Medical students taking a mandatory rotation in geriatrics

What happens when you randomly assign medical students to either a mandatory two week rotation in specialized geriatric training or to a traditional non-geriatric clerkship that sees a lot of old people?

Will there be any difference in the knowledge of geriatric conditions, the attitudes toward older adults, or geriatric clinical skills between the two groups?  Or does mere exposure to an aging patient population give students the training they need to care for older patients? These are the questions asked by Laura Diachun and colleagues in a recent article published in Academic Medicine.

The authors randomly assigned 262 Canadian medical students over the course of two years to complete either a clerkship year containing a two-week rotation with a combined geriatric medicine/geriatric psychiatry focus, or to a normal “But I Already See Old People” clerkship year. The geriatrics rotation included working with geriatric medicine and psychiatry specialists in various inpatient and outpatient clinics and community settings, as well as receiving small group teaching sessions on geriatric topics from faculty in geriatrics, social workers, physiotherapists, occupational therapists, and pharmacists. The “But I Already See Old People” control arm of the study did a two-week rotation in otolaryngology/ophthalmology and continued to evaluate and manage older adults throughout their usual clerkship rotations.

The study used a pre/post testing prior to and after the students clerkship year to assess to knowledge and attitudes in geriatrics. The authors also used a objective structured clinical examination (OSCE) five months after the conclusion of the clinical clerkship to test clinical skills.

The baseline knowledge scores on tests of geriatric knowledge and attitude didn’t differ significantly between the two groups. Post-clerkship knowledge of geriatrics was significantly better in the geriatrics rotation group than the “But I Already See Old People” group. Self-reported clinical practice also was improved in the geriatrics group with more reporting completing tasks like a Mini-Mental Status Examination (MMSE) on a greater number of older patients. The geriatrics group also scored significantly higher than the “But I Already See Old People” group in the observed structured clinical exam, and had a higher pass rate (95%) than did those in the control group (78%). Interestingly, both groups experienced a worsening of their attitude toward older adults over the course of their respective clerkships, with little difference between the two groups.

Overall I thought the authors did a nice job debunking the assumption that geriatrics can be effectively taught by mere exposure to old people.  Those with specialized geriatric training do acquire more knowledge and demonstrate better skills in geriatrics than those without this training. This study should serve as a stimulus for medical school to rethink how we will train the physicians of the future on how to care for an aging population.

The only question for me is why attitudes toward older adults worsened for both groups over the course of a one year clerkship and what can we do to remedy this.

Eric Widera is an Assistant Professor of Medicine, Department of Medicine, Division of Geriatrics at the University of California, San Francisco, who blogs at GeriPal.

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  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    I wonder if the same argument could be made about mandating a rotation through pathology. Most medical students could probably say they already see a bunch of dead people on their normal rotations.

  • Anonymous

    The only question for me is why attitudes toward older adults worsened for both groups over the course of a one year clerkship and what can we do to remedy this.

    Could it be that this is due to selection bias? The old people most frequently seen in the doctor’s office or hospital are probably the sickest compared to the general population, and are more likely to have had a lifetime of unhealthy habits and current unwillingness to change such habits. The healthy ones might come in once every year or few, between running marathons, outlifting the young kids in the weight room, and chasing their grandchildren, so they are less frequently seen than those who come in every few weeks for some problem or to get some of their many prescriptions refilled.

  • alex

    This seems like a biased study. Why in the world would you expect ENT/ophtho to be the control group versus geriatrics? An appropriate control would have been general internal medicine or FP. I’m guessing that wouldn’t have given the desired results for the authors.

  • PAULMD

    Between 3 months of medicine and a month of Home Medical Service (required), any more geriatrics and I may have slit my wrists in med school. If it is your intention to specialize in caring for the needs of the elderly in a comprehensive manner, sounds like a very responsible direction in continued training.

    The chief of internal medicine at my school (my ward attending) called me to his office and asked if he could write me an unsolicited letter of recommendation for me and strongly suggested that I apply for Internal Med. residencies.

    I told him that I was very appreciative of his offer but that I was going to pursue a surgical specialty. Frankly, I didn’t think that I was a very strong internal med student so I was curious about his praise.

    I told him that I felt like I just spent three months documenting the demise of folks that just didn’t know that they were dead yet and that I did not like “consulting” another service when we needed something done. He smiled and noded. He said I was making a mistake but said he would, “defend to the death my right to be wrong” and wrote me a great letter anyway.

    I have never forgotten that meeting almost 20 years ago. What I did take away from it was that someone that I liked and respected thought highly of me. If you knew me, that didn’t happen a lot. I banked it my “self confidence file” and think about it sometimes in moments of doubt.

    I did trust my instincts about selecting my course in training and have been about as happy and satisfied as I can personally be. I would have been miserable in internal medicine but more importantly, I would have been a miserable internal medicine doctor.