week. Ten faculty members specializing in geriatrics and 6 geriatric fellows were recruited to conduct the introductory and final care plan discussions. In
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defined as both a method and philosophy, involving problem-first learning via work in small
preparation for the week, faculty and fellows participated in an hour-long development session on PBL methodology.
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The week-long course started with an introductory discussion of a real patient case (see Figure 1). This 90-minute small group discussion was facilitated by geriatric medicine faculty and fellow pairs. At the beginning of the session, students received a case packet which included a
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brief introductory paragraph describing the patient’s age, gender, major medical problems and chief concern or problem as well as resources and instructions for activities for the remainder of
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information provided in the case. By the end of the session, student teams identified specific issues to research between sessions and a basic plan for their final presentation.
On the
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afternoon of day 1, students received a series of brief lectures on the core topics, including cognitive disorders, gait problems and falls, medication management and caregiver stress. On
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day 2, students performed an interview and assessment of the patient and (when possible) the caregiver. Students used Mini Mental Status Exam and Get Up and Go tools for cognitive and
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gait assessments respectively. In addition, they performed a systematic medication review that included dosage, timing and indication of both prescription and non-prescription drugs. They did not use a specific tool to assess caregiver burden.
Interviews focused on the patient
experience and the identification of causative factors for problems. Students were encouraged to begin to identify steps for prevention or management of subsequent events or problems. On day 3 students met with members of the interdisciplinary team at a local continuing care retirement
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the week. With this information, students brainstormed a differential diagnosis for the brief
community and then attended a panel discussion at the local senior center with representatives from Meals-on-Wheels, a nonprofit assisting older adults in managing medications, a publicly supported senior transportation agency, the State Health Insurance Information Program (SHIIP),
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caregiver support groups, and home care agencies. They also toured an Adult Day Health Program located there in the senior center. Independent Teamwork: Student teams also met independently in three pre-designated 2-hour
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meeting times to work collaboratively on the patient case activity. Between meetings, students
strategies. Key references and contacts were provided for the core problems identified in their
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case. Faculty members were also available for questions during designated “office hours” for
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answering student questions.
Final Activity: On the final day (Day 4), students met in large groups of four teams (20
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students), each with a different core problem, to present their cases to each other. Teams took turns presenting with faculty facilitating the discussion. In their presentation, each team was
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directed to address the patient’s problem(s), pertinent evidence from the literature, and approaches for the care of the patient. While each case was linked with a core problem, they were allowed (and in some cases encouraged) to include discussion of other important problems. For example, if the core problem was dementia, but the patient had fallen, they could include this in the plan. At the end of the session, each student team comprising of 5 students submitted a one-page paper summarizing their case, findings and a plan of care. In the papers, they were
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independently researched their patient’s primary problem, etiology, and appropriate management
asked to provide a brief synopsis of the case and then, based on their educational experiences and interactions over the course of the week, to identify specific problems and propose solutions.
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Measures: Student Self-Assessment of learning:
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Students rated the efficacy of the course on a 5-point Likert scale (1=not at all successful,
achieving the following outcomes. The following evaluation items on the likert scale were
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designed from the content taught in the course: 1)Develop clinical reasoning skills, integrating knowledge to solve problems outside the confines of a single discipline 2)Develop skills and
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attitudes for effective interdisciplinary teamwork 3)Work with a team of providers to formulate a plan of care for an older adult with medical illness and functional decline 4) Perform assessments
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of mobility and function of an older adult 5) Describe community resources to assist in Students were also asked to comment
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management of common problems for older adults.
about the most effective aspect of the week, the most important thing they learned and provide suggestions for improvement.
Competency identification:
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3=adequately successful, 5=extremely successful) on how successful the course was on
As detailed above, students were asked to write a one-page paper on the case they investigated. The student papers were reviewed by two authors (MY and MTH) independently, looking for evidence of learning in the pre-defined minimum geriatrics-specific competencies addressed by the students.6 In order to qualify as “evidence of learning,” the content of the papers needed to
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go beyond a simple mention of the problem to include all or most of the elements detailed in the competencies themselves. For example, if the students were allotted a case with falls as a core topic, they might have inquired about falls and performed a gait evaluation but did not provide
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an interpretation of the gait evaluation as required by the competency. (One of the competency for the falls, gait and balance reads as follows: Ask all patients > 65 years old, or their
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and then record and interpret the findings).
We also identified relevant themes not necessarily listed among the competencies, such as
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financial issues or caregiver burden. No specific measures were defined to assess caregiver burden. Credit was given for student papers if they mentioned recognition of care giver stress
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and strategies for management of care giver stress. We used constant comparative analysis to
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review and reconcile findings over several rounds until consensus was achieved on themes identified in each paper. To evaluate the volume and frequency of competencies achieved, we calculated the median number of competencies addressed across teams and the percentage of teams that actually addressed the assigned core topic. Institutional review board of our institution has exempted this research.
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caregivers, about falls in the last year, watch the patient rise from a chair and walk (or transfer),
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Results
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Experience
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Two hundred and two students participated over two consecutive years in the program. There
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51 (25.2%) Asian, 42 (20.8%) African American, and 11 (5.4%) Hispanic. Students rated the efficacy of the course (1=not at all successful
5=extremely successful) at 3.70 (SD 0.89) for
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developing clinical reasoning skills and integrating knowledge to solve problems. Students rated their experience developing skills and attitudes for effective interdisciplinary teamwork as 3.69
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(SD 0.93). In terms of interdisciplinary team assessment of an older adult with medical illness and functional decline, students rated their experience as 3.87 (SD 0.85). Efficacy in developing
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student ability to perform assessments of mobility and function of an older adult was rated as 3.85 (SD 0.88). Efficacy in using community resources to assist in management of common problems for older adults was rated as 3.89 (SD 0.95). Student comments reflected general acceptance of PBL methods: “The team based activity was extremely engaging and practical - actually working with real patients was tremendously effective relative to standard classroom based learning.” “I thought it was working with actual
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were 98 (48.5%) females and the group was ethnically diverse with 98 (48.5%) white students,
patients and making suggestions to improve their care was the best part [sic]. Health care team visits with real patients better highlighted the complexities and intricacies of aging and chronic disease better than any lecture or textbook.”
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Evidence of learning for competencies: Which competencies were addressed?
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Review of 40 final papers revealed that student teams addressed competencies across at total of 7
different domains (Figure.2). The average number of total competencies addressed in each paper
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in the competencies) were 1.44 per each paper. Sixty three percent of student papers addressed at least 1-2 competencies, while 24% papers addressed 3-4 competencies and 10% addressed 5-6
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competencies. Students most commonly described issues with falls, balance and gait (71 %). Medication management, cognitive and behavior disorders and self-care capacity were addressed
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in 47.4% of the papers (Figure 2). In addition to the pre-defined competencies the content in students’ papers reflected learning in key geriatric content areas including caregiver challenges
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in 47.4% and pain assessment and management in 23.7% . Learners evaluated financial issues, identified community resources for the elderly and discussed advance directives in about 15% of the papers (Figure 3). Below are 2 examples from student papers that included final care plans and system changes to impact outcomes for older patients. 1.
In a case of 93 year old male re-hospitalized after recent hospitalization due to poor
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were 2.5, and the average number of additional geriatric pertinent issues (identified but not listed
transitions in care, the student team suggested “empowering elderly patients to take more active role during the transition by educating patient and caregiver about care plan and the elderly playing an active role in devising their post discharge plan. Keeping up with current medication list by informing all parties about changes. Care settings operating as silos can be detrimental to patients and propose communication of care plans between settings.”
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2.
Another case was of 83 year old female with dementia living independently at home with
her husband was requiring assistance with activities of daily living and the husband is experiencing care giving burden and would like to continue to stay at home. The husband was
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feeling isolated due to lack of social interaction. The team suggested “attending free congregate lunch program offered by the local Center for senior life to increase social interaction and
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club in library to encourage his favorite activity.”
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How often did they explicitly address their assigned core topic? Interestingly, students did not always clearly address their assigned “core” issue. In order, 90%
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percent of those assigned to address caregiver issues did so, as did 87% of those assigned to a case with falls as the core topic. However, only 72% of those assigned to a dementia case and
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62% of those with medication management successfully addressed these issues. When students did not address the core issue it was because they did not achieve the level of discussion necessary to count as evidence of learning. In some cases students addressed issues other than the assigned core issues.
Discussion
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suggestions for free respite care and care giver support program and involvement with a book
Assessment of the week-long PBL activity through course evaluation and review of the final papers demonstrated that medical students achieved in-depth learning across multiple geriatric competencies through contact with real cases in a PBL format. Given involvement of caregivers
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in the interview process this became a natural focus of the student papers. Likewise, falls are an important focal event for older adults and their caregivers and were frequently addressed in student papers. Medications and dementia were not as frequently addressed by the students. This
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under-performance in the domains of dementia and polypharmacy was seen in both years and certainly suggests a need for a greater emphasis in the curriculum in these areas in the future. In
Further
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require deliberate and systematic approaches that these novice students may lack.
clarification of student performance expectations may help address problems with learner
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performance. Although the student teams were instructed to focus on one core geriatric problem, the qualitative review of their final papers showed that they were able to identify and address
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other domains in the minimum geriatric competencies as well. Students also recognized and researched other common geriatric issues in the management of geriatric patients that were not
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included in the competencies, such as financial issues, pain assessment and management, advance directives, and others.
The clinical core in aging experience allowed for richer learning as the students interacted with real patients and connected with community resources. Interaction with real people added value to student interactions and lent a broader perspective about their patients which could not have been achieved with didactics alone or simulated cases. In person interaction with inter-
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addition, identification and management of medication problems and cognitive impairment
professional health care providers and community resources permitted the learners to have interactive discussions which enhanced their learning.
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Implementing the week-long PBL activity was logistically complex in terms of selecting cases with a variety of pertinent problems from a variety of settings, and assigning them to teams. This also involved scheduling a significant number of preceptors for the events. Alternative teaching
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methods instead of real cases, such as classroom based activities or simulation used in other studies, might have been less complex logistically and more easily sustainable. One study
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multisite fourth-year geriatrics clerkship using an ambulatory and home care geriatrics program9 while two other studies used Observed Structured Clinical Examinations to supplement the
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teaching and assessment of geriatrics skills.10,11 These models successfully introduced students to several geriatrics competencies, but these curricula required longer periods of time and were
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sometimes personnel intensive. Such programs may be difficult to implement in many institutions with limited geriatrics resources and different curricular structures. One other model
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was a week-long curriculum that was successful in introducing the geriatric competencies.7 This one week model included primarily clinical encounters with patients in the hospital, clinic, longterm care and independent living in addition to reading assignments. This program along with our model demonstrates that the competencies could be addressed in a short period of time with or without geriatric specific settings.
The PBL approach used in this activity encouraged learners to use critical thinking and problem
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focused on integration of competencies through e-learning.8 Another study had a month-long
solving skills as they applied content knowledge to real case problems. Group based activities and interaction with interdisciplinary personnel helped learners appreciate social aspects of caring for older adults. Literature suggests that PBL in medical school positively affects physician competencies essential to the care of older adults, including appreciation of social and
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ethical aspects of health care, communication skills, and lifelong learning.12 The outcomes from this activity demonstrated similar outcomes seen in literature from PBL activities. This study has a few important limitations. To avoid survey burden, we did not perform a formal
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measure of students’ attitudes. Evaluation measures were limited to those performed at week’s
concepts learned. In the future, this type of curriculum would lend itself to use summative
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measures at the end of clinical training such as observed structured clinical exam (OSCE) or
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clinical evaluation exercise (CEX).
Improvements noted in clinical reasoning skills and recognition of importance of
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interdisciplinary teamwork were based on students’ self-evaluations. More objective measures of these constructs, a pre-test, and a comparison group would be needed to make stronger
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conclusions about the effectiveness of the PBL in these domains. This PBL activity demonstrated knowledge application to real cases. Follow-up evaluation to determine the effectiveness of this activity in future practice will be a next step for studying the effect on practice change. The impact of student recommendations on actual cases in solving real problems for the patients could also be evaluated.
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end. More distal measures may have demonstrated how students retained and even applied
Conclusions: Introduction of a PBL exercise provided an effective means of educating second-year medical students on core geriatrics subjects, while at the same time helping students to develop clinical
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reasoning skills, recognize importance of interdisciplinary teamwork, and understand key social and ethical issues in geriatrics on self evaluations. Future steps should include more objective measurements to determine the effectiveness of the PBL in these domains.
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Acknowledgements
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Division of Geriatrics, Duke University.
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Funding
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-Donald W. Reynolds Program for Faculty Development to Advance Geriatrics Education. -Health Resources and Services Administration Geriatric Training for Physicians, Dentists and
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Mental Health Professionals Grant. (D01HP08791).
-Geriatric Academic teaching award, Duke School of Medicine References: 1.
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school curricula: results of a national survey. Journal of the American Geriatrics Society. 2005;53(1):136-140.
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Bagri AS, Tiberius R. Medical student perspectives on geriatrics and geriatric education.
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granny safe on July 1: a consensus on minimum geriatrics competencies for graduating medical
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Atkinson HH, Lambros A, Davis BR, et al. Teaching Medical Student Geriatrics
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Competencies in 1 Week: An Efficient Model to Teach and Document Selected Competencies Using Clinical and Community Resources. Journal of the American Geriatrics Society. 2013; 61:1182–1187 8.
Helms A, Denson K, Brown D, Simpson D. One specialty at a time: achieving
competency in geriatrics through an e-learning neurology clerkship module. Academic Medicine. 2009;84(10):S67-S69.
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Strano-Paul L. Effective teaching methods for geriatric competencies. Gerontology &
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American Geriatrics Society. 2011;59(9):1739-1744.
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Table 1: Competencies addressed in student final papers
Polypharmac
Fall
Caregiver
Impairment y
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Cognitive
stress (11)
(n=8)
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(n=8)
the core problem of the case (%)
62%
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Additional competencies addressed in student 1.27 papers (avg.)
Additional geriatric content areas addressed 1.18 (avg.)
87%
90.9%
0.87
1.5
2
1.375
0.87
1
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Competency addressed in student papers for 72%
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(n=11)
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F-falls, CI-cognitive impairment, CS-caregiver stress and P-polypharmacy
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Figure.1 Organizational Scheme for Clinical Core on Aging.
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Figure 2. Frequency of geriatric competencies addressed by domain in final papers.
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Figure 3. Frequency of identification of other geriatric issues in final papers.
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ISSN: 0270-1960 (Print) 1545-3847 (Online) Journal homepage: http://www.tandfonline.com/loi/wgge20
A Problem-Based Learning Curriculum in Geriatrics for Medical Students Mamata Yanamadala, Victoria S. Kaprielian, Colleen O’Connor Grochowski, Tiffany Reed & Mitchell Tod Heflin To cite this article: Mamata Yanamadala, Victoria S. Kaprielian, Colleen O’Connor Grochowski, Tiffany Reed & Mitchell Tod Heflin (2016): A Problem-Based Learning Curriculum in Geriatrics for Medical Students, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2016.1152268 To link to this article: http://dx.doi.org/10.1080/02701960.2016.1152268
Accepted author version posted online: 24 Feb 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wgge20 Download by: [Orta Dogu Teknik Universitesi]
Date: 25 February 2016, At: 05:18
A Problem-Based Learning Curriculum in Geriatrics for Medical Students Mamata Yanamadala
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Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Family Medicine and Faculty Development and Medical Education, Campbell University School of Osteopathic Medicine, Buies Creek, North Carolina, USA Colleen O’Connor Grochowski
Tiffany Reed
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Curricular Affairs, Duke University School of Medicine, Durham, North Carolina, USA
Mitchell Tod Heflin
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Piedmont Senior Care, Cone Health Medical Group, Greensboro, NC, USA
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Department of Medicine, Duke University School of Medicine, Durham, NC, USA Address correspondence to Mamata Yanamadala, Department of Medicine, Duke University School of Medicine, Box 3003, Durham, NC, 27710. Email: [email protected]
Abstract
A geriatrics curriculum delivered to medical students was evaluated in this study. Students were instructed to review real patient cases, interviewed patients and caregivers, identified community resources to address problems, and present a final care plan. Authors evaluated the course feedback and final care plans submitted by students for evidence of learning in geriatric competencies. Students rated the efficacy of the course on a 5-point Likert scale as 3.70 for developing clinical reasoning skills and 3.69 for interdisciplinary teamwork skills. Assessment of an older adult with medical illness was rated as 3.87 and ability to perform mobility and functional assessment as 3.85. Reviews of written final care plans provided evidence of student learning across several different geriatric competencies such as falls, medication management, cognitive and behavior disorders and self-care capacity. Assessment of the curriculum demonstrated that medical students achieved in-depth learning across multiple geriatric competencies through contact with real cases.
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Victoria S. Kaprielian
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KEYWORDS: curriculum, geriatrics, medical students
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Introduction
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among all physicians.1 Older adults currently make up about 12% of the US population, yet account for 26% of all physician office visits and 35% of all hospital stays. Effective care of this
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growing population requires knowledge and skills in the management of complex medical and psychosocial problems. In response, the IOM report recommends that all primary care and
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subspecialty physicians receive enhanced training in geriatrics. Unfortunately, deficiencies exist in preparation of medical students to care for geriatric patients in the United States.2 As a result,
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students graduate with inadequate knowledge and skills in the care of older adults and, furthermore, may perceive geriatrics as a less valuable medical specialty and undesirable career option.3-5
Over the last decade, grant-funded initiatives have targeted these deficiencies. Educators in geriatrics have applied novel strategies for medical student training, including senior mentor programs, community partnerships, and standardized patients.4 In order to provide consistent
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The Institute of Medicine (IOM) has identified a critical need to expand geriatrics competence
expectations for these efforts, a national taskforce published a set of minimum competencies in care of older adults for graduating medical students in 2009.6 Significant efforts are underway to
disseminate the competencies, but, to date, few models describing and evaluating experiences in medical schools to teach these competencies have been published.7
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Multiple barriers exist to effective instruction in geriatrics, including shortage of faculty and student time and funding.
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Teaching geriatric competencies is also uniquely challenging for
educators due to the complexity and multiplicity of medical, psychosocial and functional issues.
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This complexity demands further development of effective and efficient curricula in geriatrics for medical students. Problem-based learning, particularly in examination of real cases, presents
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teamwork issues so critical to geriatrics.12 In this article we describe a week-long problem based learning experience in geriatrics delivered to second-year medical students and its relative
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METHOD
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effectiveness in promoting learning geriatric competencies.
Curriculum development.
Interventions that include contact with older adults in a variety of settings have the highest success rates over time in increasing positive attitudes of medical students towards geriatric patients.13
In addition, problem-based learning (PBL) in medical school positively affects
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an educational strategy proven to enhance learning, particularly around psychosocial and
physician competencies essential to the care of older adults, including appreciation of social and ethical aspects of health care, communication skills, and self-directed learning.12
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Review of the existing curriculum for medical students revealed opportunities to increase medical student interaction with geriatric patients. A subsequent curriculum revision led to the creation of a series of one-week intersessions between the standard clinical clerkships. These
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weeklong experiences addressed key topics spanning multiple medical specialties, including Geriatrics. Geriatrics faculty met regularly with the course director and administrators over a six
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clinical experiences on selected core issues on care of older adults, including falls, cognitive
Curriculum description.
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impairment, polypharmacy and caregiver stress.
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This week-long course titled “Clinical Core on Aging” was delivered to second year medical students after completion of their first clinical clerkship. Learning objectives included the
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following:
By the end of the week, students will be able to: 1.
Analyze the case of an older adult suffering from one of four core problems (falls,
polypharmacy, caregiver stress, or cognitive impairment) for root causes and contributing factors;
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month period to plan the curriculum. Given limited time, faculty elected to focus didactics and
2.
Cite evidence on the epidemiology of the problem, common contributing factors, and
methods of prevention; 3.
Describe community resources available to prevent or manage this core problem;
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Propose specific recommendations at the patient and system level for improving care in
this area; and Demonstrate teamwork skills.
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5.
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We aimed to use a PBL strategy to teach teamwork, clinical reasoning, and care planning. PBL is
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groups and independent study.14 This method encourages learners to use critical thinking and problem solving skills as they apply content knowledge to real world problems and issues.
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During the week, students worked in teams of five on a project with a real patient affected by one or more of four core problems, including falls, cognitive decline, caregiver stress and
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polypharmacy. Faculty reviewed and identified core issues for each case. “Polypharmacy” cases included not only those with multiple medications but also those with potentially
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inappropriate medications. Faculty and fellows recruited case patients by contacting primary providers in different settings including nursing homes, assisted living, independent living, community dwelling, and hospital. Course faculty aimed to achieve an even distribution of types of patient problems and locations of care among the student teams in order to optimize the value of discussions at the end of the week. Ten faculty members specializing in geriatrics and 6 geriatric fellows were recruited to conduct the introductory and final care plan discussions. In
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defined as both a method and philosophy, involving problem-first learning via work in small
preparation for the week, faculty and fellows participated in an hour-long development session on PBL methodology.
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The week-long course started with an introductory discussion of a real patient case (see Figure 1). This 90-minute small group discussion was facilitated by geriatric medicine faculty and fellow pairs. At the beginning of the session, students received a case packet which included a
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brief introductory paragraph describing the patient’s age, gender, major medical problems and chief concern or problem as well as resources and instructions for activities for the remainder of
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information provided in the case. By the end of the session, student teams identified specific issues to research between sessions and a basic plan for their final presentation.
On the
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afternoon of day 1, students received a series of brief lectures on the core topics, including cognitive disorders, gait problems and falls, medication management and caregiver stress. On
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day 2, students performed an interview and assessment of the patient and (when possible) the caregiver. Students used Mini Mental Status Exam and Get Up and Go tools for cognitive and
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gait assessments respectively. In addition, they performed a systematic medication review that included dosage, timing and indication of both prescription and non-prescription drugs. They did not use a specific tool to assess caregiver burden.
Interviews focused on the patient
experience and the identification of causative factors for problems. Students were encouraged to begin to identify steps for prevention or management of subsequent events or problems. On day 3 students met with members of the interdisciplinary team at a local continuing care retirement
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the week. With this information, students brainstormed a differential diagnosis for the brief
community and then attended a panel discussion at the local senior center with representatives from Meals-on-Wheels, a nonprofit assisting older adults in managing medications, a publicly supported senior transportation agency, the State Health Insurance Information Program (SHIIP),
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caregiver support groups, and home care agencies. They also toured an Adult Day Health Program located there in the senior center. Independent Teamwork: Student teams also met independently in three pre-designated 2-hour
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meeting times to work collaboratively on the patient case activity. Between meetings, students
strategies. Key references and contacts were provided for the core problems identified in their
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case. Faculty members were also available for questions during designated “office hours” for
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answering student questions.
Final Activity: On the final day (Day 4), students met in large groups of four teams (20
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students), each with a different core problem, to present their cases to each other. Teams took turns presenting with faculty facilitating the discussion. In their presentation, each team was
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directed to address the patient’s problem(s), pertinent evidence from the literature, and approaches for the care of the patient. While each case was linked with a core problem, they were allowed (and in some cases encouraged) to include discussion of other important problems. For example, if the core problem was dementia, but the patient had fallen, they could include this in the plan. At the end of the session, each student team comprising of 5 students submitted a one-page paper summarizing their case, findings and a plan of care. In the papers, they were
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independently researched their patient’s primary problem, etiology, and appropriate management
asked to provide a brief synopsis of the case and then, based on their educational experiences and interactions over the course of the week, to identify specific problems and propose solutions.
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Measures: Student Self-Assessment of learning:
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Students rated the efficacy of the course on a 5-point Likert scale (1=not at all successful,
achieving the following outcomes. The following evaluation items on the likert scale were
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designed from the content taught in the course: 1)Develop clinical reasoning skills, integrating knowledge to solve problems outside the confines of a single discipline 2)Develop skills and
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attitudes for effective interdisciplinary teamwork 3)Work with a team of providers to formulate a plan of care for an older adult with medical illness and functional decline 4) Perform assessments
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of mobility and function of an older adult 5) Describe community resources to assist in Students were also asked to comment
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management of common problems for older adults.
about the most effective aspect of the week, the most important thing they learned and provide suggestions for improvement.
Competency identification:
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3=adequately successful, 5=extremely successful) on how successful the course was on
As detailed above, students were asked to write a one-page paper on the case they investigated. The student papers were reviewed by two authors (MY and MTH) independently, looking for evidence of learning in the pre-defined minimum geriatrics-specific competencies addressed by the students.6 In order to qualify as “evidence of learning,” the content of the papers needed to
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go beyond a simple mention of the problem to include all or most of the elements detailed in the competencies themselves. For example, if the students were allotted a case with falls as a core topic, they might have inquired about falls and performed a gait evaluation but did not provide
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an interpretation of the gait evaluation as required by the competency. (One of the competency for the falls, gait and balance reads as follows: Ask all patients > 65 years old, or their
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and then record and interpret the findings).
We also identified relevant themes not necessarily listed among the competencies, such as
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financial issues or caregiver burden. No specific measures were defined to assess caregiver burden. Credit was given for student papers if they mentioned recognition of care giver stress
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and strategies for management of care giver stress. We used constant comparative analysis to
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review and reconcile findings over several rounds until consensus was achieved on themes identified in each paper. To evaluate the volume and frequency of competencies achieved, we calculated the median number of competencies addressed across teams and the percentage of teams that actually addressed the assigned core topic. Institutional review board of our institution has exempted this research.
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caregivers, about falls in the last year, watch the patient rise from a chair and walk (or transfer),
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Results
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Experience
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Two hundred and two students participated over two consecutive years in the program. There
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51 (25.2%) Asian, 42 (20.8%) African American, and 11 (5.4%) Hispanic. Students rated the efficacy of the course (1=not at all successful
5=extremely successful) at 3.70 (SD 0.89) for
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developing clinical reasoning skills and integrating knowledge to solve problems. Students rated their experience developing skills and attitudes for effective interdisciplinary teamwork as 3.69
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(SD 0.93). In terms of interdisciplinary team assessment of an older adult with medical illness and functional decline, students rated their experience as 3.87 (SD 0.85). Efficacy in developing
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student ability to perform assessments of mobility and function of an older adult was rated as 3.85 (SD 0.88). Efficacy in using community resources to assist in management of common problems for older adults was rated as 3.89 (SD 0.95). Student comments reflected general acceptance of PBL methods: “The team based activity was extremely engaging and practical - actually working with real patients was tremendously effective relative to standard classroom based learning.” “I thought it was working with actual
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were 98 (48.5%) females and the group was ethnically diverse with 98 (48.5%) white students,
patients and making suggestions to improve their care was the best part [sic]. Health care team visits with real patients better highlighted the complexities and intricacies of aging and chronic disease better than any lecture or textbook.”
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Evidence of learning for competencies: Which competencies were addressed?
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Review of 40 final papers revealed that student teams addressed competencies across at total of 7
different domains (Figure.2). The average number of total competencies addressed in each paper
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in the competencies) were 1.44 per each paper. Sixty three percent of student papers addressed at least 1-2 competencies, while 24% papers addressed 3-4 competencies and 10% addressed 5-6
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competencies. Students most commonly described issues with falls, balance and gait (71 %). Medication management, cognitive and behavior disorders and self-care capacity were addressed
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in 47.4% of the papers (Figure 2). In addition to the pre-defined competencies the content in students’ papers reflected learning in key geriatric content areas including caregiver challenges
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in 47.4% and pain assessment and management in 23.7% . Learners evaluated financial issues, identified community resources for the elderly and discussed advance directives in about 15% of the papers (Figure 3). Below are 2 examples from student papers that included final care plans and system changes to impact outcomes for older patients. 1.
In a case of 93 year old male re-hospitalized after recent hospitalization due to poor
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were 2.5, and the average number of additional geriatric pertinent issues (identified but not listed
transitions in care, the student team suggested “empowering elderly patients to take more active role during the transition by educating patient and caregiver about care plan and the elderly playing an active role in devising their post discharge plan. Keeping up with current medication list by informing all parties about changes. Care settings operating as silos can be detrimental to patients and propose communication of care plans between settings.”
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2.
Another case was of 83 year old female with dementia living independently at home with
her husband was requiring assistance with activities of daily living and the husband is experiencing care giving burden and would like to continue to stay at home. The husband was
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feeling isolated due to lack of social interaction. The team suggested “attending free congregate lunch program offered by the local Center for senior life to increase social interaction and
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club in library to encourage his favorite activity.”
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How often did they explicitly address their assigned core topic? Interestingly, students did not always clearly address their assigned “core” issue. In order, 90%
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percent of those assigned to address caregiver issues did so, as did 87% of those assigned to a case with falls as the core topic. However, only 72% of those assigned to a dementia case and
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62% of those with medication management successfully addressed these issues. When students did not address the core issue it was because they did not achieve the level of discussion necessary to count as evidence of learning. In some cases students addressed issues other than the assigned core issues.
Discussion
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suggestions for free respite care and care giver support program and involvement with a book
Assessment of the week-long PBL activity through course evaluation and review of the final papers demonstrated that medical students achieved in-depth learning across multiple geriatric competencies through contact with real cases in a PBL format. Given involvement of caregivers
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in the interview process this became a natural focus of the student papers. Likewise, falls are an important focal event for older adults and their caregivers and were frequently addressed in student papers. Medications and dementia were not as frequently addressed by the students. This
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under-performance in the domains of dementia and polypharmacy was seen in both years and certainly suggests a need for a greater emphasis in the curriculum in these areas in the future. In
Further
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require deliberate and systematic approaches that these novice students may lack.
clarification of student performance expectations may help address problems with learner
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performance. Although the student teams were instructed to focus on one core geriatric problem, the qualitative review of their final papers showed that they were able to identify and address
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other domains in the minimum geriatric competencies as well. Students also recognized and researched other common geriatric issues in the management of geriatric patients that were not
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included in the competencies, such as financial issues, pain assessment and management, advance directives, and others.
The clinical core in aging experience allowed for richer learning as the students interacted with real patients and connected with community resources. Interaction with real people added value to student interactions and lent a broader perspective about their patients which could not have been achieved with didactics alone or simulated cases. In person interaction with inter-
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addition, identification and management of medication problems and cognitive impairment
professional health care providers and community resources permitted the learners to have interactive discussions which enhanced their learning.
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Implementing the week-long PBL activity was logistically complex in terms of selecting cases with a variety of pertinent problems from a variety of settings, and assigning them to teams. This also involved scheduling a significant number of preceptors for the events. Alternative teaching
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methods instead of real cases, such as classroom based activities or simulation used in other studies, might have been less complex logistically and more easily sustainable. One study
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multisite fourth-year geriatrics clerkship using an ambulatory and home care geriatrics program9 while two other studies used Observed Structured Clinical Examinations to supplement the
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teaching and assessment of geriatrics skills.10,11 These models successfully introduced students to several geriatrics competencies, but these curricula required longer periods of time and were
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sometimes personnel intensive. Such programs may be difficult to implement in many institutions with limited geriatrics resources and different curricular structures. One other model
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was a week-long curriculum that was successful in introducing the geriatric competencies.7 This one week model included primarily clinical encounters with patients in the hospital, clinic, longterm care and independent living in addition to reading assignments. This program along with our model demonstrates that the competencies could be addressed in a short period of time with or without geriatric specific settings.
The PBL approach used in this activity encouraged learners to use critical thinking and problem
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focused on integration of competencies through e-learning.8 Another study had a month-long
solving skills as they applied content knowledge to real case problems. Group based activities and interaction with interdisciplinary personnel helped learners appreciate social aspects of caring for older adults. Literature suggests that PBL in medical school positively affects physician competencies essential to the care of older adults, including appreciation of social and
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ethical aspects of health care, communication skills, and lifelong learning.12 The outcomes from this activity demonstrated similar outcomes seen in literature from PBL activities. This study has a few important limitations. To avoid survey burden, we did not perform a formal
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measure of students’ attitudes. Evaluation measures were limited to those performed at week’s
concepts learned. In the future, this type of curriculum would lend itself to use summative
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measures at the end of clinical training such as observed structured clinical exam (OSCE) or
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clinical evaluation exercise (CEX).
Improvements noted in clinical reasoning skills and recognition of importance of
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interdisciplinary teamwork were based on students’ self-evaluations. More objective measures of these constructs, a pre-test, and a comparison group would be needed to make stronger
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conclusions about the effectiveness of the PBL in these domains. This PBL activity demonstrated knowledge application to real cases. Follow-up evaluation to determine the effectiveness of this activity in future practice will be a next step for studying the effect on practice change. The impact of student recommendations on actual cases in solving real problems for the patients could also be evaluated.
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end. More distal measures may have demonstrated how students retained and even applied
Conclusions: Introduction of a PBL exercise provided an effective means of educating second-year medical students on core geriatrics subjects, while at the same time helping students to develop clinical
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reasoning skills, recognize importance of interdisciplinary teamwork, and understand key social and ethical issues in geriatrics on self evaluations. Future steps should include more objective measurements to determine the effectiveness of the PBL in these domains.
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Acknowledgements
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Division of Geriatrics, Duke University.
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Funding
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-Donald W. Reynolds Program for Faculty Development to Advance Geriatrics Education. -Health Resources and Services Administration Geriatric Training for Physicians, Dentists and
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Mental Health Professionals Grant. (D01HP08791).
-Geriatric Academic teaching award, Duke School of Medicine References: 1.
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Table 1: Competencies addressed in student final papers
Polypharmac
Fall
Caregiver
Impairment y
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Cognitive
stress (11)
(n=8)
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(n=8)
the core problem of the case (%)
62%
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Additional competencies addressed in student 1.27 papers (avg.)
Additional geriatric content areas addressed 1.18 (avg.)
87%
90.9%
0.87
1.5
2
1.375
0.87
1
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Competency addressed in student papers for 72%
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(n=11)
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F-falls, CI-cognitive impairment, CS-caregiver stress and P-polypharmacy
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Figure.1 Organizational Scheme for Clinical Core on Aging.
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Figure 2. Frequency of geriatric competencies addressed by domain in final papers.
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Figure 3. Frequency of identification of other geriatric issues in final papers.
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