Tuesday, August 17, 2010

Debunking the “But I Already See Old People” Myth in Medical Education

What happens when you randomly assign medical students to either a mandatory two week rotation in specialized geriatric training or to a traditional non-geriatric clerkship that sees a lot of old people? Will there be any difference in the knowledge of geriatric conditions, the attitudes toward older adults, or geriatric clinical skills between the two groups?  Or does mere exposure to an aging patient population give students the training they need to care for older patients? These are the questions asked by Laura Diachun and colleagues in a recent article published in Academic Medicine.

The authors randomly assigned 262 Canadian medical students over the course of two years to complete either a clerkship year containing a two-week rotation with a combined geriatric medicine/geriatric psychiatry focus, or to a normal “But I Already See Old People” clerkship year. The geriatrics rotation included working with geriatric medicine and psychiatry specialists in various inpatient and outpatient clinics and community settings, as well as receiving small group teaching sessions on geriatric topics from faculty in geriatrics, social workers, physiotherapists, occupational therapists, and pharmacists. The “But I Already See Old People” control arm of the study did a two-week rotation in otolaryngology/ophthalmology and continued to evaluate and manage older adults throughout their usual clerkship rotations.

The study used a pre/post testing prior to and after the students clerkship year to assess to knowledge and attitudes in geriatrics. The authors also used a objective structured clinical examination (OSCE) five months after the conclusion of the clinical clerkship to test clinical skills.

The baseline knowledge scores on tests of geriatric knowledge and attitude didn’t differ significantly between the two groups. Post-clerkship knowledge of geriatrics was significantly better in the geriatrics rotation group than the “But I Already See Old People” group. Self-reported clinical practice also was improved in the geriatrics group with more reporting completing tasks like a Mini-Mental Status Examination (MMSE) on a greater number of older patients. The geriatrics group also scored significantly higher than the “But I Already See Old People” group in the observed structured clinical exam, and had a higher pass rate (95%) than did those in the control group (78%). Interestingly, both groups experienced a worsening of their attitude toward older adults over the course of their respective clerkships, with little difference between the two groups.

Overall I thought the authors did a nice job debunking the assumption that geriatrics can be effectively taught by mere exposure to old people.  Those with specialized geriatric training do acquire more knowledge and demonstrate better skills in geriatrics than those without this training. This study should serve as a stimulus for medical school to rethink how we will train the physicians of the future on how to care for an aging population.

The only question for me is why attitudes toward older adults worsened for both groups over the course of a one year clerkship and what can we do to remedy this.  Any thoughts?

by: Eric Widera


Anonymous said...

It's the iceberg theory.. 2 weeks vs. 206 weeks.. It requires a culture shift. I wonder how differently the primary care medical schools fared v. The "academic" ones.

Helen Chen said...

Re: worsening attitudes. I think it's analogous to what happens to many primary-care interested medical students and residents pre and post exposing them to a typical academic/hospital based curriculum. They can't imagine doing "that" for a career, not understanding that the care systems (or lack thereof) they see in training may be nothing like what actually pertains out in the world. Exposing students to elders who need/seek care in a tertiary academic environment (even with wonderful geriatric medicine specialists as preceptors and a fully functional interdisciplinary team) may lead them to believe that all older patients will be like "that". I suspect that those students who are able to have a longitudinal experience with an elder in the community (e.g. SAGE, PAIRS, Senior Mentor) may graduate with better attitudes and a better understanding of the heterogeneity in aging. I also think we need to be careful about the hidden curriculum and think about how and what we communicate to our learners.

ken covinsky said...

Very interesting study. While the study has both encouraging and discouraging findings, my overall take is more on the glass half full side of things--It is encouraging that a very modest investment in better Geriatric training resulted in significant improvements in skills.

Chris Langston, on the Health AGEnda blog has some additional insightful comments on the study. I encourage readers to look at the full post here: (http://www.jhartfound.org/blog/?p=2020).

The following is an except of Chris's commentary, along with my comment on his blog:

From Chris:

"...More than 50 percent of the older adults future doctors will encounter will have multiple chronic diseases, such as hypertension and heart disease. Some unknown but significant number (> 15%?) will have cognitive impairment that limits their ability to take care of themselves, and 25% will have impairments in some activities of daily living. These factors, along with differences in symptoms, prognosis, and tolerance for interventions, are just some of what makes the geriatric population and its concerns as distinct from younger adults as pediatrics is from general adult medicine.

But, rather than looking at these figures and concluding that geriatric training is therefore a core need of medical education, medical leaders often conclude the reverse. Many think that seeing lots of older patients means that doctors must already be competent in their care. The late Dr. Robert Butler used to dismiss this myth with the observation that caring for lots of older patients no more makes you an expert in their care than caring for patients who have hearts makes you a cardiologist..."

My comment:

"I think you have hit on perhaps the biggest reason it is so hard to convince our colleagues of the need for Geriatrics training. The argument we often use to create a sense of imperative—the huge number of older patients—actually works against us. How could it be that special training is needed for such a large segment of patients that our colleagues are already caring for?

I’ve been thinking about this issue the past few days as I was completing my annual monthly stint attending on the medical service. In particular, it has been interesting to think about which of our patients were most in need of Geriatrics expertise. Many of our patients over the age of 65 needed this expertise, though a minority would have done fine without it. Interestingly, I think about half of the patients we admitted under the age of 65 would benefit from a Geriatric approach—the mere fact of admission to an inpatient medical service seems to select for patients who need Geriatrics.

I wonder if we would do better expressing the need for Geriatrics based on specific clinical indications rather than just on demographics. As you noted, we need to change the way we make our case, as the demographic arguement is not working. Based on what I observed this month, here is stab at such an approach. I’m sure this could be much improved with input from others.

Patients in the following categories are especially in need of clinicians with knowledge and expertise in Geriatrics:

(1) Patients with mulitiple chronic conditions of sufficient severity so that comorbid conditions meaningfully impact the appropriate care and management of the primary condition being treated

(2) Patients with difficulty doing basic activites of daily living that are needed to live independently. This disability is either a signficiant part of the illness presentation, or significantly impacts the management of the illness.
(3) The patient has important palliative care needs, to the extent that management of symptoms, understanding goals of care, and a focus on quality of life issues are a crucial complement to traditional disease-oriented therapy."