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Confronting Ageism: The Maturing of Medical School Curricula
by Joy Hought
Geriatric Times November/December 2002 Vol. III Issue 6
Stereotypes of the elderly as frail and medically burdensome continue to impact medical students' interest in caring for them. Such ageism must be confronted if American medical schools are to produce enough physicians with skills in geriatrics to meet the demands of aging baby boomers. Today more than 50 of the country's 126 medical schools offer a geriatric curriculum, up from just 14 in 1996. While this represents an enormous improvement in exposing students to older patients, research suggests most medical graduates are still leaving school with misperceptions about the elderly intact.
Negative stereotypes about aging tend to be "related to seeing the oldest and sickest segments of the aging population, and encountering what often seem insurmountable challenges in their care," Marie Bernard, M.D., professor and chair of the Donald W. Reynolds Department of Geriatric Medicine at University of Oklahoma College of Medicine, told Geriatric Times. Those students who have the opportunity to work with the elderly often do so in university hospitals, where patients are admitted for acute care. Students are rarely exposed to healthy elders living in the community.
These observations led Bernard and her colleagues to investigate how interactions with healthy elders impacted students' attitudes toward aging. In the controlled, prospective, longitudinal trial, each of 131 entering medical students was paired with a "senior mentor" (Bernard et al., 2001). For the first two preclinical years, students were required to perform a structured interview of their mentor once per semester.
Students' attitudes were measured using the Aging Semantic Differential (ASD) scale at entry and at the end of the second year of medical school; scores were then compared to students from the previous graduating class. At two years, students in both the control and mentor groups showed improved ASD scores, but the increase was significantly greater for mentor students (mean change 0.17 versus 0.40, p=0.002). This increase remained after controlling for student age, sex, prior visits to a nursing home, prior experience working or volunteering in an old-age environment, and a prior course on aging.
Students spent a total of 12 hours over two years in the curriculum. "Our results suggest that it does not require much curricular time to have an impact on the attitudes of medical students about aging individuals," said Bernard.
Bernard and colleagues noted it was unclear whether the changes would survive students' clinical years. In fact, clinical rotations have been found to be a major culprit in reinforcing negative stereotypes (Brooks, 1993; Deary et al., 1993; Reuben et al., 1995).
"There is some evidence that entering medical students have a high interest in older persons, but that interest drops precipitously in the third and fourth years of training," Thomas Teasdale, Dr.P.H., assistant professor at Baylor College of Medicine and the Huffington Center on Aging, explained in an interview with GT.
Teasdale is on a team documenting the specific ways geriatric care is devalued during clinical training. They surveyed all third- and fourth-year students at Baylor College of Medicine (n=57 responses) and University of Texas at Houston Medical School (n=66 responses) (Triana and Teasdale, 2002).
The results of their study confirmed the presence of a "hidden curriculum": negative stereotypes were not explicitly fostered by the curriculum or condoned by the faculty, yet students informally received an ageist message. Older individuals were given appropriate attention, but geriatrics as a field was either passed over or devalued. Students noted that older patients were characterized as taking longer to care for than younger patients, and the majority also noted that taking an elective in a geriatric community practice seemed less attractive after rotations.
Several respondents reiterated their own lack of knowledge in geriatrics and end-of-life issues. Others complained of lack of compliance, too many concurrent medical problems and the presence of dementia in geriatric patients. Most respondents perceived that these factors add up to more work and more time than younger patients.
And the source of such negative views? House staff, residents and attending physicians. One student reported hearing attendings make comments such as, "They're x years old and they've lived a full life -- make him or her DNR." Respondents ranked the house staff as the most frequent source of negative reinforcement. Students noticed that some house staff disregarded certain symptoms because patients were old, and that they appeared "tired of dealing with chronic patients." House staff also routinely made derogatory comments -- not necessarily about patients, but about geriatrics as a field.
"Devaluing careers in the care of older persons can only reduce the potential pool of geriatricians," said Teasdale. "We need to develop better ways of reversing negative attitudes."
Emily Triana, the fourth-year medical student who led the study, was not surprised by students' responses. "When a medical student is exposed to patients on the wards for the first time, the first counsel on how to treat those patients comes from observing or listening to their attending, resident and even house staff members," she told GT.
"I hope that our results will start a trend in making residents, attendings and house staff more aware of the messages they are conveying to students about geriatric patients. As this occurs, hopefully more programs will begin instituting orientations or programs in which attendings, in particular, are taught how to introduce medical students to the geriatric patient," she said.
Positive impressions of geriatric care were also reported, and the source was overwhelmingly geriatric patients themselves. Many students expressed satisfaction dealing with a population they felt most people ignored, and they were touched by patients' gratitude.
Regardless of whether students left with better or worse opinions of the elderly and geriatrics, 75% of respondents reported that they felt more comfortable dealing with elderly patients than they did before they began clinical rotations. Exposure to the complexity of patients' needs taught them to deal with multiple problems systematically and not be intimidated by them, the study found.
"[Elderly] patients' complex problems can very quickly come to be seen as the student's problems as well, if the attitude toward the patient is not the right one," said Triana. She described an attending on her own rotation who had a positive impact on fellow students: "He acknowledged the fact that this patient had more problems than many of the students were used to seeing. However, he also told them that they couldn't think of themselves as the solution to all this patient's problems. They had to primarily concentrate on one problem, fix that one, and then move on to the next. And, to the elderly patient, the loving care and attention you give to even one of their problems makes a world of difference to them."
Triana attributes her own positive approach to having worked with geriatric patients under the guidance of an enthusiastic mentor. "Being around someone that loves what they do is contagious," she said. And contagion has never been more necessary. As more geriatricians are trained, more become teachers and can excite more medical students about the field.
"Plus," Triana concluded, "This is one field that certainly will have a job market once the resident begins to practice!"
Research efforts in geriatrics are increasing worldwide to help dispel the myths that contribute to low recruitment. Between the John A. Hartford Foundation and the Donald W. Reynolds Foundation, over 40 U.S. medical schools have received grants to create mandatory geriatrics curricula and improve medical student education in geriatrics, according to David Reuben, M.D.
Reuben is director of University of California, Los Angeles, Multicampus Program in Geriatric Medicine and Gerontology and director of the UCLA Claude Pepper Older Americans Independence Center. In an interview with GT, he agreed there is a tremendous momentum for innovation in geriatrics education. "Physicians-in-training need to see that there is a future in geriatrics. For those who want to be geriatrician-researchers, they need to know that the National Institute on Aging and other agencies and foundations have enough funds to support their research. For those who want to be geriatrician-educators, they need to see geriatricians in prominent roles at their medical schools," Reuben said. "For those who want to be clinical geriatricians, they need to know that a practicing geriatrician can make a reasonable living and work in an environment that facilitates the practice of high-quality geriatrics care."
References
Bernard MA, McAuley WJ, Neal KS, Belzer JA (2001), The impact of exposure of medical students to healthy elders. Poster 410. Presented at the American Geriatrics Society annual meeting. Chicago; May 9-13.
Brooks TR (1993), Attitudes of medical students and family practice residents toward geriatric patients. J Natl Med Assoc 85(1):61-64.
Deary IJ, Smith R, Mitchell C, MacLennan WJ (1993), Geriatric medicine: does teaching alter medical students' attitudes to elderly people? Med Educ 27(5):399-405.
Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M (1995), Attitudes of beginning medical students toward older persons: a five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group. J Am Geriatr Soc 43(12):1430-1436.
Triana EM, Teasdale TA (2002), Determination of the extent of ageism from an informal curricula in the medical schools at the Texas Medical Center. Poster 441. Presented at the American Geriatrics Society annual scientific meeting. Washington, D.C.; May 8-12.
