Janet E. Gordon, MD, FRCPC
Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS.
A survey in 2005 determined the hours of mandatory geriatrics content in Canadian undergraduate and postgraduate medical curricula. The present survey was undertaken to update these data for 2008–9.
A survey was sent to a designated geriatrician at each medical school.
The mandatory geriatrics content of the undergraduate curricula ranged between 10 and 299 hours, with a mean of 82. Seven of 16 schools had a mandatory clerkship rotation of a least 1 week. Fourteen family medicine programs had a rotation in geriatric medicine and all psychiatry programs required a rotation in geriatric psychiatry. A geriatric rotation was mandatory for six internal medicine, six neurology, five physiatry, one orthopedic, and one emergency medicine program. In comparison to 2004–5, the mean hours of geriatrics teaching in the undergraduate curricula had increased from 78 to 82. However, two schools saw a decrease in preclerkship teaching and one school lost a 2-week clerkship. Postgraduate requirements had changed little overall, with the exception that, for emergency medicine, geriatrics was now mandatory for only one program, instead of three.
Although the total number of hours of teaching in geriatric medicine in the undergraduate curricula had increased slightly in 2008–9 compared to 2004–5, in some schools teaching hours were reduced. In the postgraduate curricula emergency medicine requirements for geriatrics were reduced. Of greater importance is determining which core competencies are being taught and mastered, and this is an area of ongoing study.
Key words: Canada, geriatrics education, medical education, postgraduate education, undergraduate education
With changing demographics, today’s medical students and residents will care for an increasing number of older patients, and thus they need to acquire the knowledge, skills, and attitudes to provide optimal medical care for these persons. A previous survey conducted for the 2004–5 academic year showed that there were limited hours devoted to geriatric medicine teaching in the undergraduate curricula of Canadian medical schools, and that there was a wide range between schools of 7 to 196 hours.(1) The number of schools with a mandatory clerkship rotation was declining, having been nine in 1998 and eight in 2004. Although geriatric medicine and geriatric psychiatry were requirements for almost all family medicine and psychiatry residency programs, respectively, only the minority of other subspecialty programs required a geriatric medicine rotation. Although elective opportunities were widely available, they were chosen by relatively few medical students or residents.
This present survey was conducted to update this information for the 2008–9 academic year.
A survey, almost identical to the one circulated in 2004–5, was developed (Figure 1, Figure 2). Ethics approval was obtained from the Capital Health Research Ethics Board (Halifax, Nova Scotia). For the preclinical years of medical school, geriatrics content was defined as the hours of lectures, tutorials, and laboratory or clinical skills sessions that were developed by internist geriatricians, geriatric psychiatrists, or family physicians with additional care-of-the-elderly training. Clerkship and residency rotations were differentiated between those in geriatric medicine (supervised by internist geriatricians or family physicians with additional training/expertise in care of the elderly) and those in geriatric psychiatry. A rotation was defined as mandatory if it was a requirement for every medical student or resident. “Other teaching” was defined as mandatory didactic teaching delivered by a geriatrician, care-of-the-elderly physician, or geriatric psychiatrist outside of a geriatrics rotation, such as an internal medicine half-day.
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FIGURE 1 Survey sent to medical schools requesting data on undergraduate teaching in geriatrics | ||
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FIGURE 2 Survey sent to medical schools requesting data on postgraduate teaching in geriatrics. PGY = postgraduate year | ||
A geriatrician was identified at each of the 16 faculties of medicine who would be responsible for completing the survey for his or her university. This person was encouraged to contact other individuals at the medical school whom she or he believed could most accurately provide the information requested. Responses were based on the 2008–9 academic year. The completed surveys were returned to the author, who tabulated the information and recontacted each geriatrician to confirm or clarify the data when necessary. The statistical means and medians were calculated using Microsoft Office (2004; Microsoft Corp., Redmond, WA, USA).
The response rate was 100%. All medical schools had geriatrics content in the preclinical years, as shown in Table 1. Hours ranged from 4 to 49 with a mean and median of 21. Seven of the 16 schools had a mandatory clerkship rotation of at least 1 week’s duration. Assuming 40 hours per clerkship week, the total mandatory hours of geriatrics teaching ranged between 10 and 299 with a mean of 82 hours and a median of 37. Most survey respondents stated that they could not be certain of the accuracy of the percentage of students completing electives during clerkship, but only four of the schools estimated that more than 20% of their students completed an elective/selective.
TABLE 1 Undergraduate curricula
For postgraduate training, all psychiatry programs required between 8 and 24 weeks of training in geriatric psychiatry and four programs mandated a rotation in geriatric medicine (Table 2). Fourteen of the 16 family medicine programs required a specific rotation in geriatric medicine. The other two schools had geriatric medicine content integrated throughout the longitudinal family medicine rotation. Six internal medicine programs required a rotation in geriatric medicine, and in the other 10 programs, between 5% and 95% of residents completed an elective (Table 3). Six of the neurology programs required a rotation in geriatric medicine, although in one university it was only 1 week in duration, and five schools estimated that over 50% of the neurology residents did an elective/selective in geriatric medicine. Five of 12 physiatry programs required geriatrics (Table 4). Geriatrics was a requirement for only one orthopedic and one emergency medicine program (Table 5).
TABLE 2 Postgraduate curricula: psychiatry
TABLE 3 Postgraduate curricula: internal and family medicine
TABLE 4 Postgraduate curricula: neurology and physiatry
TABLE 5 Postgraduate curricula: orthopedics and emergency medicine
Compared with 2004–5, the mean hours of preclerkship teaching increased from 18 to 21. In eight of 16 schools the curriculum hours increased, but in two there was a reduction in teaching hours. The number of schools with a mandatory clerkship rotation of at least 1 week’s duration had declined from nine in 1998, to eight in 2004, to seven in 2008. Three of the clerkship rotations were only 2 weeks in duration. The total number of hours of undergraduate curricula continued to range widely between schools, being 7 to 169 hours with a mean of 78 in 2004–5, and 10 to 299 hours with a mean of 82 in the current study.
There are many obstacles to increasing and even maintaining the geriatrics content in the curricula. There is a growing demand from various fields to add new content to an already overloaded schedule, and many schools are pushed to reduce the total number of curriculum hours. Recognition of geriatric medicine as an area of specific knowledge and skills is still lacking, and there is a common misconception that as students encounter many older patients in clinical practice, they will acquire these skills during other rotations.
The Liaison Committee on Medical Education (LCME) accredits Canadian medical schools. Educational objective ED-13 states that clinical instruction must “include the important aspects of preventative, acute, chronic, continuing, rehabilitative and end of life care”. ED-17 states that “educational opportunities must be available in…multidisciplinary content areas (e.g., emergency medicine and geriatrics)”. However, these objectives do not mandate teaching in geriatric medicine. In fact, ED-15 states that the curriculum “will be guided by the contemporary content from and the clinical experiences associated with…family medicine, internal medicine, obstetrics and gynaecology, pediatrics, psychiatry, and surgery”, and does not mention geriatrics. ED-22 states that “the objectives for instruction…should include medical student understanding of demographic influences on healthcare quality and effectiveness (e.g., racial discrimination and ethnic disparities in the diagnosis of treatment and diseases)”, but does not mention the demographic influences of an aging population.(2)
Another barrier is limited resources. As class sizes increase out of proportion to the number of practicing geriatricians, there are, in some circumstances, inadequate resources to provide clinical rotations to all the undergraduate and postgraduate students. In fact, at one particular medical school there was agreement to have a 2-week mandatory clerkship rotation in geriatrics, but this could not be achieved, as the capacity did not exist.
For postgraduate education, the Royal College of Physicians and Surgeons of Canada (RCPSC) requires that all psychiatry residents complete a rotation in geriatric psychiatry, and in fact, the mandatory number of weeks has been increased to 24 starting in the 2010–11 academic year. In contrast, a rotation in geriatric medicine is not an RCPSC requirement for internal medicine, and the number of schools requiring a mandatory rotation in geriatric medicine had not changed since the previous survey was conducted 4 years earlier. Although seniors make up a large percentage of emergency room encounters, two of the three programs that required a rotation in geriatric medicine in 2004 had dropped this requirement.
The number of hours of curricular content was defined as the number of hours of curriculum created by geriatricians, care-of-the-elderly physicians, and geriatric psychiatrists. This is a difficult number for even a geriatrician working at a specific medical school to be certain about. There may also be material relevant to geriatric medicine that is taught in parts of the curriculum developed and delivered by other specialists, but his information is even more difficult to find. Curriculum mapping is a challenge faced by many medical schools. Information on the exact number of students and residents completing electives was also difficult to obtain in many programs.
Comparing 2008–9 with 2004–5, there had been a small increase in total curriculum hours. However, the range of geriatric medicine teaching in medical schools in Canada is large, and although the geriatrics content had increased in some medical schools since the last survey, in others the amount of geriatric medicine taught had decreased. In residency training programs the requirement for mandatory geriatrics rotations had decreased in the area of emergency medicine. In other specialty areas, some schools had added a mandatory rotation in geriatrics but others had dropped the requirement. This is in spite of the well-documented demographic changes that will result in a growing number of older patients presenting for medical care.
The most important objective of geriatrics teaching is to ensure that all practicing physicians will have the skills necessary to deliver optimal medical care to seniors. The number of hours of geriatric medicine in the curriculum provides limited information about whether these skills have been mastered. The Canadian Geriatrics Society has recently published a consensus document outlining 20 core competencies in the care of older persons for Canadian medical students.(3) A survey is underway by the Canadian Geriatrics Society Education Committee to document which of these 20 areas are being covered in the curricular content in each medical school. The more difficult question of which of these competencies have been achieved will require further study.
I would like to acknowledge the contributions of the following geriatricians who collected data for their universities: Ann Sclater, Memorial University of Newfoundland; Susan Gold, McGill University; Monique Saint Martin and Marie-Jeanne Kergoat, Université de Montréal; Tamas Fulop, Université de Sherbrooke; Michel Dugas, Université Laval; Terumi Izukawa, University of Toronto; Trichia Woo, McMaster University; Michelle Gibson, Queen’s University; Laura Diachun, University of Western Ontario; Barbara Power, University of Ottawa; Kristel van Ineveld, University of Manitoba; Jenny Basran, University of Saskatchewan; Darren Burback, University of Calgary; Jasneet Parmar, University of Alberta; Roger Wong and Janet Kushner Kow, University of British Columbia.
The authors declare that no conflicts of interest exist.
1 Gordon J, Hogan D. Survey of the geriatric content of Canadian undergraduate and postgraduate medical curricula. Can J Geriatr 2006;9(Suppl 1):S6–11.
2 Liaison Committee on Medical Education (LCME) [Internet]. Washington (DC): LCME Secretariat, Association of American Medical Colleges; [updated 2011 Feb 2; cited 2011 May 31]. Available from: http://www.lcme.org/
3 Parmar J; Medical Education Committee of the Canadian Geriatrics Society. Core competencies in the care of older persons for Canadian medical students. Can J Geriatr 2009;12:70–3.
Canadian Geriatrics Journal, Volume 14, Issue 2, June 2011