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When old is new

A wave of change in medical schools puts emphasis on care of seniors

Email|Print| Text size + By Alice Dembner
Globe Staff / January 28, 2008

At Brown University medical school in Providence, students discuss why the organs of their cadavers look different from their own. They spend hours studying how the brain ages. They practice physical examinations on residents of an assisted living complex. And even in obstetrics and gynecology, they learn about problems affecting seniors.

The new emphasis on aging is part of a wave of change sweeping medical schools nationwide as they focus - many for the first time - on preparing all newly minted doctors to treat the growing population of older Americans. Although students have traditionally trained in hospitals filled with older patients, many graduated with little knowledge of how elderly patients' bodies and minds differ from younger ones.

Now, medical schools are increasingly teaching students in settings that include senior centers and nursing homes. They are incorporating lessons on aging in basic coursework. And many are testing students on their skill in treating older patients before they are allowed to graduate.

"This work is crucial to the well-being of older people and the well-being of healthcare in the United States," said Dr. Richard Besdine, director of the Center for Gerontology and Health Care Research, who is leading a curriculum overhaul at Brown. "Every physician in the United States needs to be educated about care of older people unless they're going to do lifetime pediatrics."

Matthew Deren plans to be a sports orthopedist, but last week the first-year student at Brown was visiting with Lillian Donohue to practice taking a medical history, testing mental skills, and building a relationship with a patient.

Perched on the edge of a wing chair in Donohue's homey apartment at the Winslow Gardens assisted living center in East Providence, Deren learned about her love of baking as well as the severe arthritis that forces her to use a wheelchair.

At 94, Donohue is hard of hearing and struggled with a memory test, but she was reluctant to focus on her medical troubles. "I hope I didn't bore you," she said repeatedly.

Deren had gotten to know a neighbor of Donohue's last semester, visiting her several times before a fall landed her in a nursing home. There, she grew so depressed that she no longer wanted to volunteer to help in Deren's training. The relationship, he said, jolted him out of his preconceptions about aging and taught him about the importance many older people place on living on their own.

"What seems to be a little difference in independence is colossal to patients who are living here," he said. "When they lose that, they can spiral down."

Deren, a 23-year-old Belchertown native, said the training will be invaluable if he becomes an orthopedist, since older people "will be a huge part of my clientele."

By 2030, Americans age 65 and older are expected to account for about 20 percent of the nation's population, up from 12 percent now. Grants from two foundations and the Association of American Medical Colleges, awarded over the last eight years, have fueled the curriculum changes to meet the expected need for geriatric expertise.

"The vast majority of medical schools had little geriatrics until recently," said Rani Snyder, senior program officer for the Donald W. Reynolds Foundation, which has awarded nearly $60 million to 30 schools, including Brown, Harvard, and Boston universities. "Almost all our grantees are now making it integral."

At Harvard Medical School, students learn early on about end-of-life care, and practice basic doctoring skills at a nursing home. Boston University has added a unit on hip fractures to its required coursework. And the University of Massachusetts Medical School in Worcester, which received a grant from the medical colleges association, mandates that students discuss drug costs with visitors to the local senior center.

Many schools are building cases involving older patients into their clinical rotations, when students get exposure to specialties such as surgery or family practice. The schools are also focusing on ensuring students interact with older people outside the hospital.

"All students take care of lots of older adults in the hospital, but they have not necessarily been taught how best to care for them," said Dr. Anne Fabiny, chief of geriatrics at the Cambridge Health Alliance and director of the Harvard Medical School geriatric curriculum changes. In the past, for example, they might have treated a senior's pneumonia, but not learned how quickly that patient might deteriorate just from lying in the hospital for a few days. And they would have learned little about elders not sick enough to need hospitalization.

"These are the kids who are going to be taking care of us when we're in our 80s," said Fabiny. "I have a vested interest" in providing that training.

Earlier this month, second-year Harvard students Elaina Lord and Jocelyn Mason got their first experience discussing end-of-life choices with a resident of the Hebrew Rehabilitation Center in Roslindale.

Lord and Mason broached the subject awkwardly with Lois Martus as part of a one-hour training session in Martus's crowded room. Martus suffers from heart disease, among other ailments, but her main concern that afternoon was finishing the interview so she could visit with her husband.

"Have you ever talked to a doctor about what they should do if your heart stopped?" Mason blurted out.

"I don't like to talk about that," said Martus, who is 85. "I don't think about it."

"We like to ask so we can do what you want" if something happens, Lord persisted.

"Well, if my heart's failing, I'd like to be resuscitated," Martus answered.

Later, Lord said that pressing the issue was difficult, but learning to discuss end-of-life care is a critical skill. "That is essential to providing good care," she said.

At UMass, there is new emphasis on another key issue in elder care - providing treatment continuity as elders move from hospital to home. BU, which has required students to take a geriatrics rotation for more than 50 years, is beefing up instruction about issues that are not strictly medical - such as elder abuse and helping patients walk or sleep better.

Rita Elquist, a 77-year-old resident of Winslow Gardens, has taught Brown medical student Daniel Cho another important lesson: how resilient some older people are. Elquist spent the holidays in a hospital and nursing facility, but returned home in good spirits, cracking jokes about toasting the New Year with orange juice and Lorna Doone cookies. Elquist said she hopes to teach Cho to listen to his older patients and be straight with them.

"Especially when you're elderly, you need to know the severity of what's going to happen to you," she said.

Alice Dembner can be reached at Dembner@globe.com.

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