November 1977
AGS CONFERENCES ON GERIATRIC EDUCATION
Geriatric Education at the Undergraduate Level RALPH GOLDMAN, MD
Professor of Medicine (Geriatrics), Department of Medicine, University of California Medical Center, Los Angeles, California Attempts to introduce material on geriatrics and gerontology into the undergraduate medical curriculum have been frustrated by the concept that there is no relevant substantive information to be taught, combined with a subtle subjective distaste for the management of decremental disease, dementia and death. The problems are to mitigate the subjective attitudes and to demonstrate that there are important substantive data worthy of inclusion in the curriculum. There probably has been no social revolution so profound and rapid as the historical change from a 5-10 percent probability ofliving 65 years, to the present 75 percent expectation of reaching that age in most of the developed nations. As diseases of nutrition, infection and reproduction decrease, and as management of trauma improves, it is inevitable that survival will be prolonged and that chronic diseases of an older population will become more important. Experience indicates that life for most individuals is potentially enjoyable until the terminal illness. Already, more than 30 percent of the practice of internal medicine consists of the care of patients over 65. The physician takes this in stride. The primary attitudinal problem relates to the identification of geriatrics with the unpleasant and irremediable aspects of aging alone, rather than with the totality, which includes the more frequent care of the active, interesting, and generally healthy older person. To combat this negative image of old age, students could be exposed during the first year, possibly through family or social medicine, to the relatively healthy aged. A useful device is to obtain a taped oral history from a grandparent, or from a comparable and competent elder in the community. When properly done, this can be an effective means of dignifying age, and of bringing to the young a sense of history and the reason for generational differences in attitudes. Throughout the clinical training it is essential: 1) that the clinical role-models treat age with
dignity and not with the frequent disdain, distaste and disrespect which leads to the diagnosis of the "crock" syndrome; 2) the management of chronic disease and the responsibility to the patient should be emphasized in such a manner as to avoid the current overwhelming focus on acute conditions; and 3) attention to the intellectual aspects of medicine should not be allowed to obscure the importance of the patient as an individual. Although we believe that this can be done, numerous surveys indicate that between the first and fourth years students lose their initial humanistic approach, particularly toward the aged. Positive techniques are needed to counteract this tendency. A second attitudinal area is more personal. The care of the aged often causes identification and internalization of anxieties regarding deeremental change, loss of self-image and the reality of mortality and death. There may be guilt on the part of the family because of past behavior, or on the part of the physician because of the failure of therapy. To the extent that these emotions exist they should be identified and examined, so that the student can deal with them in himself, in other medical attendants, and in the family. The substantive aspect of geriatrics also contains two areas. The more specific and direct area, which probably requires no more than ten curricular hours, should be presented as geriatrics and gerontology at appropriate times in relation to the general material. This should include presentation of relevant demography, sociology, biology and theories of aging; changes in symptomatology and diagnostic criteria with age; specific medical problems such as the nature and management of senility, pressure sores, and the almost universal minor problems (diet, constipation, changes in sleep patterns, exercise, sex); the use and management of extended care facilities; and the techniques, potentials and limitations of geriatric rehabilitation.
485
AGS CONFERENCES ON GERIATRIC EDUCATION
In addition, there should be a sensitization to, and identification of, age-related data by all faculty at both the basic science and clinical levels. Several examples are appropriate. It is well known that the glomerular filtration rate decreases with age. It is less well known that the serum creatinine level does not rise proportionately because of an age-related decrease in muscle mass. Thus, when .the serum creatinine value is used to guide drug dosage, the filtration rate, and consequently the size of the dose, may be overestimated - with inadvertent, potentially dangerous results. About one-sixth of all deaths are due to cancer. Burnet has pointed out that there is a decrement in immune surveillance which is reciprocal to an increased risk of cancer with age. This relationship is provocative. If it is established that decreased immunity is a factor in carcinogenesis, we can say that the patient died of cancer; or we can as well state that the patient died because of an age-related decrement in immune surveillance. In either case, age and aging are critical factors. The maximum heart rate also decreases with age. When the heart rate is used as a guide for
486
Vol. XXV
conditioning, the target rate is lowered appropriately. The heart rate possibly also could be standardized against age as a significant variable of management and prognosis in disease. These, and many other age-related data are available and are of importance in almost all aspects of medicine. They can and, in our view, should be incorporated into teaching by sensitized faculty members in all specialties. They may provoke questions leading to improved care of the patient, or stimulate research. In this format, the relevant teaching can be performed by appropriately oriented faculty in each of the existing areas. Although we do not propose a separation of teaching in gerontology and geriatrics from the main undergraduate curriculum as it now exists, present experience convinces us that unless there is one respected faculty member focusing attention on geriatrics, these curricular modifications will not be achieved. Thus, we urge that these recommendations be given serious consideration, and that one faculty member with appropriate qualifications, and with a commitment to geriatrics, be appointed to coordinate the program.
AGS CONFERENCES ON GERIATRIC EDUCATION
Geriatric Education at the Undergraduate Level RALPH GOLDMAN, MD
Professor of Medicine (Geriatrics), Department of Medicine, University of California Medical Center, Los Angeles, California Attempts to introduce material on geriatrics and gerontology into the undergraduate medical curriculum have been frustrated by the concept that there is no relevant substantive information to be taught, combined with a subtle subjective distaste for the management of decremental disease, dementia and death. The problems are to mitigate the subjective attitudes and to demonstrate that there are important substantive data worthy of inclusion in the curriculum. There probably has been no social revolution so profound and rapid as the historical change from a 5-10 percent probability ofliving 65 years, to the present 75 percent expectation of reaching that age in most of the developed nations. As diseases of nutrition, infection and reproduction decrease, and as management of trauma improves, it is inevitable that survival will be prolonged and that chronic diseases of an older population will become more important. Experience indicates that life for most individuals is potentially enjoyable until the terminal illness. Already, more than 30 percent of the practice of internal medicine consists of the care of patients over 65. The physician takes this in stride. The primary attitudinal problem relates to the identification of geriatrics with the unpleasant and irremediable aspects of aging alone, rather than with the totality, which includes the more frequent care of the active, interesting, and generally healthy older person. To combat this negative image of old age, students could be exposed during the first year, possibly through family or social medicine, to the relatively healthy aged. A useful device is to obtain a taped oral history from a grandparent, or from a comparable and competent elder in the community. When properly done, this can be an effective means of dignifying age, and of bringing to the young a sense of history and the reason for generational differences in attitudes. Throughout the clinical training it is essential: 1) that the clinical role-models treat age with
dignity and not with the frequent disdain, distaste and disrespect which leads to the diagnosis of the "crock" syndrome; 2) the management of chronic disease and the responsibility to the patient should be emphasized in such a manner as to avoid the current overwhelming focus on acute conditions; and 3) attention to the intellectual aspects of medicine should not be allowed to obscure the importance of the patient as an individual. Although we believe that this can be done, numerous surveys indicate that between the first and fourth years students lose their initial humanistic approach, particularly toward the aged. Positive techniques are needed to counteract this tendency. A second attitudinal area is more personal. The care of the aged often causes identification and internalization of anxieties regarding deeremental change, loss of self-image and the reality of mortality and death. There may be guilt on the part of the family because of past behavior, or on the part of the physician because of the failure of therapy. To the extent that these emotions exist they should be identified and examined, so that the student can deal with them in himself, in other medical attendants, and in the family. The substantive aspect of geriatrics also contains two areas. The more specific and direct area, which probably requires no more than ten curricular hours, should be presented as geriatrics and gerontology at appropriate times in relation to the general material. This should include presentation of relevant demography, sociology, biology and theories of aging; changes in symptomatology and diagnostic criteria with age; specific medical problems such as the nature and management of senility, pressure sores, and the almost universal minor problems (diet, constipation, changes in sleep patterns, exercise, sex); the use and management of extended care facilities; and the techniques, potentials and limitations of geriatric rehabilitation.
485
AGS CONFERENCES ON GERIATRIC EDUCATION
In addition, there should be a sensitization to, and identification of, age-related data by all faculty at both the basic science and clinical levels. Several examples are appropriate. It is well known that the glomerular filtration rate decreases with age. It is less well known that the serum creatinine level does not rise proportionately because of an age-related decrease in muscle mass. Thus, when .the serum creatinine value is used to guide drug dosage, the filtration rate, and consequently the size of the dose, may be overestimated - with inadvertent, potentially dangerous results. About one-sixth of all deaths are due to cancer. Burnet has pointed out that there is a decrement in immune surveillance which is reciprocal to an increased risk of cancer with age. This relationship is provocative. If it is established that decreased immunity is a factor in carcinogenesis, we can say that the patient died of cancer; or we can as well state that the patient died because of an age-related decrement in immune surveillance. In either case, age and aging are critical factors. The maximum heart rate also decreases with age. When the heart rate is used as a guide for
486
Vol. XXV
conditioning, the target rate is lowered appropriately. The heart rate possibly also could be standardized against age as a significant variable of management and prognosis in disease. These, and many other age-related data are available and are of importance in almost all aspects of medicine. They can and, in our view, should be incorporated into teaching by sensitized faculty members in all specialties. They may provoke questions leading to improved care of the patient, or stimulate research. In this format, the relevant teaching can be performed by appropriately oriented faculty in each of the existing areas. Although we do not propose a separation of teaching in gerontology and geriatrics from the main undergraduate curriculum as it now exists, present experience convinces us that unless there is one respected faculty member focusing attention on geriatrics, these curricular modifications will not be achieved. Thus, we urge that these recommendations be given serious consideration, and that one faculty member with appropriate qualifications, and with a commitment to geriatrics, be appointed to coordinate the program.
