“What if grandma is a little confused, but you’re trying to tell her how Johnny is supposed to take his medications?” asks Van Zuilen. “All doctors—even pediatricians—have to have an awareness of common geriatric problems.”
The Center on Aging team wanted to spread geriatrics throughout the curriculum, but they also wanted to make sure students were learning. “The issue is competence,” says Roos. “You don’t want to measure what you’ve taught, you want to measure what was learned.”
Support from the Donald W. Reynolds Foundation will make that possible—specifically, a $2 million, four-year grant for a novel competency-based approach to geriatrics training. Competency-based training is student-centered, focused on making sure students learn what they need to learn. “Competency learning says, ‘Wait, if your grade is a little low, let’s do it again,’” says Mark O’Connell, M.D., senior associate dean for medical education. “The traditional curriculum let a calendar define when it was time to learn something. Competency-based curriculum changes that to mastering knowledge in a sequential way.”
Need-to-know skills are measured throughout the program so both students and educators can identify what they need to improve. The geriatrics competency training involves every UM medical student and many of the medical staff and clinical educators. The goal is not to create geriatricians, but to assure that every graduate has a minimum competence in geriatrics.
he Donald W. Reynolds Foundation, one of the largest private foundations in the United States, was created in 1954 by the late media entrepreneur for whom it is named. The grant to the School of Medicine is intended to improve physicians’ knowledge of common geriatric syndromes, including dementia, delirium, falls, urinary incontinence, and pressure sores. The UM grant leadership team also includes Jorge G. Ruiz, M.D., Michael J. Mintzer, M.D., and Tara Kai, M.A.
Much of the basic learning will occur during geriatrics rotations throughout the four years. Students are exposed to caring for older patients from year one, when they actually meet some volunteer patients. “Our first-year medical student population visits my friends, family, and neighbors—literally,” says Lisa J. Granville, M.D., former director of the medical student longitudinal curriculum in geriatrics and palliative care and a key architect in the Donald W. Reynolds Foundation grant process. “I forewarn them, ‘One of you gets my mother-in-law.’”
Mike Abraham did. “I formed a bond with her,” says the third-year medical student about his experience during visits to the Miami Jewish Home for the Aged. “You practice clinical skills, and it’s pretty cool because they like to see you. They tell you about their families and how their grandson is a doctor.”
That experience hasn’t been universally embraced by students who don’t always understand the wisdom of taking time out from ambitious first-year science to chat about family with a stranger. “Once you get out there,” says O’Connell, “you’ll know the value of this.”
Every medical student has 24 hours of training in each of the first two years and required clerkships in years three and four—all focused on caring for older patients. It’s far more emphasis on older patients than programs at most other medical schools, but faculty members don’t waste a minute of clinic and classroom time.
To that end, students routinely spend time at another “university,” says Van Zuilen. “We ask them to go online to our Geriatrics University Web site. We have tutorials, like a balance and gait assessment. They have a chance to look at all the components of the exam, to do some practice exercises.”
The GeriU Web project is headed by Jorge G. Ruiz, M.D., also the director of the Geriatric Medicine Fellowship and the VA’s Home-Based Primary Care Program. The online preparation sets a minimum-knowledge baseline for faculty and students who can then use their time together to concentrate on technique instead of terminology. And students who need a refresher before an exam or a clinical encounter can revisit the site.
A competency-based learning approach also provides accurate measures of student success. Before, when faculty members asked a student to be familiar with dementia, the educational goal was vague. Now the students arrive with specific knowledge of, for example, the DSM IV criteria for vascular dementia, a stroke diagnosis guideline. Van Zuilen explains, “You can’t measure ‘be familiar with.’”
The UM approach to geriatrics training is innovative. For instance, the older patients that the first-year students meet are typically vibrant and healthy, which reinforces that most seniors—more than 90 percent, in fact—are active and independent. “It lets you see that just because a person is older doesn’t mean they don’t have normal lives,” says Abraham. “But the training also gets you thinking about the social recognition of disease, like whether they can go to the bathroom or get to the store for their medication.”
Because the training is progressive, by their fourth year medical students are much better prepared to deal with all patients, including the most frail and dependent elderly in nursing homes.
aculty and staff in the Division of Gerontology and Geriatric Medicine don’t define “old” with numbers. They look at function more than age—a vertical field of activities rather than a date on a horizontal timeline. The critical measure is called “activities of daily living.”
The first rule of thumb: Can the older person do all the things she knew how to do in kindergarten, like bathe, dress, groom, use the bathroom, and feed herself? The second is: How well can this older person handle the tasks she learned when she first lived on her own, like paying bills, doing laundry, shopping?
“Today the average 80-year-old person is more functional than the 80-year-old of 20 years ago. More 80-year-olds can walk up a flight of stairs,” explains Roos. As UM President Donna E. Shalala wrote in an essay about aging in The World Almanac 2003, “The fact is: older Americans are now living not only longer but also better.”
The last critical part of the competency-based training mission—which the Donald W. Reynolds Foundation program team describes as a “sneak attack”—is aimed at the primary care practitioners and residents in training. These mentors have a tremendous influence over medical students’ attitudes and behaviors. The strategy is to expose them to the instructional activities used in geriatrics to reinforce student learning. But it also helps these non-geriatricians acquire basic competencies in caring for the elderly and extend the knowledge to colleagues. By helping the student-learner with geriatrics, they’re also helping themselves and their patients.
Now UM’s experts on aging are working with senior medical educators and administrators to make sure the program succeeds and spreads across the School of Medicine. They hope their success in imparting geriatrics competency will become a model for teaching and learning in other medical disciplines and other medical schools.
“Florida’s five medical schools are working on creating a standardized curriculum of the learning objectives and the evaluation tools that show mastery in geriatrics,” says O’Connell. This Florida Consortium on Geriatrics Medical Education will standardize medical skills and may strengthen grant applications and research collaboration.
“We want to spread this approach across the faculty so that they
will hold themselves much more accountable for specific learning by their
Roos. “The truth is, I may have learned a lot in medical school,
but the one thing I didn’t learn is how to teach. I feel like I’m
just now learning how.”
Kelly Kaufhold is a senior media relations officer and writer in the Office of Communications at the School of Medicine. Photography by John Zillioux.