Cultivating Future Physicians to Care for Mental Illness in the Elderly:

1. Cultivating Future Physicians to Care for Mental Illness in the Elderly: A Proposed Curriculum for a Medical Student Geropsychiatry Elective Deidre E. Williams, MD; Alice X. Huang, MS; Arnaldo Moreno, MD Department of Psychiatry, University of California-San Francisco Introduction The Oliva Model Curriculum Goals and Objectives Currently there are not enough practicing geropsychiatrists to meet the needs of the expanding elderly population (IOM 2008, Luchins and Brown 2007). To increase the number of physicians entering the field, it is important to cultivate interest at early stages of training. A geropsychiatry clinical elective in medical school would provide opportunities for students to acquire basic skills in geropsychiatry regardless of their future specialization and offer students with potential interest in geropsychiatry a chance to seek mentorship, engage in research, and explore the field as a career. While there is much work being done to address minimal geriatric competencies in undergraduate medical education (AAMC Geriatric Competencies 2008, Leipzig et al 2009), there is scarce data on how medical schools should address geropsychiatry. A search of PubMed and the Med-Ed Portal yielded only one potential curriculum for geropsychiatry in medical school that has yet to be tested (Marin et al 1988). Although select geropsychiatry topics are often included as part of geriatrics curricula (AAMC GQ 2008), there is no standard by which to measure whether this adequately covers the level of knowledge in geropsychiatry that medical students should have.   A formal needs assessment should be done to determine the basic components of geropsychiatry curriculum for undergraduate medical education. This assessment should include review of the current literature, a search of recommendations by medical education, accreditation, and professional associations, and a survey of geropsychiatry educators, fellowship directors, and clinicians. Course directors for rotations in medicine, geriatric medicine, and psychiatry should be consulted to determine areas of overlap in curricular objectives.  Using this assessment, we will apply the Oliva model (Oliva 2004) of curriculum development to develop a curriculum for a geropsychiatry clinical elective. The Oliva model was chosen because it is fairly complete and detailed, provides multiple opportunities for feedback, and involves pathways for developing both curriculum and instruction. Oliva’s model includes 17 steps, of which the 10-step “curriculum sub model” (as compared to the “instructional sub model”) is used here (see diagram). After implementing the curriculum, we will perform an assessment of students' achievement of the curriculum objectives within our instructional methods and making changes as indicated. Suggestions will then be given for how this curriculum could be improved and implemented for different levels of medical learning. Goals Objectives Diagram from Developing the Curriculum, Oliva, 2005 Core Elements of the Curriculum at UCSF Application Discussion The curriculum proposed here could be improved and expanded in a number of ways, not the least of which is a comprehensive, formal needs assessment. Oliva’s model can also be used to plan details of instruction, and then evaluate and improve both curriculum and instruction. However, given the lack of available literature in this area, the curriculum proposed here is a good starting point for medical schools wishing to include formalgeropsychiatry component to their clinical curriculum. • Step 1: Specify the needs of students in general: • Ability to diagnose and manage psychiatric conditions in the elderly commonly encountered in a primary care setting. • Ability to recognize and manage psychiatric aspects of medical illness and treatment in the elderly. • Ability to differentiate delirium, dementia, and depression in the elderly. • Ability to assess cognitive function in the primary care setting. • Appreciation of the psychosocial and ethical issues surrounding end-of-life care. • Ability to effectively utilize the mental health resources available to the elderly in their hospital system. • Ability to navigate the legal and ethical issues involved in caring for elderly with mental health and cognitive disability. • Ability to effectively utilize available community psychiatry resources. • Ability to function as part of a multidisciplinary team in caring for the elderly. • Opportunity to seek career mentorship in geriatric psychiatry. • Early exposure to working specifically with elderly populations under supervision of specialists in the field. • Step 2: Specify the needs of society • Need to provide mental health care to elderly population in the primary care and specialty care settings. • Need to meet the mental health needs of the expanding elderly population. • Need for efficient utilization of mental health care resources for the elderly. • Need for primary care providers to be able to recognize and treat common mental illnesses and psychiatric aspects of medical illness in the elderly. • Step 3: Write a statement of philosophy and aims of education • The aims of medical education include producing medical caregivers who: are competent within their specialty and know when and how to make appropriate referrals; understand and can manage the needs of special patient populations; have an understanding of ethical dilemmas they are likely to encounter within their scope of clinical and systems-based practice and can approach these in a thoughtful way; and can provide competent general medical care. • A key philosophical point is that elderly patients with psychiatric issues are in many ways vulnerable, and there exists a duty to protect them by taking special effort to ensure that they have adequate access to care, and that this care comes at the hands of practitioners who understand the ethical issues inherent in treating this particular population. • Step 4: Specify the needs of the particular students: • Familiarity with the psychiatric resources available at the particular institutions in which one trains. • Special training with specific patient populations unique to a particular training site. • Step 5: Identify the needs of the particular community • As medical students may go on to practice any specialty in any location, programs should thoroughly address issues related to all common practice settings; however, special attention may be paid to unique patient populations. • Step 6: Specify the needs of the subject matter • Psychiatry and geriatrics: dementias and delirium, late-life psychosis, late-life depression and anxiety, ECT, psychotherapy in the elderly, palliative and end-of-life care, assessing cognitive function, Medicare and health access issues • Psychiatry and primary care: routine care elderly patients with chronic mental illness, recognition and treatment of common psychiatric conditions in the elderly, psychiatric side effects of commonly used drugs, appropriate use of referrals to psychiatric care • Steps 7 and 8: Specify the curriculum goals and objectives • See table • Step 9: Organize and implement the curriculum • This step would be carried out by each particular medical school, with attention to the patient populations, treatment settings, faculty, and other program resources available. • Step 10: Evaluate the curriculum and modify the curricular components • This step would be carried out by individual programs who have implemented the curriculum, perhaps with the use of a more formal before-and-after needs assessment. 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