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Age and Ageing Advance Access originally published online on April 23, 2007
Age and Ageing 2007 36(4):366-368; doi:10.1093/ageing/afm047
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Commentary

Undergraduate training in geriatric medicine: getting it right

Frank Lally and Peter Crome

Keele University, School of Medicine, Stoke-on-Trent, Staffordshire, UK

Address correspondence to: Peter Crome. Email: p.crome{at}pmed.keele.ac.uk

Keywords: education, medical, undergraduate, geriatric medicine

It is pehaps inevitable that every specialty within medicine believes that its fundamental principles should be included in the core undergraduate curriculum and should be accompanied by a compulsory placement. The General Medical Council's (GMC) policy document ‘Tomorrow's Doctors’ [1] stresses the importance of students learning about the special problems associated with older people's health. For example, it states that young doctors must respect age and the vulnerability of particular patient groups including older people. They also emphasise that graduates must understand human development, which includes growing old. Importantly, the document states that students must have opportunities to interact with a range of people including visiting an older person, a learning experience that is now included in many curricula. However, they are silent on the issue of whether there should be a compulsory attachment to a geriatric medicine unit, as indeed they are, about other hospital specialties. The present policy suggests that a quarter to a third of the curriculum should be based on student-selected components. The interpretation and implementation of such advice will be different in each medical school but the risk is, that at this time of demographic change, with growing numbers of older people, and with other demands on the curriculum, exposure to geriatric medicine might be overlooked and reduced.

The concern that the teaching of geriatric medicine now has a reduced place in UK medical schools has been supported by the findings of a recently published survey [2]. Questionnaire responses from UK medical schools found that although geriatric medicine is taught to all students in almost all responding medical schools (21/23), it was taught as a distinct discipline in only two. This contrasts with the findings of studies undertaken twenty years ago [3, 4] when geriatric medicine was more likely to be taught as a separate subject. The 1981 survey found that geriatric medicine was formally taught separately in all but two of the thirty medical schools. The comparable figures in the 1986 follow-up survey were 25 out of the 27 medical schools. The mode of teaching then, was mainly clinical instruction (74% in 1981 and 70% in 1986) with tutorials taking up about 25%. Although placement in geriatric medicine is now less likely, some positive changes are noted. For example, geriatric medicine subjects are now more likely to be included in examinations than during the 1980s and geriatric medicine cases are being included in problem-based learning.

Alongside the apparent decline in geriatric medicine content in the curriculum is a decline in the number of medical schools with separate departments or divisions of Geriatric Medicine. At the time of writing, at least seven medical schools in England which previously had academic departments no longer have professorial appointments in the subject. The effects of the reduction in academic support on the research agenda has been commented upon by the House of Lords Select Committee on Science and Technology [5, 6] and the effects of this loss on training is equally worrying. The presence of a professor within the discipline is likely to result in that subject having a greater share of the curriculum as was highlighted by the previous survey [3].

These issues pertaining to the teaching of geriatric medicine are not confined to the UK. In the USA there is no national medical curriculum and the inclusion of geriatric medicine placements is optional, although geriatric medicine is to some extent included in most curricula [7]. One recent publication has identified geriatric medicine education there as having the ‘largest education gap in any field’ in terms of the number of educators available [8]. The American Geriatrics Society has promulgated suggested core competencies in geriatric medicine that should be included in the training of all doctors at the undergraduate level [9].

A WHO survey of geriatric medicine teaching [10] found that of countries that had national regulations governing the overall curricula, only 41% mentioned geriatrics in the regulations in some way. It was reported that of these, only half had mandatory geriatric medicine training and that 27% of the 161 schools participating in the survey had no training in geriatric medicine at all.

Although the argument that geriatric medicine should be included in the curriculum has largely been won in the UK, the debate about making training placements compulsory continues. The reasons for making such attachments in geriatric medicine compulsory are substantial and include both the demographic imperatives, per se, as well as the consequential effects on how health care will be delivered [11]. The most important reason is that students need to see specialised assessments of older people being conducted and implemented professionally with improved outcomes as a consequence [12]. The attachment should be long enough to follow patients from acute admission to recovery, rehabilitation and discharge. Observing attempts to assess and treat older people on acute medical wards where staff are less interested, skilled and confident in the problems of frail older people is no substitute. There is also evidence that placements within geriatric medicine improve attitudes of medical students to older people compared to teaching conducted on a sessional basis [13]. Exposure to clinical geriatrics early on in a medical student's career must also be part of any strategy to excite interest in, and to encourage recruitment to, academic geriatric medicine. Exposure to geriatric medicine should be regarded as important as specialties such as obstetrics, paediatrics and psychiatry, subjects that are difficult to imagine existing as only optional attachments.

Contrary arguments have been put forward. The most frequent is that as older people are seen and treated ‘everywhere’ specific placements in ‘geriatric’ units are not necessary. Pack et al. [14] have also reported that in their medical school the preliminary analysis of results of Objective Structured Clinical Examinations in students who had placements in geriatric medicine and those who did not have such placements were similar. As a consequence of bed closures and amalgamation of geriatric and general medicine wards the issue of whether geriatric medicine has sufficient capacity for placements has arisen. Where there is a genuine problem with teaching capacity, imaginative solutions might include using ortho-geriatric, rehabilitation, intermediate care and community hospital beds—the places where geriatric medicine is now also practised [15].

The British Geriatrics Society (BGS) has sought to redress the absence of specific guidelines with the publication of an undergraduate curriculum for geriatric medicine and gerontology [16]. The BGS believes the curriculum, which is available at http://www.bgs.org.uk/Publications/Compendium/compend_5-1.htm, should be regarded as a framework that can be adapted to suit the undergraduate curricula of all UK medical schools. The curriculum is conventionally sub-divided into the key areas covering the knowledge, skills and attitudes that newly qualified doctors will need when they start caring for older people. By following the curriculum graduates will develop core competencies such as history taking from an elderly person, formulating a differential diagnosis, preparing an initial management plan and understanding the importance of a multi-disciplinary (sometimes multi-agency) team approach to the care of older people.

The only reference to older people in the GMC's recommendations for the training of newly qualified doctors [17] is in describing communication skills where it mentions avoiding negative assumptions based on various issues including disability and age. Despite the overwhelming presence of older people in most departments of a modern hospital, only a minority of graduates will gain supervised specialised training in geriatrics. Thus it becomes more important to ensure that a suitable level of education in geriatric medicine is given at the undergraduate stage. The International Association of Gerontology and Geriatrics has recently produced an abbreviated curriculum in the form of a ten commandment statement [18].

Unfortunately the research base on how best to teach geriatric medicine is limited. This is of major importance given that medical students have been shown to have less favourable attitudes toward geriatric medicine and older patients compared to other specialities and patient groups [19–21].

The GMC states that all medical courses must include within the core curriculum the behavioural and attitudinal components in which all medical graduates should be confident [22]. It has been demonstrated that the introduction of aspects of care of the elderly at medical school can have a positive effect on the attitudes of students toward elderly care [23, 24]. One of these studies [24] used geriatric cases for student problem-solving exercises in order to determine if medical students' attitudes toward older people would change as a result of the experience. The authors found that there was a statistically significant improvement in empathy and attitude in caring for older people in those students that had participated in the sessions.

Role models have been shown to be an important mechanism in attracting undergraduate students to a career in geriatric medicine [25]. The addition of a geriatric medicine module of as little as one week to an undergraduate program has demonstrated significant improvements in attitude toward and knowledge of the older patient [26]. Another attempt at maximising exposure of undergraduates to clinical geriatric medicine has been made at McGill University [27]. In this study the effects of integrating existing 10 weekly sessions in geriatric medicine into a single integrated week were examined. Students who had completed the integrated week attained better grades in geriatric components of final examinations than those who had continued on the original 10 separate sessions. In addition, students who had taken part in the one-week block demonstrated a more developed attitude toward geriatric medicine.

The WHO survey on geriatrics in the medical curriculum stated; ‘the basic principles of the special care needs of older persons should not be of exclusive concern to specialists’ [10]. This mandates that all students must understand and must be able to practise the basic principles of assessment and management of older people. The BGS has a key role in promoting best practice in this area and in assisting geriatricians in teaching hospitals to devise and improve curricula and the learning experience. This is likely to be of more importance in centres without a thriving academic geriatric medicine culture. The GMC will introduce an updated edition of ‘Tomorrow's Doctors’ in 2008 and has published some preliminary observations [28]. To get it right, we must press for clearer emphasis, greater empathy and enhanced evidence relating to the needs of one of the most vulnerable groups of the community.


   Key points
Top
 Key points
References
 

  • Fewer UK medical schools contain obligatory geriatric medicine rotations than they did twenty years ago.
  • This may be the result of the greater emphasis on student-selected components in the undergraduate curriculum.
  • Changes in demography and clinical practice necessitate exposure to evidence-based practice of geriatric medicine for 21st century medical students.
  • The British Geriatrics Society is playing a key role in promoting the content of geriatric medicine in a future undergraduate curriculum.


   References
Top
 Key points
 References
 

  1. General Medical Council. Tomorrow's Doctors. (2003) London General Medical Council.
  2. Bartram L, McGrath A, Crome C, Crome I, Corrado O, Allen S. Geriatric medicine training in UK undergraduate medical schools. Rev Clin Gerontol (2006) 15:1–7.
  3. Smith RG, Williams BO. A survey of undergraduate teaching of geriatric medicine in the British medical schools. Age Ageing (1983) (Suppl.):2–6.
  4. Smith RG, Williams BO. Undergraduate teaching of geriatric medicine in the United Kingdom: changes in the years 1981–1986. Med Educ (1988) 22:498–500.[Web of Science][Medline]
  5. House of Lords Science and Technology Committee. Ageing: Scientific Aspects Volume I: Report. (2005) London: The Stationary Office Ltd.
  6. House of Lords Science and Technology Committee. Ageing: Scientific Aspects Follow Up. (2006) London: The Stationary Office Ltd.
  7. Warshaw GA, Bragg EJ, Shaull RW, Lindsell CJ. Academic geriatric programs in US allopathic and osteopathic medical schools. JAMA (2002) 288:2313–9.[Abstract/Free Full Text]
  8. Centers for Disease Control and Prevention and Merck Institute of Aging and Health. The State of Aging and Health in America (2004) 35:20–21.
  9. Core Competencies for the Care of Older Patients: Recommendations of the American Geriatrics Society. The Education Committee Writing Group of the American Geriatrics Society. Acad Med (2000) 75:252–5.[Web of Science][Medline]
  10. Keller I, Makipaa A, Kalenscher T, Kalache A. Global Survey on Geriatrics in the Medical Curriculum. (2002) Geneva: World Health Organisation/International Federation of Medical Students' Associations.
  11. Ebrahim S. Demographic shifts and medical training. BMJ (1999) 319:1358–60.[Free Full Text]
  12. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet (1993) 342:1032–6.[CrossRef][Web of Science][Medline]
  13. Maurer MS, Costley AW, Miller PA, et al. The Columbia Cooperative aging program: an interdisciplinary and interdepartmental approach to geriatric education for medical interns. J Am Geriatr Soc (2006) 54:520–6.[CrossRef][Web of Science][Medline]
  14. Pack L, Fuller R, Pell G, Roberts T. Response to: survey of training in geriatric medicine in United Kingdom undergraduate medical schools. Age Ageing (2007) 36:230.[Free Full Text]
  15. Crome P. Authors reply. Age Ageing (2007) 36:231.[Free Full Text]
  16. British Geriatrics Society. The Medical Undergraduate Curriculum in Geriatric Medicine. (2004).
  17. The New Doctor–Recommendations on General Clinical Training. (2005) London: General Medical Council.
  18. International Association of Gerontology and Geriatrics. Geriatric Medicine. Basic Contents for Undergraduate Medical Students. (2006).
  19. Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: a five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group. J Am Geriatr Soc (1995) 43:1430–6.[Web of Science][Medline]
  20. Arnold L, Shue CK, Jones D. Implementation of geriatric education into the first and second years of a baccalaureate-MD degree program. Acad Med (2002) 77:933–4.[CrossRef][Medline]
  21. Warren DL, Painter A, Rudisill J. Effects of geriatric education on the attitudes of medical students. J Am Geriatr Soc (1983) 31:435–8.[Web of Science][Medline]
  22. Core Education Outcomes. (2003) London: General Medical Council.
  23. Smith CW, Wattis JP. Medical students' attitudes to old people and career preference: the case of Nottingham Medical School. Med Educ (1989) 23:81–5.[Web of Science][Medline]
  24. Varkey P, Chutka DS, Lesnick TG. The aging game: Improving medical students’ attitudes toward caring for the elderly. J Am Med Dir Assoc (2006) 7:224–9.[CrossRef][Web of Science][Medline]
  25. Burack JH, Irby DM, Carline JD, Ambrozy DM, Ellsbury KE, Stritter FT. A study of medical students’ specialty-choice pathways: trying on possible selves. Acad Med (1997) 72:534–41.[Web of Science][Medline]
  26. Roscoe LA, Schonwetter RS, Wallach PM. Developments: advancing geriatrics education: evaluation of a new curricular initiative. Teach Learn Med (2005) 17:355–62.[CrossRef][Web of Science][Medline]
  27. Duque G, Gold S, Bergman H. Early clinical exposure to geriatric medicine in second-year medical school students-The McGill experience. J Am Geriatr Soc (2003) 51:544–8.[CrossRef][Web of Science][Medline]
  28. General Medical Council Education Committee. Strategic Options for Undergraduate Medical Education Consultation. (2006) London: General Medical Council.
Received 5 February 2007; accepted in revised form 20 February 2007.


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