Medical educators and researchers have written about

Transcription

1 Effectiveness of a Geriatric Medical Student Scholars Program: A Qualitative Assessment Linda M. Goldenhar, PhD, and John R. Kues, PhD In 2003, the University of Cincinnati College of Medicine initiated a 4-year Geriatric Medical Student Scholars (GMSS) program in which a selected group of 14 medical students participated in a variety of extracurricular geriatrics-related activities such as one-on-one mentoring and discussion groups. These students were also required to compose journal entries describing GMSS program-related activities using a semistructured on-line computer program designed specifically for this purpose. The reflective journals, in combination with the American Geriatrics Society (AGS) competencies, were used to evaluate the degree to which the GMSS program achieved its goal of enhancing students understanding of the complex health and social challenges facing older adults. Using a confirmatory qualitative analysis strategy, the AGS competencies served as an a priori codebook to evaluate the student journal entries. Of the original 53 AGS competencies identified as being relevant for a first- or second-year medical student, 74% were used at least one time, and only 26% were never used. These findings strongly suggest that the GMSS program successfully moved this group of first- and second-year medical students closer to at least understanding the content of many of the AGS competencies by providing them with geriatrics-related experiences and a geriatrics-related framework they could draw on when participating in curricular and extracurricular activities. The findings also point to the potential value of using reflective journaling as a tool for conducting process evaluation of medical education interventions. J Am Geriatr Soc 54: , Key words: journaling; AGS competencies; medical students From the College of Medicine, University of Cincinnati, Cincinnati, Ohio. This work was supported by a grant from the Donald W. Reynolds Foundation, Las Vegas, Nevada. Address correspondence to Linda M. Goldenhar, PhD, Assistant Dean, Medical Education, Director, Office of Evaluation and Research, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH linda.goldenhar@uc.edu DOI: /j x Medical educators and researchers have written about how important it is to expose medical students to geriatrics curricula early in their medical training. The reasons they have suggested doing this include that incoming medical students tend to have less-than-positive attitudes toward older people, 1 5 the rapidly aging population will require more geriatrics-focused health care, 6 and current medical graduates are not being adequately prepared to provide the care needed by the aging population. 7 Medical schools, sometimes with the support of funding organizations, have responded to this need by developing geriatricsfocused curricula Research findings suggest that geriatrics-related educational interventions can improve student attitudes toward, and comfort working with, elderly persons, 1,11 14 and increasing students willingness to care for geriatric patients in their future practices. 15,16 In 2003, the Geriatrics Division of the University of Cincinnati College of Medicine began the implementation and evaluation phases of a 4-year longitudinal geriatrics education program for medical students called the Geriatric Medical Student Scholars (GMSS) program. The goal of the GMSS program is to expose a self-identified and selected group of medical students to a variety of extracurricular didactic and especially clinical activities designed to enhance their understanding of the complex health and social challenges facing older adults. The American Geriatrics Society (AGS) medical student competencies 17 provided the framework for developing and evaluating the effectiveness of the GMSS program s educational activities. The teaching methods used to deliver the content are based primarily on the principles of adult learning theory 18 and include role modeling/mentoring, active and self-directed learning, and reflective journaling. Qualitative analysis of students journal entries allowed the research question Do students written reflections about their geriatrics experiences in the GMSS program correspond to the AGS competencies? to be explored. METHODS Student Recruitment At the beginning of the 2003/04 academic year, students were recruited to the GMSS program after they had the opportunity to interview an elderly person during orientation week, as well as via an campaign and JAGS 54: , 2006 r 2006, Copyright the Authors Journal compilation r 2006, The American Geriatrics Society /06/$15.00

2 528 GOLDENHAR AND KUES MARCH 2006 VOL. 54, NO. 3 JAGS during an activities fair. Interested students attended a meeting to hear more about the GMSS program. Those still interested completed applications, which the GMSS faculty reviewed. Eight entering freshman students and six secondyear students were selected to participate (5% and 4% of each class, respectively). Over the course of the academic year, one student dropped out of the program. Mentoring Given that mentoring has been shown to be a powerful way for people to learn personal and professional skills, the most important teaching/learning activity of the GMSS program was to establish a mentoring relationship between a GMS scholar and a geriatric medicine faculty member. The GMSS mentors received training on ways to help their mentee understand the realities of providing care to older people, interpret their experiences, and learn how to use what they learned in the program to improve their ability to provide competent health care to their elderly patients. Learning Opportunities The scholars attended monthly AGS student chapter meetings at which topics were presented by, and discussed with, geriatrics experts. Topics included end-of-life ethical and legal considerations, hospital nursing home interface, personal experiences of aging, and a panel discussion by four residents of a retirement community. There were also special dinners at which experts presented on a variety of topics. Finally, scholars were expected to attend GMSS group meetings, where they discussed with their peers and the GMSS coordinators their progress, in and thoughts about, the GMSS program. Reflective Journaling Reflective journaling is an integral tool in adult education and has been regularly used in nursing education to help students reflect on the meaning of experiences and events they encounter during their training 19,20 and to become critical thinkers. 21,22 Documented benefits include a better ability to define and articulate clinical experiences and to be able to release any related emotions, observe and record clinical experiences, empathize with patients, 20 and connect theory to clinical practice. 23 The use of reflective journaling in medical education appears to be quite limited. One study 24 used reflective journaling (and reflection groups) with second-year medical students to foster self-awareness and emotional development related to early clinical experiences. In addition, for the past 20 years, residents experiences and struggles while rotating through a medical intensive care unit were collected in a journal and then analyzed. 25 Requiring scholars to write in journals about their experiences was seen as an outstanding professional and personal learning opportunity, as well as a potentially valuable method for conducting process evaluation of the effectiveness of the GMSS program as a medical education intervention. A special Web-based on-line journaling program was developed. On-line applications have been used successfully in nursing education for reflective journaling activities. 26,27 The program was structured to help guide the journaling process by ensuring that students focused on their GMSS program experiences (Appendix 1). The University of Cincinnati institutional review board approved this study, including the student consent form. Analysis The scholars were asked to submit two journal entries per month for 4 months, equaling eight entries per student and a total of 104 entries across all 13 students. Because of technical difficulties, one student s entries were unusable, leaving 98 journal entries submitted by the 12 remaining scholars (average entries/student; range 6 10 entries). No systematic pattern of delinquency or diligence was identified (e.g., male vs female, first year vs second year); therefore the collected qualitative data were combined into one transcript containing all 98 journal entries. Two coders (LG and JK) independently reviewed the complete transcript multiple times and coded pertinent sentences, phrases, and paragraphs. They used the AGS competencies (Year 1 and 2 relevant) as the a priori codebook for reviewing and coding the student journal entries (Appendix 2). This is known as a confirmatory (vs exploratory) analysis strategy. 28 In addition to the confirmatory strategy, the researchers noted and later developed codes for themes that emerged from the data that were unrelated to any of the AGS competencies. The two coders (LG and JK) reviewed and compared their independently coded transcripts. A tally of converging and diverging codes was compiled so that a measure of intercoder agreement could be calculated. 28 Coding divergences were of two types: disagreements over whether a particular passage should be coded at all or agreement that a passage should be coded but disagreement over which code(s) to use. The two reviewers spent approximately 20 hours each individually reading and coding the transcripts and approximately 10 additional hours (five 2-hour sessions) meeting to discuss coding convergences and discrepancies. RESULTS Descriptive quantitative findings pertaining to characteristics of the journal entries and examples of coded passages illustrating how participating in the GMSS program enhanced students geriatrics-related knowledge and attitudes are presented. Journal Entries The journal entries varied widely in content and focus. Of the 98 student journal entries, 50% focused on aging-related extracurricular activities (30 entries) or aging-related curricular activities (19 entries). Forty-four percent of the entries were distributed across aging-related personal experiences with older family members or friends (19 entries), general thoughts/ideas/reflections related to aging (15 entries), aging-related interest areas (8 entries), and other (6 entries). AGS Competencies Of the original 53 AGS first- or second-year relevant competencies, 39 (74%) were used to code student journal entries at least one time. Table 1 includes a listing of the coded competencies and the number of times the two coders

3 JAGS MARCH 2006 VOL. 54, NO. 3 GERIATRIC MEDICAL STUDENT SCHOLAR S PROGRAM ASSESSMENT 529 Table 1. Coding Consistencies Between the Two Investigator/Coders American Geriatrics Society Competencies Used as Codes Coder 1 Coder 2 n Awareness of the various myths and stereotypes related to older people 4 3 Recognition that ageism, like racism, affects all levels and aspects of society, including health 6 5 professionals and can adversely affect optimal care of elderly patients Recognition of the heterogeneity of older personsfa diverse group with different personalities, 8 11 values, functional levels, and medical illnesses; each person needs to be viewed as an individual regardless of chronological age and to be cared for in a unique fashion Self-awareness of the students personal attitudes toward their own aging, disability, and death 6 7 Compassion and understanding attitude on the part of the physician for care givers of frail older 6 5 people and the difficulties they face An appreciation of the need for improving and optimizing function for older people rather than just 7 1 focusing on diseases Knowledge related to basic science 2 2 Demography and epidemiology of aging, including the growth in numbers of older people and 2 0 heterogeneity of the older population Theories of aging including biochemical/molecular, cellular, genetic, and biopsychosocial 3 1 Normal aging versus diseases at the molecular, cellular, tissue, and organism levels 3 2 Loss of homeostatic control mechanisms may account for much of the aging process 1 0 Anatomic and histological changes associated with aging 3 2 Pathology associated with normal aging and age-associated disease processes 3 1 Physiology of aging in various organ systems 4 4 Pharmacological changes in aging 4 6 Knowledge related to clinical practice 2 3 Geriatric syndromes and conditions; a basic understanding of risk factors, causes, symptoms, 4 4 signs, differential diagnosis, initial diagnostic evaluation, and preventive strategies Knowledge of diseases and disorders that are more common or have particular features in older 6 6 people; a broad knowledge of pathophysiology, presenting symptoms and signs, differential diagnosis, and initial diagnostic evaluation for common diseases older people Knowledge of psychosocial issues: identification, presenting symptoms and signs, and appropriate 6 5 referral of common psychosocial problems and issues Normal behavioral late-life changes, including retirement 1 3 Psychopathology, including affective disorders, psychotic disorders, anxiety disorders, responses 1 1 to medical illness, depression, and substance abuse Sexuality and aging 3 3 Home safety 1 1 Community resources, including those used to prevent institutionalization 4 3 Adaptation to care in alternative living situations, including long-term care facilities 0 1 Knowledge of prevention 0 1 Primary prevention strategies 6 7 Secondary prevention, with age-appropriate screening for diseases and identification of geriatric 1 0 syndromes Tertiary prevention strategies 2 0 Knowledge of ethical issues in geriatric care 2 3 Advance directives 4 3 Decision-making capacity 1 1 Euthanasia, assisted suicide 0 1 Healthcare rationing 1 2 End-of-life care 7 7 Healthcare Financing 5 1 Mechanisms and Implications (Medicare, Medicaid, managed care, capitation) 2 1 Cultural aspects of agingfinfluence of culture and ethnicity on the aging process, health and 1 0 disease perception, and access to medical care The components of providing culturally competent medical care 3 0

4 530 GOLDENHAR AND KUES MARCH 2006 VOL. 54, NO. 3 JAGS identified each. The calculated kappa statistic of 0.63 (Po.001) indicates a strong level of agreement between the two coders across the 53 competencies. 29 There were nine instances in which one investigator used a competency as a code at least once, but the other did not use it all. There were four instances when one of the investigators used a code three or more times as often as the other investigator. Both coders used eight of the 39 AGS competencies most frequently. Four are attitudinal, and four relate to clinical science knowledge: recognition of the heterogeneity of older personsfa diverse group with different personalities, different values, different functional levels, and different medical illnesses; end-of-life care; self-awareness of the students personal attitudes toward their own aging, disability, and death; primary prevention strategies; knowledge of diseases and disorders that are more common or have particular features in older people; recognition that ageism, like racism, affects all levels and aspects of society, including health professions, and can adversely affect optimal care of elderly patients; compassion and understanding attitude on the part of the physician for caregivers of the frail elderly and the difficulties they face; and knowledge of psychosocial issuesfidentification, presenting symptoms and signs, and appropriate referral of common psychosocial problems and issues. More than one quarter of the competencies (n 5 14) were not used as a code by either investigator (Appendix 3). None of the competencies related to clinical skills were found in the students journal entries. This is likely because the students were in their preclinical years of training, although several competencies pertaining to the demographics of the elderly population were also not used. Emerging Themes The two coders (LG and JK) identified codable passages in the transcripts for which there was no code in the codebook (the AGS competencies). After deliberating over the meaning of those passages, they agreed that they reflected students attitudes toward becoming physicians and working with older patients. Thus, a new competency code was created and labeled: self-awareness of what doctoring (specifically being a geriatrician) is aboutfresponsibilities, limitations, etc. Twenty-six data elements were coded with this new attitudinal competency. Illustrative Quotations The following quotations illustrate the effect that the GMSS program had on the scholars progress toward attaining the AGS medical student competencies. They are divided into the three major AGS competency categories: attitudes, basic science knowledge, and clinical science knowledge. Attitudes Although the students reflected on a number of attitudinal issues covered by the AGS competencies, the code most often used pertained to student recognition that older people were a heterogeneous group and that each person/ patient should be viewed as an individual regardless of chronological age. The quotations below illustrate this recognition. We saw a 94-year-old woman today who was surprisingly alert and articulate.... It served as a strong reminder that everyone ages differently and the life of a geriatrician is not all end-of-life cases and DNR cases. It wasn t what you d expect.... The elderly person was still leading a full life and could expect to live more full years. The young person was fighting for her life, and the same time period will probably be much more limited for her.... The take-home message is that to be elderly is not necessarily to be frail, to be at death s door.... By seeing this fairly healthy elderly patient will help me keep that in mind in the future. The following quotations illustrate the attitude of self-awareness of what doctoring is about (particularly being a geriatrician), the new competency that emerged from the data (i.e., not one of the original AGS competencies). As we age, we start to appreciate a slower-paced lifestyle. It strikes me how in contrast that is with the working style of most physicians. Doctors buzz into the examining room, speak a mile a minute, fill out some prescription, and shove the patient out the door. It makes me wonder how any patient, and especially elderly patients, feel satisfied from the physician experience and, more importantly, what they actually learn about their health.... When a doctor does a home visit, he/she can learn more/different information than can be obtained from a regular appointment in the office. For example, a physician can ask to see the patient s medications or to see what kind of lifestyle the patient leads.... This would include diet, support system, hygiene, etc. Knowledge The knowledge category includes basic and clinical science understanding. The GMSS program gave these students the opportunity to relate what they were learning in their basic science classes to geriatric medicine, as well as to bring knowledge gained during mentored-clinical experiences back to the classroom. Basic Science Knowledge Now that I have become more reflective on geriatric issues, the discussions of age-related changes in anatomy and physiology become more pertinent to me. I have become more attentive to these details, rather than glossing over them under the weight of material to be learned. Dr. FFF discussed some of the physiological changes of aging: decreased sensations, such as taste, sight, and smell; decreased acidity in the stomach with decreased intestinal motility, decreased insulin production, etc. These physiological changes led to certain diseases like periodontal disease, emotional distress, decreased organ function and many more. Clinical Science Knowledge My mentor s favorite example,... a person may present with urinary tract infection and have no complaints of dysuria or other

5 JAGS MARCH 2006 VOL. 54, NO. 3 GERIATRIC MEDICAL STUDENT SCHOLAR S PROGRAM ASSESSMENT 531 expected symptoms.... This was interesting because we learn the typical presentations in class but fail to mention the atypical symptoms. I am somewhat relieved because it is hard enough to learn all the diseases and their typical presentations without adding atypical symptoms. I am glad to have the opportunity to see some examples of patients who do not fit into the characteristics and descriptions I have learned. DISCUSSION Evaluating the degree to which students achieve acceptable levels of knowledge and skills needed to become competent physicians is an integral aspect of medical education and most often focuses on student achievement in required courses and clinical rotations. It rarely examines learning that takes place during unstructured extracurricular experiences like the GMSS program. Extracurricular activities such as this program provide students with the opportunity to learn about aspects of doctoring including professionalism, cultural competency, healthcare ethics, and doctor patient communicationfconstructs that are much more difficult to assess. In this study, reflective journaling was used as an evaluative way to capture this type of learning. Its use in undergraduate medical education has been limited, and student journal entries have never been linked with professional competencies. The fact that 74% of the AGS competencies were used to code the students journal entries strongly indicates that the GMSS program was successful in its goal of getting the GMSS program participants to become aware of and perhaps understand the intent of many of the AGS competencies. It did this directly by providing them with geriatricsrelated clinical and didactic experiences and indirectly by providing them with a geriatrics-related framework they could use when participating in other curricular and extracurricular activities. For most of the scholars, the GMSS program provided them with their first contact with elderly patients. They came to the clinical encounter with their own set of beliefs and biases regarding older people, and as evidenced in the journals, many were surprised, in a positive way, by what they saw. Although it has not been measured as an outcome, it will be important to determine whether these experiences enhance students willingness to care for geriatric patients in their future practices, as has been observed in other studies. 15,16 The journaling data analyzed identified a number of AGS competencies that were not discussed in the student scholars journals. For example, as noted earlier, neither investigator used any of the skill-based AGS competencies to code the journal passages. Indeed, there is no way to determine whether the lack of journal entries related to these competencies reflects a deficit in the GMSS program or the curriculum in, but this information gives faculty some useful information for future content development for medical students. Journaling may be an educational intervention itself, because it provides students the opportunity to take time to reflect on their educational experiences. It is possible that the intensity of the medical school curriculum affords students little time to process what they have learned or to reflect on how the knowledge, attitudes, and skills gained might be integrated into their professional and personal lives. It was apparent in many of the journal entries that students used the opportunity to reflect on how particular experiences might be incorporated into their future careers as physicians. Finally, traditional deductive qualitative methods would dictate that coders review the journal transcripts and allow codes (themes) to emerge from the data rather than imposing predetermined codes, but because the purpose of this study was to evaluate the extent to which students were reflecting AGS competencies in their writings, it was decided that using the AGS competencies as the primary codebook was the best approach. It was not possible to adequately code a number of the student reflections using the AGS competencies, and a new code needed to be added to the codebook. This new code, which pertained to students thoughts and attitudes about becoming physicians and caring for patients, reflected the most common theme for all 12 students. The findings from a previous study 24 corroborate this finding, albeit with a twist; it found that one of the three areas of stress identified by second-year medical students pertained to the role and responsibility of the physician. In both cases, the findings could be taken as an indication that educational strategies like mentoring and one-on-one precepting with experienced clinicians help medical students learn about professionalism and ethics, topics that are much more difficult to teach using traditional classroom methods. CONCLUSION The findings reported here indicate that the GMSS program is a feasible educational intervention and may help to enhance the medical student s understanding of the complex health and social challenges facing older adults. In addition, the findings also indicate that student reflections about their educational experiences in the GMSS program correspond to the content areas of many of the AGS competencies. These students chose to participate in the GMSS program, because they had some level of interest in the health needs of the elderly population. Had all of the students in the class been required to journal about any or all of their clinical experiences, it is likely that the analysis of their entries would not necessarily address the content of the AGS competenciesfat least not to the extent found here. In conclusion, this study points to the potential value of using reflective journaling as a tool to evaluate medical education interventions. This will require validation in future studies. ACKNOWLEDGMENTS We wish to thank Dr. Gordon Margolin, Ms. Elizabeth Gothelf, Dr. Gregg Warshaw, and all the GMSS faculty mentors and students for their coordination of and participation in the GMSS program. Their dedication to geriatrics and medical student education allowed these student scholars to learn and grow in ways that would not otherwise have been possible. Financial Disclosure: None. Author Contributions: Linda M. Goldenhar: as evaluator on the GMSS project, conceptualized using reflective journaling and using AGS competencies to evaluate the GMSS program; designed journal entry program and explained the process to the students, and informed them as to

6 532 GOLDENHAR AND KUES MARCH 2006 VOL. 54, NO. 3 JAGS when their entries were due; conducted confirmatory qualitative analysis on journal entries; and worked with Dr. Kues interpreting the results and preparing the manuscript. John R. Kues: conducted confirmatory qualitative analysis on journal entries, worked with Dr. Goldenhar interpreting the results and preparing the manuscript. Sponsor s Role: The sponsor had no role in the design, methods, subject recruitment, data collection, analysis or preparation of this manuscript. REFERENCES 1. Coccaro EF, Miles AM. The attitudinal impact of training in gerontology/ geriatrics in medical school. A review of the literature and perspective. J Am Geriatr Soc 1984;32: Adelman RD, Albert RC. Medical student attitudes toward the elderly: A critical review of the literature. Gerontol Geriatr Educ 1987;7: Warren DL, Painter A, Rudisill J. Effects of geriatric education on the attitudes of medical students. J Am Geriatr Soc 1983;31: Reuben DB, Fullerton JT, Tschann JM et al. 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: 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: Ebrahim S. Demographic shifts and medical training. BMJ 1999;319: Anderson MB. A thematic summary of the geriatrics curricula at 40 U.S. medical schools. Acad Med 2004;79(Suppl 7):S213 S Burns E, Bates T, Cohan M et al. The Medical College of Wisconsin s program to strengthen geriatrics education. Wisc Med J 2003;102: Supiano MA, Fantone JC, Grum C. A web-based geriatrics portfolio to document medical students learning outcomes. Acad Med 2002;77: Thornhill J 4th, Richeson N, Roberts E. Senior mentor program: A geriatrics focused curriculum. Acad Med 2002;77: Adelman RD, Fields SD, Jutagir R. Geriatric education. Part II. The effect of a well elderly program on medical student attitudes toward geriatric patients. J Am Geriatr Soc 1992;40: Alford CL, Miles T, Palmer R et al. An introduction to geriatrics for first-year medical students. J Am Geriatr Soc 2001;49: Wooliscroft JO, Calhoun JG, Maximun BR et al. Medical education in facilities for the elderlyfimpact on medical students, facility staff, and residents. JAMA 1984;252: Sainsbury R, Wilkinson TJ, Smith CW. Attitudes of medical students to old people: A cross-national comparative study. Med Educ 1992;26: Smith CW, Wattis JP. Medical students attitudes to old people and career preference. The case of Nottingham Medical School. Med Educ 1989;23: Wener S, Foley C, Jaffe A. Three years of a required geriatrics module for thirdyear medical students. Acad Med 1991;66: American Geriatrics Society [on-line]. Available at Accessed November 7, Kaufman DM. ABC of learning and teaching in medicine: Applying educational theory in practice. BMJ 2003;326: Boud D. Using journal writing to enhance reflective practice. In: English LM, Gillen MA, eds. Promoting Journal Writing in Adult Education. New Directions in Adult and Continuing Education No. 90. San Francisco: Jossey-Bass, 2001, pp Callister LC. The use of student journals in nursing education: Making meaning out of clinical experience. J Nurs Educ 1993;32: Brown HN, Sorrell JM. Use of clinical journals to enhance critical thinking. Nurse Educ 1993;18: Bilinski H. The mentored journal. Nurse Educ 2002;27: Ruthman J, Jackson J, Cluskey M et al. Using clinical journaling to capture critical thinking across the curriculum. Nurs Educ Perspect 2004; 25: Pololi LP, Frankel RM, Clay M et al. One year s experience with a program to facilitate personal and professional development in medical students using reflection groups. Educ Health (Abingdon) 2001;14: Sekeres MA, Stern TA. On the Edge of Life, II: House Officer Struggles Recorded in an Intensive Care Unit Journal. Prim Care Companion J Clin Psychiatry 2002;4: Cohen JA, Welch LM. Web journaling. Using informational technology to teach reflective practice. Nurs Leadersh Forum 2002;6: Daroszewski EB, Kinser AG et al. Online, directed journaling in community health advanced practice nursing clinical education. J Nurs Educ 2004;43: Bernard HR, Ryan GW. Text analysis: Qualitative and quantitative methods. In: Bernard HR, ed. Handbook of Methods in Cultural Anthropology. Walnut Creek, CA: Rowman and Littlefield Publishers, Inc., 1998, pp Maclure M, Willett WC. Misinterpretation and misuse of the kappa statistic. Am J Epidemiol 1987;126: Appendix 1. Structure of the On-Line Journaling Program Below are five broadly defined areas designed to help you focus your journal entries. We do not expect that you will necessarily write in all five areas each time you make a journal entry, BUT YOU MIGHT! As you write in each area, rather than simply reporting events, please reflect on: & & & Any specific knowledge you gained with respect to aging and caring for aging patients. Any skills you obtained that will be useful for caring for aging patients. How the activity or experience affected you and your attitudes toward aging and caring for aging patients. The five areas are: 1. Aging-related extracurricular activities (either with your mentor, other mentors, other GMSS or non-gmss students). 2. Aging-related curricular activities (course lectures, questions you or others asked in class, any clinical experiences). 3. Aging-related interest areas (things you learned from Fast Facts or other materials, research questions you might want to pursue or ask about). 4. Aging-related personal experiences with older family members or friends. 5. General thoughts/ideas/reflections related to aging. GMSS 5 Geriatric Medical Student Scholars.

7 JAGS MARCH 2006 VOL. 54, NO. 3 GERIATRIC MEDICAL STUDENT SCHOLAR S PROGRAM ASSESSMENT 533 Appendix 2. Code Book Containing American Geriatrics Society Competencies Relevant for Year 1 and 2 Medical Students I. Attitudes A. Awareness of the various myths and stereotypes related to older people. B. Recognition that ageism, like racism, affects all levels and aspects of society, including health professionals, and can adversely affect optimal care of elderly patients. C. Recognition of the heterogeneity of older personsfa diverse group with different personalities, values, functional levels, and medical illnesses. Thus, each person needs to be viewed as an individual regardless of chronological age and to be cared for in a unique fashion. D. Openness and willingness to work with other disciplines in caring for older patients (more appropriate for Year 3 and 4 students). E. Self-awareness of the students personal attitudes toward their own aging, disability, and death. F. Compassion and understanding attitude on the part of the physician for caregivers of frail older people and the difficulties they face. G. An appreciation of the need for improving and optimizing function for older people, rather than just focusing on diseases. H. Self-awareness of what doctoring (specifically being a geriatrician) is aboutfresponsibilities, limitations. II. Knowledge A. Related to basic sciences 1. Demography and epidemiology of aging, including the growth in numbers of older people and heterogeneity of the older population. 2. Theories of aging, including biochemical/molecular, cellular, genetic, and biopsychosocial. 3. Normal aging versus diseases at the molecular, cellular, tissue, and organism levels. Normal aging is heterogeneous, affecting different tissues and organs in different individuals at different rates. 4. Practicing physicians need to identify preventable, reversible, and treatable aging processes and manage them accordingly. 5. Loss of homeostatic control mechanisms may account for much of the aging process. 6. Anatomic and histological changes associated with aging. 7. Pathology associated with normal aging and age-associated disease processes. 8. Physiology of aging in various organ systems. 9. Pharmacological changes in aging and relevance to therapeutic decisions. B. Related to clinical practice 1. Geriatric syndromes and conditions. Students should be familiar with common geriatric syndromes and conditions and have a basic understanding of risk factors, causes, symptoms, signs, differential diagnosis, initial diagnostic evaluation, and preventive strategies. 2. Knowledge of diseases and disorders that are more common or have particular features in older people. Although students individual clinical experiences may provide greater or lesser exposure to these disorders, students should have at least broad knowledge of pathophysiology, presenting symptoms and signs, differential diagnosis, and initial diagnostic evaluation for common diseases older people. 3. Knowledge of psychosocial issues. Students should be familiar with identification, presenting symptoms and signs, and appropriate referral of common psychosocial problems and issues. a) Normal behavioral late-life changes, including retirement b) Psychopathology, including affective disorders, psychotic disorders, anxiety disorders, responses to medical illness, depression, and substance abuse c) Underreporting of symptoms and illnesses d) Sexuality and aging e) Elder abuse and neglect f) Suicide g) Home safety h) Community resources, including those used to prevent institutionalization i) Adaptation to care in alternative living situations, including long-term care facilities 4. Knowledge of prevention a) Primary prevention (e.g., exercise, nutrition, and psychosocial interventions designed to maximize function to allow independent living) b) Secondary prevention with age-appropriate screening for diseases and identification of geriatric syndromes c) Tertiary prevention strategies (e.g., rehabilitation and chemoprophylaxis in the postmyocardial infraction patient) 5. Knowledge of ethical issues in geriatric care a) Advance directives b) Decision-making capacity c) Euthanasia, assisted suicide d) Healthcare rationing e) Pain management f) End-of-life care (Continued )

8 534 GOLDENHAR AND KUES MARCH 2006 VOL. 54, NO. 3 JAGS Appendix 2. (Contd.) 6. Healthcare financing a) Mechanisms and implications (Medicare, Medicaid, managed care, capitation) 7. Cultural aspects of aging. Students should be familiar with the influence of culture and ethnicity on the aging process, health and disease perception, and access to medical care, with emphasis on: a) Demography of ethnic older people in the United States b) The heterogeneity of the federally designated minority elder groups c) Risk factors and disease prevalence in these older people d) The components of providing culturally competent medical care III. Skills A. Basic history taking 1. Students should be competent in performing the basic elements of geriatric assessment, with standardized methods for assessing physical, cognitive, emotional and social functioning as appropriate. Specific examples include screening examinations for mental status, geriatric depression, and functional status, including activities of daily living and instrumental activities of daily living. Appendix 3. American Geriatrics Society Competencies Not Used as a Code Attitudes Openness and willingness to work with other disciplines in caring for older patients Knowledge (general) Normal aging is heterogeneous, affecting different tissues and organs in different individuals at different rates Practicing physicians need to identify preventable, reversible, and treatable aging processes and manage them accordingly Underreporting of symptoms and illnesses Elder abuse and neglect Suicide Pain management Demography of ethnic older people in the United States The heterogeneity of the federally designated minority elder groups Risk factors and disease prevalence in these older people Clinical skills Basic history taking Students should be competent performing the basic elements of geriatric assessment with standardized methods. Specific examples include screening exams for mental status, geriatric depression, and functional status, including activities of daily living