Geriatrics Recruitment Resources

Geriatrics Recruitment in the Context of the Formal, Informal and Hidden Curriculums
Where to Focus Geriatrics Recruitment Efforts
References

One of the main reported reasons people decide to become physicians is that they want to help people and make a positive difference in the lives of their patients and families. Geriatric medicine is one of the specialties that most emphasizes personal and sustained relationships with patients and families.¹ Geriatric medicine has the potential to meet a major goal of prospective physicians, one that leads to career satisfaction and fulfillment.

The data support this: In a 2002 survey, geriatrics was ranked first in job satisfaction among physicians.² But even though geriatricians report high career satisfaction and the field meets some initial career objectives of prospective physicians, the number of geriatricians remains low and is currently declining. In fact, there are many barriers to choosing a career in geriatric medicine.

• The earning potential of geriatricians is the lowest of all medical specialties.³
• Throughout the course of medical school, many students receive the impression that geriatrics is a field that is not respected by other physicians.
• Too often, residency programs reinforce the stereotype of older patients as unmanageable or difficult because residents only meet hospitalized elders who are, by definition, among the most ill and frail.
• Medical trainees often encounter positive geriatrician role models too late in their training, after their career choices have been made.

Since 2004 about 10% of each year’s graduating class of medical students who choose a residency in internal medicine or family medicine have indicated an interest in pursuing geriatrics.⁴ But residency programs seem to deter many potential geriatricians: In internal medicine, of the 2,638 residents who took the IM-ITE, only 1.3% indicated they were planning to pursue a career in geriatrics.⁵ These numbers point to opportunities as well as challenges. There is a larger potential pool of students and residents interested in geriatrics than many are aware of. But to encourage and sustain their interest, geriatrics must be a respected, valued career choice for doctors.

The Institute of Medicine’s April 2008 report, Retooling for an Aging America: Building the Health Care Workforce,⁶ acknowledges that "as the population of older adults grows to comprise approximately 20 percent of the U.S. population, they will face a health care workforce that is too small and critically unprepared to meet their health needs." If aging Americans are to continue to stay in the best health possible, bold initiatives designed to "boost recruitment and retention of geriatric specialists and health care aides" are needed. According to the report, "Geriatric specialists are needed in all professions not only for their clinical expertise, but also because they will be responsible to train the entire workforce in geriatric principles."

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Geriatrics Recruitment in the Context of the Formal, Informal, and Hidden Curriculums
Given the uneven incentives for pursuing a career in geriatric medicine cited above, it is important for those charged with recruiting into geriatrics to understand the multiple points at which students can be influenced in their career choices. What leads to trainees’ waning interest in geriatrics as they progress through their medical training can be considered in the context of what Hafferty ^{7, 8} has conceptualized as the formal, informal, and hidden curriculums within medical education.

The Formal Curriculum is the group of explicit goals and objectives for a specific set of skills that students need to master to become a physician. The extent to which geriatrics is included in the formal curriculum for medical trainees varies widely. The Hartford CoEs and the Donald W. Reynolds Foundation Aging and Quality of Life grant programs are making considerable progress in integrating geriatrics into the formal curriculum for medical students and residents. Some examples of CoE formal curriculum for medical students are highlighted in this manual. These educational activities can provide a valuable means of geriatrics recruitment by exposing trainees to positive role models and clinical experiences that help to dispel common misconceptions about caring for older adults and to reinforce the unrecognized positive aspects of working in geriatrics.

Underlying the formal curriculum is the Informal Curriculum— the unscripted, predominantly ad hoc, and highly interpersonal form of teaching and learning that takes place among and between faculty, fellows, residents, and students. It usually occurs outside of formal learning environments. The informal curriculum is communicated primarily through role models, and deeply influences trainees’ values, professional identities, and career choices.

Many CoE recruitment efforts have focused on communicating the positive aspects of geriatrics through the informal curriculum, not only to trainees but to faculty and medical school administrators as well. Some of these approaches are described in this manual.

The Hidden Curriculum is defined as a set of influences that function at the level of organizational structure and culture. It is what the leaders of the institution most value. There are four components to the hidden curriculum:^7,8,9

1. Institutional polices
2. Evaluation activities
3. Resource allocation
4. Institutional "slang"

The hidden curriculum impacts both the formal and informal curriculums. Medical school leaders have objectives for the institution that lead to an emphasis on what is taught and valued. For example, when a new initiative in a medical school is announced, there are undertones to that announcement that convey what is valued. Leaders may offer incentives to those who help to meet these objectives.

Negative attitudes about the field of geriatrics are often communicated to trainees by medical school faculty and leaders. As a result, an important strategy to recruiting and retaining trainees in geriatrics has been to increase nongeriatrics faculties’ appreciation of geriatrics as a discipline. Further, when geriatrics is integrated into all four years of a medical school curriculum or is a required rotation for residents, the message is that the field is valued by the institution at large. As noted, many CoE activities are focused on increasing geriatrics training throughout the medical school curriculum. These efforts can influence the hidden curriculum as well as the formal and informal curriculum, all of which have the potential to enhance recruitment of trainees to geriatrics.

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Where to Focus Geriatrics Recruitment Efforts
Geriatric medicine professionals who are assigned the task of recruiting the next generation of geriatricians need to keep the formal, informal, and hidden curriculums in mind as they develop recruitment efforts. They should seek opportunities to increase awareness of the hidden curriculum among faculty, students, and trainees, and make the case for geriatrics. For example, they can:

• Join the admissions committee. Geriatrics faculty can identify and support premedical students who already show an interest in geriatrics prior to medical school admission. The other committee members will in turn know to alert geriatrics faculty when they read a student statement indicating an interest in geriatrics. The geriatrics faculty can also advocate for premedical students with geriatrics interest during the selection process.
• Speak with the Dean of Admissions about the growing older adult population and the critical need to identify and support students with an interest in geriatrics.
• Join faculty committees such as the medical education committee. The interaction with faculty in other specialties raises awareness about and increases the stature of geriatrics, and offers opportunities to influence the school’s hidden curriculum. For example, when a student mentions to another committee member his/her interest in caring for older adults, the committee member will refer the student to the geriatrics faculty member. Having geriatrics faculty on the medical education committee also enables geriatrics teaching to be infused throughout different aspects of the medical school curriculum and enables the other medical specialties to see the value added aspect of geriatrics.
• Join the internship selection committee. This can enable the geriatrics faculty to identify and support medical students who already show an interest in geriatrics. The geriatrics faculty is also present at the rank list meeting to act as an advocate for students who show an interest in geriatrics.
• Meet with the local internal medicine and family medicine program directors and offer to give lectures in geriatrics or allow their residents to rotate through the geriatrics program.
• Be aware of the possibility of “losing” students at the transition points between levels of training. There are four main transition points for promoting positive models of geriatrics and recruiting students. Approaches to each of these are included in this manual.

• Premedical to Medical School
  Connect early on with students who demonstrate an interest in geriatrics and foster that interest. Make sure that the geriatrics program is visible to applicants as an important and attractive feature of the medical school.
• Preclinical to Clinical Years
  Provide opportunities for students to have exposure to geriatrics throughout the first and second years of medical school, e.g., encourage students to apply for the Medical Student Training in Aging Research (MSTAR) Program. Remain in contact with and foster these students throughout all of their clinical rotations. This leads to good will about geriatrics that students communicate to their peers.
• Medical School to Internship
  This may be the most critical transition, during which promising students in geriatrics may fall through the cracks due to competing priorities and the challenges of internship. Help students through the internship application process by listening to them discuss their specialty choice, reading their essays, and writing letters of recommendation. When students receive their match, provide them with the geriatrics faculty contacts at their residency program, and contact the geriatrics faculty to alert them that the student is entering a residency at their school.
• Residency to Fellowship
  Support residents throughout their clinical rotations by listening to their concerns about taking care of patients, providing positive exposure to the care of older patients, and helping them choose a fellowship.

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References
1. Cravens, DD, Campbell, JD. Mehr, DR. Why geriatrics? Academic geriatricians’ perceptions of the positive, attractive aspects of geriatrics. Family Medicine 2000;32(1):34-41.
2. Leigh, JP, Kravitz, RL, Schembri, M, et al. Physician career satisfaction across specialties. Arch Intern Med 2002;162:1577-1584.
3. Association of Director of Geriatric Academic Programs Status of Geriatrics Workforce Study. Training and Practice Update. May 2008. www.americangeriatrics.org/adgap/adgapTandP_update.pdf. Accessed August 15, 2008.
4. Association of American Medical Colleges. 2006 Medical School Graduation Questionnaire. http://www.aamc.org/data/gq/allschoolsreports/2006.pdf. Accessed August 15, 2008.
5. West, CP, Popkave, C, Schultz, HJ, et al. Changes in career decisions of internal medicine residents during training. Ann Intern Med. 2006;145:774-779.
6. Institute of Medicine Committee on the Future Health Care Workforce for Older Americans. Retooling for an Aging America: Building the Health Care Workforce. April 2008. www.iom.edu/agingamerica. Accessed August 15, 2008.
7. Hafferty, FW. Beyond curriculum reform: confronting medicine's hidden curriculum. Acad Med. 1998 Apr;73(4):403-7.
8. Hafferty, FW, Franks, R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994 Nov;69(11):861-71.
9. Suchman, AL, Williamson, PR, Litzelman, DK, et al. Toward an informal curriculum that teaches professionalism: Transforming the social environment of a medical school. J Gen Intern Med 2004;19 501-504.

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