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Ambulatory Geriatric Care Rotation for Third-year Medical Students and Internal Medicine Interns

at the Wake Forest University School of Medicine

SUMMARY

Target Audience
Third-year medical students and Internal Medicine interns

Purpose
To provide valuable learning opportunities in the care of older patients prior to the time when medical trainees’ career choices have been set

Program
A mandatory one-month rotation in a variety of clinical settings: long-term care, home, hospice, primary care clinics, and consultative geriatrics clinics

History
The program began in 2000

Operating Costs
Faculty time

Outcomes
As of 2007, 192 students and 144 interns have completed this program. Students’ perceptions of the amount of geriatrics training have risen steadily over the last 3 years; upper-level internal medicine residents score in the 97th percentile for geriatrics on the in-training examination

Available Materials
Rotation Curriculum; Geriatric Lecture Series Schedule

For More Information
Hal Atkinson, MD, MS
Wake Forest University School of Medicine
(336) 713-8583
hatkinso@wfubmc.edu

Program Overview

A one-month rotation in the Acute Care for the Elderly (ACE) unit is required for all upper-level Internal Medicine residents. However, by the time many residents complete this rotation, their career paths have been set and post-residency training plans have been determined.

The one-month Ambulatory Geriatrics Experience Rotation was created in 2000 to reach students and interns before those critical career decisions are made, as a means to attract more medical trainees to careers in geriatrics. Because the strongest tool for attracting trainees to geriatrics is clinical role models, trainees develop relationships with outstanding geriatrician mentors during the rotation, while developing their core clinical skills.

This rotation was made mandatory for all Internal Medicine interns in 2007. Third-year medical students have previously been randomly assigned to participate in a two-week experience as part of their Ambulatory Internal Medicine rotation. The goal is to provide this experience for all third-year students.

The Rotation’s main goals are to:

dispel the common misconception that older patients receive the majority of their medical care in the inpatient setting
help students and interns develop an appreciation for the health care system for older people
integrate essential geriatrics knowledge and skills into medical trainees’ clinical practice, regardless of the ultimate specialty they choose.

Program Operations

Students are given the opportunity to provide care to older patients in a variety of clinical settings: long-term care, house calls, hospice, primary care clinics, and consultative geriatrics clinics. The program objectives are for participants to:

demonstrate communication and professional skills necessary to work productively with older adults
demonstrate sensitivity to patient preferences and cultural backgrounds
practice competent internal medicine for older people (expectations adjusted for student or resident status)
demonstrate knowledge of and attentiveness to geriatric syndromes
demonstrate a rational approach to drug prescribing in the older adult
identify the basic structure, financing, and challenges of the health care system for older people, including transitions of care between settings.

The Ambulatory Geriatrics Experience rotation includes the following:

Geriatric Memory Assessment Clinics: Within the weekly clinic, learners observe neuropsychological testing and learn from the geriatrics attendings and fellows how to differentiate between various types of cognitive impairment, address safety concerns, and administer pharmacological and nonpharmacological aspects of treatment.
Primary Care Outpatient Clinic: Learners work with geriatrics attendings, fellows, and a geriatric nurse practitioner. Third-year medical students progress from shadowing to active evaluation, while more advanced learners practice history-taking, physicals, and medical decision making.
Physician's House Call Program: During weekly house-call visits with the geriatrics fellows, learners get a first-hand glimpse of the patient’s home environment. During orientation, learners are asked to evaluate social settings and pay particular attention to care strategies that disabled patients and their families use to remain at home. This allows students to see not only the medical but also the social aspects of geriatric care.
Long-Term Care (Nursing Home and Assisted Living): Learners conduct weekly rounds at various long-term care facilities. They are encouraged to read hospital discharge summaries and use them to guide their decision making. Students also learn the common pitfalls encountered when patients make the transition to a long-term care setting and the importance of appropriate discharge summaries. Students participate in case-based discussions led by the attendings. They attend lectures on how to determine the appropriate level of care for patients, health care financing, and long-term care issues, such as caring for chronic wounds, reducing polypharmacy, and addressing advanced directives.
The ACE Transition Program: Learners and the geriatrics fellow make an investigative visit to a patient who has been discharged from the ACE unit. The ACE team has daily interdisciplinary meetings where cohesive discharge plans are discussed and implemented. The ACE Transition Program visit helps to determine how well the patient is making the transition to home; to assess the need for subacute or acute rehabilitation or hospice from the inpatient setting; and to assess how the individual patient and caregivers are coping. For example, when a patient is discharged from the hospital to rehabilitation at a nursing home for the first time, the information gathered from the ACE Transition Program visit is presented to the interdisciplinary ACE team on a weekly basis. In this way, teaching rounds focus on continuous quality improvement and interdisciplinary education.
Didactic Teaching: Learners participate in the ongoing Geriatrics lecture series, which includes topics such as wound care, rehabilitation, theories of aging, cognitive behavior therapy, and falls. Students and residents are also active participants in a bimonthly Journal Club, and residents work together to present a journal article each month. A notebook of readings is also provided to each trainee, containing material from the American Geriatrics Society Geriatrics Review Syllabus and additional core reading material on levels of care, health care financing, and individual geriatric syndromes. A goal for the next year is to develop electronic modules with associated prerecorded “minilectures” to supplement the ongoing lectures and provide consistency of learning for each rotating trainee.
Pre- and Post-test: A knowledge-based multiple choice and fill-in-the-blank test is given at the beginning and the end of each rotation.
Research Opportunities: Learners, particularly fourth-year medical students, are exposed to the ongoing research within the Sticht Center on Aging and are encouraged to develop research projects.

The curriculum was written in accordance with Accreditation Council for Graduate Medical Education guidelines for competencies in patient care, medical knowledge, practice-based learning and improvement, interpersonal skills and communication, professionalism, and systems-based practice.

Staffing Requirements

All six clinical geriatrics faculty participate in some aspect of the Ambulatory Geriatrics Experience rotation, including the nursing home medical director; the clinic director, as preceptor for the outpatient clinics; and the ACE attending who facilitates the interdisciplinary team meeting and the ACE Transition Program reports. An administrative staff member handles all the scheduling for the rotation (10% effort).

Additionally, PhD faculty participate actively in Journal Clubs, the Aging Conference, and the Core Conference Series.

Program Costs and Funding Sources

The medical school provides financial support to cover approximately 5 -10% of each faculty member's effort. The medical school also recognizes teaching excellence for faculty devoted to medical student education, which can be used as part of the published promotion process.

Process and Outcomes Data

Students’ perceptions of the amount of education in geriatrics have steadily risen over the last three years, as measured by the American Association of Medical Colleges (AAMC) graduation survey. The in-training examination results for geriatric medicine have also steadily risen over the last three years: upper-level internal medicine residents score in the 97th percentile for geriatrics.

Students rate the Ambulatory Geriatrics Experience rotation, the outpatient clinic, the nursing home, the consultation clinic, house calls, and the ACE Transition Program on a scale of 1 (very poor experience) to 10 (very best experience ever). They can also indicate what they liked and didn’t like about their experience. Students can also evaluate specific faculty attendings, fellows, nurses, mid-level practitioners, etc. Of the feedback from 40 interns between 2006 and 2007, the average rating was 7.83/10.

A dedicated tracking system is planned to quantify the outcomes of the program and track future careers in geriatrics. There is also a plan to include a reporting system to identify students who choose a career in geriatric medicine.

Implementation Lessons

The feedback provided by learners through their evaluations continually informs the rotation curriculum. Feedback has been generally positive. The ACE Transition Plan portion is the newest addition to the AGE rotation and has received varied responses from "very interesting to see how people actually live" to "sometimes we travel to unsafe places." The Geriatrics Primary Care Clinic uniformly receives praise, and learners express the desire to spend more time there.
It is essential to have “champions” among the institution. The program has outstanding support from the Internal Medicine Residency office, the Residency Program Director, and the coordinator for the Ambulatory Internal Medicine rotation for third-year medical students. The positive feedback and the institutional support have been leveraged to make the Ambulatory Geriatrics Experience rotation mandatory for all Internal Medicine residents.

Available Materials

Tools/Resources

For More Information

Hal Atkinson, MD, MS
Assistant Professor
Section on Gerontology and Geriatric Medicine
J. Paul Sticht Center on Aging
Wake Forest University School of Medicine
Winston-Salem, NC 27157
(336) 713-8583
hatkinso@wfubmc.edu

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