How will we know what works and what doesn't?

Learners and methods alike will be evaluated for success.

Tom Fitzgerald Photo: Martin Vloet

Tom Fitzgerald, Ph.D., and his colleagues in the Department of Medical Education have their work cut out for them. One of their most pressing jobs right now is to think about how the Medical School will evaluate its success in raising the geriatrics consciousness of its students and house officers. While most of the techniques are familiar, some of them aren't.

"There are two things I'm going to be evaluating," says Fitzgerald, an assistant professor and assistant research scientist in the Department, as well as associate director for education and evaluation at the VA's Geriatric Research, Education and Clinical Center. "First are the learners, by making sure that they're proficient in their knowledge and skills about geriatric patients. Second is our curriculum, to make sure that the learning environment is appropriate for the students and also to evaluate each educational component to see which things are working and which are not working, so we can change them."

And, he points out, there are three different components of evaluation — one for medical students, one for residents, and one for faculty. Plenty of tools exist for the former, and the Medical School has faculty development models from similar initiatives in the past. Assessing the residents' progress, however, is almost terra incognita.

"What we'll do there is look at what kind of curriculum each residency program designs and the problems they have implementing it," says Fitzgerald, "so we can figure out for the residency directors what things work, what things don't work, and what the barriers are, anticipated and unanticipated. We'll be developing benchmarks. This is a new area. In our search through the literature, we found nothing quite like this."

The whole effort of weaving geriatrics into the curriculum is kind of daunting; a major shift in the wind, if not a sea change. "We'll establish demonstration of proficiency in these competencies as a requirement for graduation," says Mark Supiano, an associate professor of internal medicine who heads the medical student component of the
initiative. "We want to send the message clearly to our students that they should take this seriously."

Says Norman Foster, professor of neurology and a member of the steering committee for the project: "As a geriatric neurologist, my particular interest is to make sure that all physicians who treat adults are able to recognize individuals who have cognitive disturbances, particularly dementia or memory problems, and that those are handled appropriately. Not everyone will be treating Alzheimer's disease, but everyone will be treating someone who has Alzheimer's disease."

The consciousness-raising will begin "on day one of entry into the University of Michigan Medical School," says Supiano. Specific activities in the curriculum will address the core competencies established by the American Geriatrics Society, and "medical students will be told that they are expected to successfully complete each of these activities over the course of four years. To cut to the chase, there will be a separate line item on their transcript that designates proficiency in caring for older people."

Using the Web, as the Medical School increasingly does in many areas of the curriculum, for both training and assessment is one of what Supiano calls "several innovative approaches to get the geriatric message across to the students." Students rotating through internal medicine outpatient clinics would report — on-line to a geriatric consultant — their encounters with older patients who presented with a geriatric problem or condition. The Web-based program will allow students to get feedback from the geriatric consultant, participate in on-line discussions, and link to a library of resources.

"One other element is the standardized patient-instructor," he says. "These are individuals who are trained to act as patients, and trained to provide feedback to the student as they're being evaluated by the student. We'll develop a design for a standardized patient-instructor to cover the area of geriatric functional assessment."

Incorporating geriatrics training at the house officer level will be a bit more complex. Brent Williams, associate professor of internal medicine and a geriatrician, heads that aspect of the program. "Our basic commitment is to develop the educational programs in the places where the residents are doing their current clinical work-in the subspecialty clinics, in the hospital before and after an operation, in the emergency room and so forth, so that the residents will integrate geriatrics into what they perceive as their daily work," he says. "And that is a huge challenge."

"We'll work with the core faculty within each department to identify the issues related to geriatrics that are most salient in their own practice and how to get that information across," says Foster. "There's really been very little done in this so far. There's been considerable work done to try to train people in the geriatrics specialty, but this is a little more sophisticated issue — trying to apply geriatrics knowledge and the skills of geriatrics to discipline-specific needs."

Luckily, the human resources for such a task are relatively abundant at Michigan. "One of the reasons the Reynolds Foundation came to this center is that we actually have a very large faculty of multidisciplinary people who either have certification or a strong interest and training in geriatrics as well as other areas of medicine, or areas outside medicine," says Karen Hall, one of those faculty members who will be training their colleagues. "There probably aren't many centers in the U.S. that could marshal as large a group of people."

Those specialties — such as internal medicine, psychiatry and neurology — whose histories have inherently included a higher level of geriatric awareness will provide the bulk of the training for what might be called the "consumer" specialties. "In internal medicine, we're going to be starting with hematology/oncology, nephrology and rheumatology, with the idea of then moving on through all the other subspecialties," says Jeffrey Halter, director of the U-M Geriatrics Center and of the deployment of the Reynolds grant. "Outside of internal medicine, we're starting with obstetrics and gynecology and emergency medicine. Our selection doesn't necessarily reflect priority for need; it's more of a practical issue of which departments have expressed interest and have identified individuals to begin to participate in this process."

Eve Losman Photo: D.C. Goings

One of the individuals who came forward in emergency medicine is Eve Losman, M.D., (Residency 1999), a clinical instructor. "What interests me is looking at geriatric patients as a special population with special needs where a special skill set is needed to take good care of them and developing that skill set in faculty as well as residents," she says.

"To be perfectly honest, a year ago, I never thought, 'Gosh, geriatrics is going to be my area of expertise,'" Losman adds. "I was much more interested in learning more about educating people in the medical profession. But as I read the literature and did some research on my own about geriatrics and emergency medicine, I realized the need was enormous. The baby boomers are going to get old."

Also:

Treating Older Patients: Not just 'older versions of younger adults'

How will we know what works and what doesn't?