Teaching Geriatric Medicine: It’s Personal

By: Benjamin A. Bensadon, EdM, PhD, Department of Geriatric Medicine, University of Oklahoma Health Sciences Center

Geriatrics is a tough sell. As our article in the November issue illustrates, the multiple factors contributing to its ongoing unpopularity are psychological, economic, cultural, and pervasive. Though daunting, especially as our nation’s population continues to live longer, I believe there are many ways academic medicine can (and must) help.

The clearest cause for optimism may be the upcoming expansion of the MCAT in 2015, the importance of which cannot be overstated. Incorporating psychological and behavioral science content may result in more diverse medical school applicants, and hopefully lead institutions to follow suit with their curricula. Training in related areas such as communication, psychosocial aspects of medical illness, and the team-based biopsychosocial model, are particularly vital to elder care. Our attempts to infuse these concepts into our curriculum included several notable examples that struck a personal chord with our 4th-year medical students.

One method for acquainting students with geriatric care is exposure to “cool elders,” a program where we invite older community members to share their personal aging experiences (medical and other). By carefully selecting speakers students could identify with, and facilitating informal, honest, and non-threatening dialogue, we created a learning atmosphere where students observe “evidence” that dispels stereotypes related to both aging and psychosocial aspects of illness. For example, after one presentation by a husband and wife team of 90 year olds, I asked the couple “OK, so you have all these future physicians sitting here, they’ll be practicing in a few months, what makes a doctor a good doctor?”  The couple replied in unison, “TLC [tender loving care].” A few students smiled, others seemed surprised, all were engaged. The couple went on to add, “Oh you’ll get the diagnosis stuff, sure, that’s important, but we really need to know you care.”

In another example, a couple joked about their challenges with failing eyesight, reduced driving capability, and COPD self-management. The students were particularly moved when the man, diagnosed with emphysema 13 years earlier, said he had taught himself the harmonica in an attempt to improve his lung capacity. They also seemed disappointed when he reported most of his physicians were pessimistic about his prognosis. When he later adjusted his nasal cannula, pulled a harmonica out of his pocket, and played the students a song, their mouths dropped open in disbelief.

Opportunities to follow patients longitudinally, visit them in their homes, and experience intergenerational day care, all provided learners unique exposure to older patients’ challenges and capacity for resilience, a reality often distorted by aging-related bias and stigma. Perhaps nowhere was this more evident than in students’ reflection essays after attending community-based dementia support groups for patients and their family caregivers. Students frequently admitted personal misconceptions that the exposure corrected.

I was surprised that I, myself, had never considered caregiver health when now it seems like an obvious part of the care. To be honest, before attending, I wasn’t sure how the experience would help me in practice, but I left feeling that these women’s stories and struggles greatly impacted the way I view dementia.

They also differentiated between traditional learning from textbooks and experiential learning via the group, highlighting the latter’s unique capacity to affect students on both cognitive and affective levels.

Attending this group was absolutely eye-opening. In most of medical school, we focus on brain tissue change with dementia, but I didn’t realize my education was incomplete until I met these individuals and realized there are many aspects of patient care that go beyond just the patient.

Most students also reported being surprised and inspired and many ranked it their best learning experience in medical school.

Regardless of specialty, US demographics suggest that, for most graduating medical students, contact with older patients is inevitable. Fortunately, a care approach informed by negative, stereotypical views of aging is not, if we are willing to think outside the box and implement novel, evocative curricula to help shape students’ perceptions. In the US, geriatrics consistently ranks low in reimbursement but high in physician satisfaction, underscoring that geriatricians find their work gratifying and meaningful for different, often personal reasons. To be effective, then, our educational efforts must take a similarly personal approach to reaching our increasingly diverse students.

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One Comment

  1. Kemi Tomobi
    October 24, 2013 at 2:52 AM

    Indeed, the geriatric population is medically underserved.   Today, the elderly are living and coping with conditions that were once considered diseases that killed children.  What is especially alarming is that according to the article, there are only 8 geriatric neurologists in the United States.  How will the population, aged 65 and over get the care they need?

    One approach may be to consider the KSAs’, that is, the knowledge, skills, and attitudes that trainees need to be more competent in geriatric care.

    Knowledge  How many providers and providers-in-training counsel the elderly about exercise? Not many, according to a study with nurse practitioners and a study with physicians (1, 2).  It could be that providers use socioeconomic status and frailty to guide counseling.  But there are health benefits to exercise.  Exercise helps reverse the bodily processes of muscle weakness and atrophy.  Yoga can reduce pain and improve psychological well-being (3).  The Center for Disease Control recommends 2 hours and 30 minutes of moderate intensity aerobic activity per week.  But only 1/3 of men and 1/4 of women ages 65-74 engage in leisure physical activity.

    Some of the elderly are very active, and exercise quite frequently, and are of a higher education and socioeconomic status, and have fewer than two of chronic conditions, such as emphysema, arthritis, or hypertension.

    The older one gets, the more likely one can develop hypertension.  This finding is pronounced in minorities.  Efforts must be taken to encourage the elderly, including minorities, to exercise.

    Therefore, exercise is an example of how  having the proper knowledge about the elderly population can help improve practice.

    Skills In addition to the proper knowledge, it takes great skill to take care of the elderly.  A research report published and discussed earlier this year on AM Rounds revealed that storytelling was a skill used to improve medical students attitudes towards people with dementia (4).  It appears that the art of storytelling is one that is worth cultivating.  Perhaps a person without dementia will also love to engage in the art of storytelling.  Thus cultivating this skill helps with communication skills, increases empathy, and other skills required to bond with this population.

    Attitudes Such skills help to increase positive attitudes towards the elderly.  The main paper of discussion mentions success with a comprehensive geriatric clerkship in increasing positive attitudes towards the aged population (5).  Perhaps exposure to a variety of aged people, in the clinical setting and in other settings with healthier older people helps to reduce the negative bias towards elderly.

    In summary, addressing the KSAs is a great strategy to target best practices in geriatric medical education and make providers from all specialties more equipped to take care of the elderly.  What remains  to be determined is a long term solution to increasing the number of providers interested in geriatrics and thus directly address the medical needs of this population.

    References:

    1. Melilo KD, Houde SC, Williamson E, & Futrell M.  (2000). Perceptions of nurse practitioners regarding their role in physical activity and exercise prescription for older adults.  Clin Excell in Nurse Pract., 4 (2):108-116.

    2. Costello E, Leone JE, Ellzy M., Miller TA. (2012). Older adult perceptions of the physicians’ role in promoting physical activity.  American Journal of Health Promotion 27 (2): 71-74.

    3. Chen KM, Chen MH, Chao HC, Hung HM, Lin HS & Li CH.  (2009). Sleep quality, depression state, and health status of older adults after silver yoga exercises: cluster randomized trial.  Int. J Nurs Stud.. 46 (2):154-163.

    4. George DR, Stucker HL, & Whitehead MM. (2013). An arts-based intervention at a nursing home to improve medical students’ attitudes towards persons with dementia. Academic Medicine 88(6):837-842.

    5. Bensadon, BA, Teasdale, TA. & Odenheimer, GL. (2013). Attitude adjustment: shaping medical students’ perceptions of older patients with a geriatric curriculum. Academic Medicine. 88(11):1-5.