Discussion Relating to the “When” and “Where” of Geriatric

In the analysis of NOSM’s undergraduate curriculum objectives, it was revealed that students were formally exposed to less than one quarter of the Canadian Geriatrics Society’s recommended core geriatric competencies during their first year, and even fewer during their second year, and fourth year which consisted of clinical rotations in the regional hospitals of Sudbury and Thunder Bay. The bulk of the competencies were met during the students’ third year. Consequently, NOSM students are not formally exposed to a significant portion of geriatric competencies, in accordance to stated course objectives, until they begin their Comprehensive Community Clerkships during their third year.

Literature indicates that early clinical exposure to geriatric medicine and older adults is beneficial in training undergraduate medical students in the care of the elderly (Duque, Gold & Bergman, 2003; Lally & Crome, 2007; Wilkinson, Gower & Sainbury, 2002). Early exposure is said to facilitate an improved understanding of knowledge, assist in the development of clinical skills, and within the proper context, promote positive attitudes toward older individuals (Duque, Gold & Bergman, 2003; Wilkinson, Gower & Sainsbury, 2002). Further,

Littlewood et al. (2005) articulated that early exposure in clinical and community settings is a means by which to “foster a socially responsive career orientation” (p. 389), and in the interest of this project, perhaps a receptiveness to geriatric medicine. In addition to influencing students’ understanding of subject matter and refining clinical skills, Littlewood et al. (2005) stated that early exposure in clinical and community settings can nurture student empathy toward patients, develop their self awareness and confidence, respond to their feelings of uncertainty, and assist them in acquiring insight into the social issues of ‘real people’ within the communities they train. The opportunity for students to acquire early experience in clinical and community settings is evident within NOSM’s undergraduate curriculum, as students spend four weeks studying in an Aboriginal community at the end of their first year and a total of eight weeks studying in a small rural community during their second year. In respect to fostering community awareness, NOSM does exceedingly well. A notable strength of the curriculum is its capacity to impart the realities, in a broad sense, of the communities the school serves. The theme of Northern and Rural Health was found to be clearly visible throughout the entire curriculum.

A medical student’s initial exposure to an elderly person most typically occurs in the setting of a hospital or long-term care facility (Varkey, Chutka & Lesnick, 2006; Westmoreland et al., 2009). In these settings, the elderly are often acutely ill, they may have several chronic conditions, be on multiple medications, confused as a result of delirium, or cognitively impaired (Varkey,

Chutka & Lesnick, 2006; Westmoreland et al., 2009). “For an inexperienced medical student, elderly patients with complex medical problems can be frightening, frustrating, and at times, overwhelming” (Varkey, Chutka & Lesnick, 2006, p.227). Unfortunately, the initial exposure to these frail elderly can negatively influence a student’s perception of growing old (Westmoreland et al., 2009).

It has been repeatedly stated in the literature that medical students’ exposure to older individuals in a variety of environments, outside of the traditional hospital setting is an effective venue for improving attitudes and sensitivity to geriatric issues (Adelman, Hainer, Butler, & Chalmers, 1988; Eleazer, Doshi, Wieland, Boland & Hirth, 2005; Fitzgerald et al., 2003; Freter, Gordon & Mallery, 2006; Golden et al., 2010; Jogerst & Hartz, 1999). Home visits to seniors living independently in the community or semi-independently in retirement homes and assisted living settings have been found to not only increase comfort levels in being with seniors, but also to increase the awareness of community resources and areas of rehabilitation (Eleazer et al., 2005; Jogerst & Hartz, 1999). Furthermore, exposure to those who have made positive adaptations and continue to function independently, allow students the occasion to appreciate the strengths of older adults (Robinson & Rosher, 2001). Eleazer et al., (2005) imply that the utilization of the alternative teaching sites of retirement homes and assisted living settings could serve as prerequisites to caring for the elderly in long-term care facilities, given that the former locations

enhance student comfort levels with the elderly. Nondidactic clinical experiences during the clerkship years in ambulatory and acute care settings were also found to increase students’ comfort in caring for older patients (Eleazer et al., 2005). Awareness surrounding the context of training is important. Diachun, Hillier and Stolee (2006) cite the significance of medical students having the opportunity to interact and form relationships with older patients. It has been recognized that certain environments are more conducive to enhancing relationships than others (Chodosh et al., 1999). Hospital based experiences were perceived as a barrier to establishing relationships as compared to opportunities in ambulatory care settings (Chodosh et al., 1999).

In regard to the specific location or “where” of geriatric competencies within the undergraduate curriculum, it was noted that 15 of the 20 recommended competencies were dispersed throughout NOSM’s four year program in various teaching settings. According to Supiano, Fitzgerald, Hall & Halter (2007), it is not at all uncommon for medical education objectives to be presented throughout the entire undergraduate curriculum as opposed to one discrete course. Yet “the distributed nature of this content imposes a number of challenges, including student identification of this content and the appropriate evaluation of student performance” (Supiano et al., 2007, p.1650). That being said, there are advantages to integrating objectives in this manner. Integrating objectives vertically, or across all years of the curriculum allows for an increase in time dedicated to a given topic because learning objectives can be incorporated into

more than one existing course (Eleazer, Egbert, Caskey, Egbert & Hornung, 1994; Eleazer et al., 2006). In turn, incorporating objectives across multiple courses can improve student knowledge and retention of concepts (Sinclair, Skoll & Ubhi, 2007). Favorably, the analysis of NOSM’s undergraduate curriculum did reveal that many of the Canadian Geriatrics Society’s recommended competencies were listed in the stated objectives of multiple courses. The ultimate goal is to ensure that all recommended geriatric competencies are present in multiple themes across the entire curriculum.