Medical Student Training in Geriatrics Model Program in the Osteopathic Profession Anita Chopra, MD, FACP, AGSF Professor and Director of Education and Clinical Programs New Jersey Institute for Successful Aging UMDNJ-School of Osteopathic Medicine

The Aging Imperative in Medical Education Our nation’s aging population is growing dramatically Our nation’s aging population is growing dramatically 35.6 million million million million is the fastest growing segment of the entire population 85+ is the fastest growing segment of the entire population 4 million million by million million by population represent 50% of all ambulatory care visits to primary care physicians population represent 50% of all ambulatory care visits to primary care physicians 1 The old-old consume 50% of Medicare dollars The old-old consume 50% of Medicare dollars 1 Centers for Disease Control and Prevention, NCHS, National Ambulatory Care Survey, 2002

The Aging Imperative in Medical Education 20% of the Medicare population has at least five chronic conditions and visits 14 different physicians in 37 office visits each year 2 20% of the Medicare population has at least five chronic conditions and visits 14 different physicians in 37 office visits each year 2 There are fewer than 7,000 certified geriatricians falling significantly short of the current need of 14,000 and the projected need of 36,000 by There are fewer than 7,000 certified geriatricians falling significantly short of the current need of 14,000 and the projected need of 36,000 by Less than 2% of graduating physicians seek careers in geriatric medicine 4 Less than 2% of graduating physicians seek careers in geriatric medicine 4 2 Berenson, RA & Horvath, J. Confronting Barriers to Chronic Care Management in Medicare. Health Affairs. 2003; W Medical Never-Never Land : Ten Reasons Why America Isn’t Ready for the Coming Age Boom. Washington, DC, Alliance for Aging Resource, Medical Student Training in Geriatrics at the Begiining of the 21 st Century, ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine, October 2003

“Too often, illnesses in older people are misdiagnosed, overlooked or dismissed as the normal process of aging, simply because health care professionals are not trained to recognize how diseases and drugs affect older patients differently than younger patients. All of these situations potentially could translate into suffering by patients.” Geriatric Medicine: A Clinical Imperative for an Aging Population, A Report from the American Geriatrics Society and ADGAP, October 2005

Training the future providers of geriatric care …. Are we on the right road?

Academic Geriatric Programs in Osteopathic Medical Schools Academic units Academic units 3 Free standing Departments of Geriatrics 3 Free standing Departments of Geriatrics 1 Center/Institute 1 Center/Institute 9 Divisions of Geriatrics 9 Divisions of Geriatrics 3.1 FTE’s median # of faculty working in academic geriatrics 3.1 FTE’s median # of faculty working in academic geriatrics 20% is median time spent on medical student teaching 20% is median time spent on medical student teaching ISH ADGAP Database Project. Survey of Directors of Geriatric Academic Programs in U.S. Osteopathic Medical Schools. Spring (n=10, 50% response rate) survey data used for schools who did not respond

Academic Year # Responding Part of Existing Required Course Separate Required Course Separate Elective Course Do Not Offer (86%) 8 (7%) 0 (0%) 5 (4%) (93%) 10 (8%) 68 (54%) 0 (0%) AAMC Survey of Medical Schools Teaching Geriatric Topics

All Schools InadequateAppropriateExcessiveCount %67.1%3.8%11, %57.5%3.9%14, %70.3%5.2%9,610 AAMC Medical School Graduation Questionnaire Do you believe that the time devoted to instruction in Geriatrics was adequate, appropriate or excessive?

UMDNJ-SOM Model Geriatric Program Established in 1989 as a free standing Center for Aging at UMDNJ-SOM Established in 1989 as a free standing Center for Aging at UMDNJ-SOM Evolved to a statewide New Jersey Institute for Successful Aging in Evolved to a statewide New Jersey Institute for Successful Aging in Interdisciplinary faculty and clinical services Interdisciplinary faculty and clinical services Geriatric Medicine Geriatric Medicine Geriatric Psychiatry Geriatric Psychiatry Geriatric Neurology Geriatric Neurology Ranked among the top 20 Best Graduate Schools in Geriatric Medicine for six consecutive years Ranked among the top 20 Best Graduate Schools in Geriatric Medicine for six consecutive years  Gerontological Nursing  Geriatric Social Work  Neuropsychology

Geriatric Curriculum Across the Years Integrated Coursework – Yr 01 and 02 Integrated Coursework – Yr 01 and 02 Required Geriatric Course – Yr 02 Required Geriatric Course – Yr 02 Required One Month Clerkship – Yr 03 Required One Month Clerkship – Yr 03 Elective Geriatric Rotation – Yr 04 Elective Geriatric Rotation – Yr 04

Geriatric Curriculum: Year 01 Integrated geriatric content Integrated geriatric content Genetics of Alzheimer’s disease Genetics of Alzheimer’s disease Biochemistry and age-related changes Biochemistry and age-related changes Neuroscience and the aging brain Neuroscience and the aging brain Pharmacology Pharmacology OMM: c riteria for use of OMT for specific at risk patients OMM: c riteria for use of OMT for specific at risk patients

Geriatric Curriculum: Year 02 Required Geriatric Course Required Geriatric Course Principles of Geriatric Medicine Principles of Geriatric Medicine Theories of Aging Theories of Aging Pharmacology and Drug Prescribing Pharmacology and Drug Prescribing Physiology of Aging Physiology of Aging Comprehensive Geriatric Assessment Comprehensive Geriatric Assessment Aging Society and Ethnogeriatrics Aging Society and Ethnogeriatrics Common Geriatric Syndromes Common Geriatric Syndromes Confusion: Dementias & Delirium Confusion: Dementias & Delirium Incontinence Incontinence Falls, Immobility and Pressure Ulcers Falls, Immobility and Pressure Ulcers Psychiatric disorders – agitation, psychotic disorders, depression and suicide Psychiatric disorders – agitation, psychotic disorders, depression and suicide

Geriatric Curriculum: Year 02 (continued) Integrated Coursework in Geriatrics Integrated Coursework in Geriatrics Introduction to Patient Dynamics Introduction to Patient Dynamics Death and Dying Seminar Death and Dying Seminar Pain Seminar Pain Seminar OMM OMM Bone pain Bone pain Abnormal AP curves including Dowager’s Abnormal AP curves including Dowager’s Vertebral compressions Vertebral compressions Normal and abnormal gait and preventing falls Normal and abnormal gait and preventing falls Parkinson’s disease Parkinson’s disease Simulated Cases Simulated Cases

Geriatric Curriculum: Year 03 One month Required Geriatric Clerkship Acute care – 2 weeks Acute care – 2 weeks Content Areas: Content Areas: Nosocomial infection and use of OMT for pneumonia and UTI Nosocomial infection and use of OMT for pneumonia and UTI Confusion Confusion Malnutrition Malnutrition Pressure Ulcers Pressure Ulcers Long term care – 1 week Long term care – 1 week Sites: Sites: Nursing homes and continuing care retirement communities Nursing homes and continuing care retirement communities Subacute Care Subacute Care Home and Hospice Care Home and Hospice Care Content Areas: Content Areas: OBRA OBRA Drug Prescribing Drug Prescribing Agitation related to dementia Agitation related to dementia Depression Depression Incontinence Incontinence

Geriatric Curriculum: Year 03 One month Required Geriatric Clerkship (continued) Ambulatory Care – 1 week Ambulatory Care – 1 week Experiences: Experiences: Primary care Geriatric Medicine Primary care Geriatric Medicine Geriatric Neurology Geriatric Neurology Geriatric Psychiatry and Neuropsychology Geriatric Psychiatry and Neuropsychology Case Management Case Management Family and team meetings Family and team meetings Specialty programs – Memory Assessment, Huntington’s Specialty programs – Memory Assessment, Huntington’s Content Areas: Content Areas: Comprehensive Geriatric Assessment: Function, Cognitive, Affective. Psychosocial Comprehensive Geriatric Assessment: Function, Cognitive, Affective. Psychosocial Health promotion Health promotion

 Interdisciplinary team conferences  Ethics Seminar  Quality of Life  Advance Directives  End of Life  Student Case Presentations  Falls  Dementia  Ethnogeriatrics  Heart disease  Substance Abuse  Polypharmacy  Online Case Studies  Required readings Geriatric Clerkship Curriculum

Geriatric Clerkship WebCT site

Geriatric Curriculum: Year 04 Elective rotations Elective rotations Geriatric Medicine, Neurology or Psychiatry Geriatric Medicine, Neurology or Psychiatry Tailored to individual student learning needs Tailored to individual student learning needs 2 – 4 week options 2 – 4 week options

New Directions 3-C Curriculum 3-C Curriculum Expand to a one month Geriatric Course in Year 02 Expand to a one month Geriatric Course in Year 02 Integration of basic science and clinical concepts Integration of basic science and clinical concepts Case-based learning Case-based learning Approach to the older adult and ethnogeriatrics Approach to the older adult and ethnogeriatrics Polypharmacy Polypharmacy Falls, Immobility and Iatrogenesis Falls, Immobility and Iatrogenesis Cognitive dysfunction Cognitive dysfunction New evaluation strategies New evaluation strategies OSCE OSCE Competency-based checklist across geriatric curriculum Competency-based checklist across geriatric curriculum

Student Voices…….. “ Nothing against geriatrics, but I did not expect to like this rotation at all. I was wrong. The faculty was excellent. I saw first hand the passion they have for their work and how rewarding caring for older adults can be.” “ Nothing against geriatrics, but I did not expect to like this rotation at all. I was wrong. The faculty was excellent. I saw first hand the passion they have for their work and how rewarding caring for older adults can be.” “ The clerkship provided an insight into the complicated care involved in geriatrics. It also highlighted the non-medical issues that have to be addressed with the elderly such as financial, social and housing issues.” “ The clerkship provided an insight into the complicated care involved in geriatrics. It also highlighted the non-medical issues that have to be addressed with the elderly such as financial, social and housing issues.” “ I think the most valuable aspect of my Geriatrics experience was being able to work with the team - the geriatrician, neuropsychologist and the social worker and then being able to work with patients in all the settings. Because I was afforded this experience, I have taken the philosophy of being fully immersed in all aspects all of my other rotations, making each rotation a better learning experience. Thanks for all of your hard work, dedication, organization and for making this an extremely worthwhile experience.” “ I think the most valuable aspect of my Geriatrics experience was being able to work with the team - the geriatrician, neuropsychologist and the social worker and then being able to work with patients in all the settings. Because I was afforded this experience, I have taken the philosophy of being fully immersed in all aspects all of my other rotations, making each rotation a better learning experience. Thanks for all of your hard work, dedication, organization and for making this an extremely worthwhile experience.” “ I liked how we received a well-balanced rotation getting a chance to experience inpatient, ambulatory and long term care settings. I also came to appreciate the expertise of the practitioners in the department. It was obvious that it is truly a Center of Excellence in Geriatrics.” “ I liked how we received a well-balanced rotation getting a chance to experience inpatient, ambulatory and long term care settings. I also came to appreciate the expertise of the practitioners in the department. It was obvious that it is truly a Center of Excellence in Geriatrics.”

For more information Contact: Anita Chopra, MD Director of Education and Clinical Programs, NJISA (856) or or Pamela Basehore, MPH Associate Director for Education, NJISA