Caring for an increasing number of elderly patients

The focus of geriatric training in undergraduate and postgraduate programs needs to be twofold: to increase the knowledge and skills of all practicing physicians and to recruit and train maximum number of trainees for specialized care. The three main groups of physicians providing specialized geriatric care are geriatric medicine, care of the elderly (family medicine) and geriatric psychiatry. At the moment, all of these avenues of training are undersubscribed, for a variety of reasons including limited exposure to positive experiences in geriatrics early in training and debt loads leading students and residents to choose more highly paid specialties.

Like several other specialities, geriatric medicine faces a human resource crisis. The evidence suggests that good role-modelling and early and consistent exposure to geriatric principles and care, are effective at improving geriatric care and also increasing interest in geriatrics as a career. The current situation where there is minimal exposure to geriatrics in the pre-clinical year of medical school and clinical exposures that emphasize care of acutely ill patients on general medical wards or general surgical wards may actually increase the problem of negative attitudes to the elderly and negative attitudes to geriatric medicine as a career choice.

Despite the changing demographics, much of the emphasis in undergraduate teaching in Canada remains on younger age groups. For example, a review of problem-based learning cases at a Canadian university found that the average age of cases used in first and second-year medical school was 33. Over 20% were pediatric patients, and half were below 30. Only 7% were 65 or older and none were over age 70 This problem may arise from authors mistakenly believing that including frail elderly patients in case-based teaching would be too complex to meet learning objectives. This problem is also accentuated by lack of coordination between different courses and faculty members about the content and the demographics used in teaching cases, as well as lack of clarity on the educational focus of different parts of the curriculum.

There have been increases in geriatric content in Canadian medical schools in the last 10 years. A survey done in 2006 revealed an increase in hours of geriatric teaching in pre-clerkship (mean of 17 hours). Unfortunately, these hours appear to be unbalanced in their content. For example, in one centre there were 21 hours of geriatric content but 17 hours of this was devoted to dementia. The range of total hours dedicated to geriatric content, including clerkship, was very wide and ranged from 7 to 198 hours. There has been an increase in the number of centres with mandatory geriatric clerkship rotations. These gains are potentially threatened by the increase in class sizes, which means that many geriatric rotations face capacity problems. Significant gaps still exist, especially in clinical skills and problem-based learning courses.

Given the shortage of physicians with specialized training in care of older patients and the large increase in class size in the last decade it is increasingly difficult to provide all students and residents with positive exposure to geriatric care such as with a mandatory geriatric medicine rotation.

In 1999, the John A. Hartford Foundation in the United States funded 40 medical schools to develop and implement substantial curriculum with a focus on geriatric care. In 2004, a supplement to Academic Medicine summarized the experiences of the participating universities. None of the schools developed a separate course on geriatrics; all chose to integrate the content and learning activities throughout the curriculum. The main goal across the schools was to provide students with a fundamental set of attitudes, knowledge and skills to enable them to provide excellent care to older patients. The parallel goal was to promote faculty acquisition of knowledge about care of older patients and the aging process. Outcomes consistently identified included:

• Establishing a relationship between students and older individuals and supporting students’ understanding of the relationship between disease, lifestyle, and social issues in managing care of older people
• Enhancing students’ knowledge of normal and abnormal physical changes related to aging
• Informing students about health care systems and models of care
• Familiarizing students with care of elders as part of a multidisciplinary team
• Fostering understanding of ethical issues in geriatric care, including end of life care

Strategies used to reach these outcomes included:

• Senior mentor programs (including using retired physicians as mentors)
• Partnerships with community agencies and nursing homes
• Use of geriatric standardized patients
• Faculty development programs for geriatric content
• Student interest groups
• Courses in palliative/end of life care.

Understandable concerns are raised in clinical skills courses about the challenges of providing trainees with exposure to frail older people. It is felt that older patients are difficult to recruit in hospital or clinic setting or to act as simulated patients. The use of volunteer patients can provide students with a reasonable facsimile of an older patient presenting to a clinician, particularly in the need to modify the physical and history to deal with mobility problems or sensory changes. Certainly many of the frail older people I see in hospital would still be excellent candidates for history and physical by medical students but are not always sought by the recruiting authorities. Geriatric content can be included without needing frail elderly SP’s by using situations where students interact with “family members” to gain experience with geriatric clinical or ethical issues or to improve communication skills.

The Education Committee of the Canadian Geriatrics Society has released core competencies in geriatric care for medical schools in Canada (see appendix 1: Core Competencies ). These have been distributed to the Undergraduate Deans of medical schools, to the Association of Faculties of Medicine of Canada (AFMC) and to the Medical Council of Canada. The following principles are felt to arise from the competencies.

• Programs that link students with healthy seniors have the potential to expose students early in their training to the positive aspects of aging and care of seniors. Successful programs have been developed in Canada, including a well-publicized one at Western. Home visiting programs can be effective and inspiring and can be developed in conjunction with palliative care programs, as has been done here at Queen’s.
• Ensuring vertical integration of geriatric content was found to be effective in the John A. Hartford Foundation evaluation. Mixing vertical integration, a core lecture series and horizontal experiences should be considered when revising the overall curriculum.
• The best time to add significant geriatric content is likely when significant review of the overall curriculum is already occurring.
• Ensuring that the content of Problem Based Learning courses (PBL) and Clinical Skills reflects the clinical experiences of physicians in Canada would be an excellent start. Formally reviewing case-based teaching to ensure a good mix of geriatric content and participation is important.
• Exposing students to the principles and practices of work in long-term care is also important. Models to do this include exposing students to experiences in a long-term care facility with guidance and supervision from an experienced long-term care physician. This model has worked extremely well at Queen’s University.
• The current trend to inter-professional education is crucial as it models effective ways to provide effective care for seniors and exposure to interdisciplinary care will hold trainees in good stead as they enter clinical practice.
• Ensuring that Geriatric medicine objectives are included in core curriculum of Medicine and Surgery clerkship rotations is a minimum. These are clinical rotations where exposure to frail elderly patients without good role modeling and a sound understanding of geriatric principles may negatively affect attitudes to older patients. If students understand the systems of care, work with teams and have good knowledge and skills in caring for seniors, medicine and surgery may be excellent learning opportunities. Ideally, every medical student should do a rotation in Geriatric Medicine but this is a challenge in some centres as mentioned above. However, innovations including community-based supervision or long-term care rotations could help to ensure exposure for a wider range of students.

One positive aspect of attempting to integrate geriatric content and principles into the medical school curriculum is that most geriatricians and care of the elderly physicians are enthusiastic about teaching and can be “evangelical” about the positive aspects of working with older patients. Involving interested faculty members and ensuring support and “buy-in” from high levels of administration is obviously crucial to success.

There have been recommendations since the 1960’s suggesting that medical training programs increase geriatric content. It appears that this will finally have to happen given the crisis in hospitals and long-term care facilities and the realization that the “future is now” with regard to seniors and health care.