Adrian Blundell

European undergraduate curriculum in geriatric medicine developed using an international modified Delphi technique

Introduction: the rise in the number of older, frail adults necessitates that future doctors are adequately trained in the skills of geriatric medicine. Few countries have dedicated curricula in geriatric medicine at the undergraduate level. The aim of this project was to develop a consensus among geriatricians on a curriculum with the minimal requirements that a medical student should achieve by the end of medical school. Methods: a modified Delphi process was used. First, educational experts and geriatricians proposed a set of learning objectives based on a literature review. Second, three Delphi rounds involving a panel with 49 experts representing 29 countries affiliated to the European Union of Medical Specialists (UEMS) was used to gain consensus for a final curriculum. Results: the number of disagreements following Delphi Rounds 1 and 2 were 81 and 53, respectively. Complete agreement was reached following the third round. The final curriculum consisted of detailed objectives grouped under 10 overarching learning outcomes. Discussion: a consensus on the minimum requirements of geriatric learning objectives for medical students has been agreed by European geriatricians. Major efforts will be needed to implement these requirements, given the large variation in the quality of geriatric teaching in medical schools. This curriculum is a first step to help improve teaching of geriatrics in medical schools, and will also serve as a basis for advancing postgraduate training in geriatrics across Europe.

Are we teaching our students what they need to know about ageing? Results from the UK National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine

Introduction - Learning about ageing and the appropriate management of older patients is important for all doctors. This survey set out to evaluate what medical undergraduates in the UK are taught about ageing and geriatric medicine and how this teaching is delivered. Methods – An electronic questionnaire was developed and sent to the 28/31 UK medical schools which agreed to participate. Results – Full responses were received from 17 schools. 8/21 learning objectives were recorded as taught, and none were examined, across every school surveyed. Elder abuse and terminology and classification of health were taught in only 8/17 and 2/17 schools respectively. Pressure ulcers were taught about in 14/17 schools but taught formally in only 7 of these and examined in only 9. With regard to bio- and socio- gerontology, only 9/17 schools reported teaching in social ageing, 7/17 in cellular ageing and 9/17 in the physiology of ageing. Discussion – Even allowing for the suboptimal response rate, this study presents significant cause for concern with UK undergraduate education related to ageing. The failure to teach comprehensively on elder abuse and pressure sores, in particular, may be significantly to the detriment of older patients.

UK medical teaching about ageing is improving but there is still work to be done: the Second National Survey of Undergraduate Teaching in Ageing and Geriatric Medicine

Introduction: in 2008, a UK national survey of undergraduate teaching about ageing and geriatric medicine identified deficiencies, including failure to adequately teach about elder abuse, pressure ulcers and bio- and social gerontology. We repeated the survey in 2013 to consider whether the situation had improved. Method: the deans of all 31 UK medical schools were invited to nominate a respondent with an overview of their undergraduate curriculum. Nominees were invited by email and letter to complete an online questionnaire quantifying topics taught, type of teaching and assessment undertaken, and the amount of time spent on teaching. Results: one school only taught pre-clinical medicine and declined to participate. Of the 30 remaining schools, 20 responded and 19 provided analysable data. The majority of the schools (95–100%) provided teaching in delirium, dementia, stroke, falls, osteoporosis, extra-pyramidal disorders, polypharmacy, incontinence, ethics and mental capacity. Only 68% of the schools taught about elder abuse. Thirty-seven per cent taught a recognised classification of the domains of health used in Comprehensive Geriatric Assessment (CGA). The median (range) total time spent on teaching in ageing and geriatric medicine was 55.5 (26–192) h. There was less reliance on informal teaching and improved assessment:teaching ratios compared with the 2008 survey. Conclusions: there was an improvement in teaching and assessment of learning outcomes in ageing and geriatric medicine for UK undergraduates between 2008 and 2013. However, further work is needed to increase the amount of teaching time devoted to ageing and to improve teaching around elder abuse and the domains of health used in CGA.

Equipping tomorrow's doctors for the patients of today

As the proportion of older patients with frailty presenting to health services increases, so does the need for doctors to be adequately trained to meet their needs. The presentations seen in such patients, the evidence-based models of care and skillsets required to deliver them are different than for younger patient groups-so specific training is required. Several research programmes have used detailed and explicit methods to establish evidence-based expert-validated curricula outlining learning outcomes for undergraduates in geriatric medicine-there is now broad-consensus on what newly qualified doctors need to know. There are, despite this, shortcomings in the teaching of undergraduates about geriatric medicine. National and international surveys from the UK, EU, USA, Canada, Austria and the Netherlands have all shown shortcomings in the content and amount of undergraduate teaching. Mechanisms to improve this situation, aside from specifying curricula, include developing academic departments and professorships in geriatric medicine, providing grants to develop teaching in geriatric medicine and developing novel teaching interventions to make the best of existing resources. Under the last of these headings, innovations have been shown to improve outcomes by: using technology to ensure the most effective allocation of teaching time and resources; using inter-professional education as a means of improving attitudes towards care of older patients; focusing teaching specifically on attitudes towards older patients and those who work with them; and trying to engage patients in teaching. Research areas going forward include how to incentivise medical schools to deliver specified curricula, how to choose from an ever-expanding array of teaching technologies, how to implement interprofessional education in a sustainable way and how to design teaching interventions using a qualitative understanding of attitudes towards older patients and the teams that care for them.

Undergraduate teaching in geriatric medicine using computer-aided learning improves student performance in examinations

BACKGROUND computer-aided learning (CAL) is increasingly used to deliver teaching, but few studies have evaluated its impact on learning within geriatric medicine. We developed and implemented CAL packages on falls and continence, and evaluated their effect on student performance in two medical schools. METHODS traditional ward based and didactic teaching was replaced by blended learning (CAL package combined with traditional teaching methods). Examination scores were compared for cohorts of medical students receiving traditional learning and those receiving blended learning. Control questions were included to provide data on cohort differences. RESULTS in both medical schools, there was a trend towards improved scores following blended learning, with a smaller number of students achieving low scores (P < 0.01). Feedback from students about the CAL packages was positive. DISCUSSION blended learning was associated with improvement in student examination performance, regardless of the setting or the methods adopted, and without increasing teaching time. Our findings support the use of CAL in teaching geriatric medicine, and this method has been adopted for teaching other topics in the undergraduate curriculum.

Undergraduate Teaching in Geriatric Medicine: The Role of National Curricula

There has been recent international concern that the teaching of geriatrics may be in decline. Research has suggested that support for geriatrics in national undergraduate curricula is the key to effective delivery of teaching in the specialty. We set out to determine the geriatric medicine content in the U.K. generic curriculum, reviewing this in the context of the international guidance available on undergraduate teaching in geriatric medicine. Ten learning outcomes from the U.K. generic curriculum were identified as being relevant to geriatric medicine. The domains of learning and actual learning outcomes were similar among the specialty curricula from different countries. Expert-judge consultation revealed general satisfaction that these outcomes were adequate in depth and scope. Our findings show the U.K. generic curriculum supports the learning outcomes suggested in the specialty undergraduate curricula in geriatrics providing additional weight to calls for a comprehensive review of undergraduate teaching in geriatrics. This process of validating specialty curricula against national guidelines might be usefully replicated in other countries.

The development and evaluation of mini-GEMs - short, focused, online e-learning videos in geriatric medicine.

ABSTRACT Mini Geriatric E-Learning Modules (Mini-GEMs) are short, focused, e-learning videos on geriatric medicine topics, hosted on YouTube, which are targeted at junior doctors working with older people. This study aimed to explore how these resources are accessed and used. The authors analyzed the viewing data from 22 videos published over the first 18 months of the Mini-GEM project. We conducted a focus group of U.K. junior doctors considering their experiences with Mini-GEMS. The Mini-GEMs were viewed 10,291 times over 18 months, equating to 38,435 minutes of total viewing time. The average viewing time for each video was 3.85 minutes. Learners valued the brevity and focused nature of the Mini-GEMs and reported that they watched them in a variety of settings to supplement clinical experiences and consolidate learning. Watching the videos led to an increase in self-reported confidence in managing older patients. Mini-GEMs can effectively disseminate clinical teaching material to a wide audience. The videos are valued by junior doctors due to their accessibility and ease of use.

Development of a curriculum for advanced nurse practitioners working with older people with frailty in the acute hospital through a modified Delphi process

BACKGROUND advanced nurse practitioners (ANPs) are experienced nurses who undertake some activities traditionally performed by medical staff. There are four pillars of advanced practice: advanced clinical skills, leadership, education and research. ANPs are starting to specialise in the management of older adults with frailty in the acute hospital. However, the role and competencies required for this have not been well defined. This study aimed to establish an expert consensus on the role description and essential competencies for ANPs working with older people with frailty to develop a curriculum. METHODS a literature review and workshops including multi-professional and lay representatives generated a role description and a list of 69 competencies. A modified Delphi process was then conducted with three rounds involving a panel of 31 experts including representatives from the RCN, BGS Education and Training Committee, BGS Senior Nurses and Practitioners Group, Chartered Society of Physiotherapy Older People Network, College of Occupational Therapists Older People Specialist Section and lay representatives. Consensus on the statements was established by 70% panel agreement. RESULTS the role description reached 100% agreement within three rounds. Twenty-five essential competencies were agreed after Round 1, increasing to 43 after Round 2 and 49 after Round 3. CONCLUSION this Delphi study has allowed, for the first time, a national panel of clinical experts and lay representatives to refine and agree a set of competencies for ANPs working with older people with frailty. It is the first step towards ensuring consistency in the training of ANPs in geriatric medicine.

Teaching and Learning the Content of Geriatric Medicine

Different theories of learning can be successfully applied to the teaching of geriatric medicine to undergraduates. These include andragogy, reflection, experiential learning and motivation. It is important to have robust assessments for students and also evaluation of educational programmes. In recent years there has been an increasing literature on the practicalities of teaching undergraduates and several examples are discussed in this chapter.

Better teaching in basic gerontology should be seen as both a goal and an opportunity for those shaping undergraduate curricula

In a commentary piece in this issue of Age and Ageing, Tinker and colleagues [1] return to the issue of lack of gerontological coverage in curricula with an impassioned and well-argued plea for comprehensive teaching about social gerontology in undergraduate programmes. They define social gerontology as demography, social policy and the psychology and sociology of ageing. Their rationale for incorporating such teaching is to equip doctors for a world where they are increasingly asked to help lead and shape models of health care where concerns about an increasing prevalence of frailty and dependency predominate. In addition, they highlight such teaching as a possible route to combat the well-documented issues of ageism within the medical profession, often accompanied by a disregard for aged care as an area of specialist interest [2, 3]. The commentary piece is a welcome call to arms but, as with all such arguments, it is perhaps at its most useful when subjected to robust critique. For the commentary to usefully steer our efforts in undergraduate education, three main counter-arguments must be accommodated: the ‘not enough space’ argument; the ‘not enough evidence’ argument and the argument of disciplinary territorialism. The ‘not enough space’ argument is well rehearsed and oft repeated. The body of medical knowledge is expanding exponentially, and it is now impossible to accommodate all desirable information in an undergraduate curriculum. Medical course directors are regularly subjected to pleas from specialist groups about the importance of their own particular discipline in the curricular mix. Against this background, the response from gerontologists should not be to shout louder but to act smarter: to seize upon cogent parts of the pedagogical zeitgeist that may represent a ‘way in’. The increased emphasis on multidisciplinary teaching, harnessing new teaching technologies, engaging patients and carers in teaching and upon longitudinal themes in curricula represent opportunities to gerontologists and should be harnessed [4]. The ‘not enough evidence’ argument comes from the claims, not yet fully proven, that more and better teaching about older people and ageing can substantially and positively influence attitudes and behaviours of the medical profession in a meaningful way. Incorporating better, more sensitive, metrics of how teaching impacts upon these domains [5], alongside research to consider how educational exposure modifies career aspirations and specialty selection [6], is therefore important. This latter point is cogent to the needs of health services, which are increasingly seeking, in the UK at least, to recruit generalist doctors with specialist expertise in ageing and frailty. The argument of disciplinary territorialism will be familiar to regular attendees of gerontological conferences. Social gerontology may, or may not, incorporate psychology of ageing. Physiology of ageing might be seen, historically, as being subsumed within medical gerontology, which shows incomplete overlap with geriatric medicine, geratology and ‘healthcare for older people’ [7]. Gerontechnology opens up the worlds of architecture, engineering and design [8], while cultural gerontology [9] introduces aspects of philosophy and epistemology perhaps otherwise given short shrift. Thus, ever more complex Venn diagrams ensue. At their best, these disciplinary sub-divisions remind us about the wide range of gerontological interests that require to be incorporated, not excluded, from medical teaching. At their worst, they represent opportunities for conflict and exclusion. When we explored the teaching of geriatric medicine in UK medical schools in 2008 [10] and again in 2013 [11], we found a mixed picture. While the total number of hours devoted to specific teaching about older people remained low at 55 h from a typical 5-year course, there were improvements seen in the coverage of many core domains. The improvements were most marked in clinical topics, particularly syndromes commonly seen in older patients, and essential overarching topics such as medical ethics as applied to ageing. Among the several significant deficiencies, there were shortcomings in teaching about service models, social ageing, cellular and physiological ageing, with these being taught (examined) in 84 (68), 74 (63), 68 (58) and 84 (63)% of medical schools surveyed, respectively. These might collectively be seen as representing the broader discipline of gerontology, as opposed to geriatric medicine. The reason for the continued poor performance in teaching about gerontology in national surveys is unclear. One issue could be that course coordinators find it more difficult to map the delivery of broad overarching concepts, as opposed to teaching about discrete medical pathologies, within an undergraduate course. A stroke lecture—whether delivered by geriatricians or neurologists—is likely to be clearly identifiable as such. Aspects of social gerontology might, by contrast, be taught over multiple interventions as part of medical sociology, public health and behavioural sciences curricula. Thus, ascertainment bias might have played some role in the reported deficiencies.