Age and Ageing Advance Access originally published online on June 1, 2007
Age and Ageing 2007 36(4):358-360; doi:10.1093/ageing/afm065
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Will undergraduate geriatric medicine survive?
The decline in undergraduate geriatric medicine education in United Kingdom (UK) Medical Schools [1] follows the trajectory of a progressive neurodegenerative disorder. First there is a niggling suspicion, [2] but within 2 years something is definitely amiss [3]. Over the years, the problem worsens and after 25 years a tipping point is reached [4]. The trajectory is steep and accelerating.There are fewer geriatric medicine academics [1]. The demands of the Research Assessment Exercise [5] points to where those remaining should focus their attention. Is geriatric medicine's decline in the undergraduate curriculum inevitable?
Thanks to UK medicine we live longer, and, thanks to geriatric medicine, morbidity has been pushed later into our lifespans. The entry point to undergraduate geriatric medicine must, therefore, be the physiology of ageing [6]. Without understanding the physiological canvas on which disease is painted, students cannot understand the picture that the patient presents. Students will learn by working with older people in general but learn more by understanding that even healthy older people are biologically different. Is geriatric medicine's decline in the undergraduate curriculum a failure to recognise this?
Without time spent in geriatric medicine will students understand patients' heterogeneity, concepts surrounding frailty and that many older people are well? Geriatric medicine is messy and complex. It does not have neat boundaries to its practice and is difficult to understand unless immersed in its world. Many diseases become commoner with advancing age, are multidimensional and may coexist. Why older people experience them, how they might be managed and the roles and ways of working in the team that will do this are core to geriatric medicine [6]. Is geriatric medicine's decline in the undergraduate curriculum because organ-based medicine is displacing the need for individual clinicians to manage comorbidities or a failure to realise that few specialties offer such rich opportunities for solving patients' problems through interprofessional team-working or both?
Lally and Crome [1] have added a further point [4] to the trajectory of a ‘disease’, which, if nor arrested will mean the death of undergraduate geriatric medicine in the 31 medical schools of the country that invented the specialty.
We must value the educational leadership academic medicine can give to our specialty. It is in all geriatricians' interests to see strong local academic geriatric medicine units linked to a network of district general hospitals (DGHs). Research informs practice and practice is the classroom. Academics should lead from a research base that reflects our specialty's clinical practice all underpinned by the sociology and biology of ageing.
Geriatric medicine should be learned by every undergraduate student, something too important to be left to just academics. What students need to know to practice is best taught by those in practice. The NHS Plan [7] established the potential to change the medical school/NHS relationship. Some medical schools—Bristol for example [8]—map onto a number of local geographical localities through which students rotate rather than a ‘teaching hospital’. Students are no longer ‘on attachment’ but on a number of local sites within the NHS, each with a university infrastructure. There can be few DGHs where geriatric medicine is not practised. There is an increasing opportunity for NHS teaching leads to work closely with local medical schools to change the curriculum. Moreover medical schools have within their DGH partners, colleagues pursuing teaching skills courses at many levels. NHS geriatricians expect enthusiastic medical students to follow their specialty and become their colleagues of the future. It is difficult to be a role model [9] if the students do not know that the specialty exists.
We must challenge the argument that students see geriatric medicine practised elsewhere in the curriculum. They see skilled colleagues practising their specialty on chronologically older people, but is this geriatric medicine? There is a strong case for time to be spent in our specialty based on changing demography and the needs of the doctor and wider society at qualification. So, while we want to enthuse the geriatric medicine specialists of tomorrow it is the surgeons, oncologists and anaesthetists for whom the issues of ageing will colour the backdrop against which they will operate, irradiate or intubate.
We must be more imaginative over what we include in the geriatric medicine undergraduate curriculum and how we deliver it. Medical students may better match to the learning opportunities of the NHS [7] but DGHs are merging, beds are being reduced and community hospitals are closing. Where are the elderly—are we exploiting all the learning opportunities? Many are relatively well and in their own homes. Some are very dependent and in nursing homes. In between, they inhabit varying localities satisfying rising care needs. Older people come together in community activities. Just as students in paediatrics learn about normal children in nurseries our students have much to learn in the community whether in nursing homes, the day centre or on the bowls green. Learning about older people needs to happen where older people actually are.
Most students go on to work with older people, so all must learn about geriatric medicine; that is the conclusion of the University of South Carolina (USC) [10]—a university that had never had a course in ageing or geriatrics. USC considers this so important that instead of a course it is introducing a Vertical Curriculum in Geriatrics across all 4 years. It is community focussed, based on the American Geriatrics Society curriculum [11] and involves healthy ‘free range’ senior mentors as a learning resource. Meanwhile, changing demographics in Turkey have prompted a new geriatrics course based on the British Geriatrics Society (BGS) curriculum [6] but, impressively, in a university without a geriatric medicine department [12].
The General Medical Council 5-year cycle of visits to medical schools is an opportunity for our academics and the BGS to influence faculty deans. It is though the unheard voices of the huge numbers of NHS geriatricians and other grades who deliver the teaching that can potentially make the most difference to the future of undergraduate geriatric medicine.
Undergraduate Medical Dean, Gloucestershire Academy, University of Bristol, Redwood Education Centre, Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, UK
Email: peter.fletcher{at}bristol.ac.uk
References
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- Making a Submission to the RAE 2008. Accessed 28th April 2007. www.rae.ac.uk/aboutus/subs.asp.
- British Geriatrics Society. The Medical Undergraduate Curriculum in Geriatric Medicine. (2004) Compendium document 5.1 (revised).
- Department of Health. The NHS Plan: a Plan for Investment, a Plan for Reform. (2000).
- Mumford DB. Clinical academies: Innovative school-health Services Partnerships to Deliver Education. Acad Med (2007) 82:435–40.[CrossRef][Medline]
- Briggs S, Atkins R, Playfer J, Corrado OJ. Why do doctors choose a career in geriatric medicine? Clin Med (2006) 6:469–72.[Web of Science][Medline]
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- Karadenizli D, Tander B, Sarikaya S. How to create a geriatric medicine block in a university without a geriatrics department. Med Educ (2007) 41:426–9.[CrossRef][Medline]
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  A. L. Gordon, A. G. Blundell, J. R. F. Gladman, and T. Masud Undergraduate education in geriatrics within the United Kingdom Age Ageing, November 1, 2007; 36(6): 705 - 705. [Full Text] [PDF]
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