words by maryann brinley / photography by andrew hanenberg
he anxiety level in this simulation center is high. It is going to be a busy, nerve-wracking morning. Patients with delirium, incontinence, acute back pain,
difficulty sleeping, repeat episodes of falling, mild cognitive impairment, and signs of depression are all waiting to be seen. A gentleman with a terminal diagnosis of lung cancer is also about to hear this news for the first time. Third-year medical students completing four-week-long geriatric clerkships will spend 15 minutes with each one of these elderly patients in apparently typical examining rooms equipped with secret cameras and windows for outsider viewing. Under pressure and in the spotlight today, tomorrow these doctors-in-training will be judged and graded on their performances by professors as well as peers. The only good news may be that the patients are not really sick but simply actors simulating their assigned diagnoses.
Seated in a wheelchair, Libby Weisberg, a veteran standardized patient at the School of Osteopathic Medicine’s Clinical Education and Assessment Center (CEAC), has assumed many patient roles including persistent nausea and abdominal pain, confirmation of Parkinson’s disease, acute confusion, and among her most dramatic was receiving the news that her leg would need to be amputated. “Today, I have a bad back,” she says. Her assigned case history leaves much of the role-playing and dialogue creatively open-ended as long as she sticks to her story line. “I’m supposed to be a 71-year-old widow who lives alone. This morning while reaching for a coffee mug, I fell off a stool and hurt my back. I’m in severe pain. Each encounter is different,” she admits. “You should see how different each student handles the same case. Some already have a kind and gentle manner.” Others have more to learn on their journeys to becoming skilled at geriatrics.
SOM — which has ranked among the top 20 medical schools nationally in geriatrics for the past nine years — takes the teaching of geriatric medicine very seriously. Pam Basehore, MPH, Associate Director of Education at the New Jersey Institute for Successful Aging (NJISA) at the school, says, “There has been a long- standing struggle nationally to infuse geriatrics into an already crowded medical school curriculum. The Institute of Medicine recently documented that our healthcare workforce is woefully unprepared to meet the needs of the baby boom generation. What sets SOM apart is that we have been on the forefront and have had a structured geriatric curriculum since 1989.”
With 17 full-time geriatric faculty members and the interdisciplinary experience offered through NJISA, students learn from not just geriatricians but also social workers, nurse practitioners, neuro-psychologists, neurologists, and geriatric psychiatrists. “The interdisciplinary nature of NJISA offers a unique experience for our students.” They are exposed to a full continuum of care for the elderly, from home visits to doctors’ offices, hospitals, nursing homes and hospices. They are taught to tend to the healthy as well as the sick and dying. Basehore says, “For years, we’ve included end-of-life issues and advance directives as vital components of our students’ training. This is all part of what makes us unique.”
In the simulation center buzzing with activity today, the eight patient encounters for this Objective Structured Clinical Exam (OSCE) were made possible this year through a grant from the Donald W. Reynolds Foundation for $1,998,421. Once a month on a Thursday, a group of students navigate this gamut of patient problems and are graded on their competence the day after. Basehore says, OSCEs are “a rich evaluation tool. We can really look at what students have learned and see if they are ready to care for older adults.”
This year, the Reynolds grant was awarded to 10 recipients in the U.S. and given to SOM because of its leadership in geriatric education. Along with this expanded, geriatric OSCE, the funds were designated to enrich geriatric education across the curriculum in all four years; to enhance residency training in geriatrics for primary care, emergency medicine and psychiatry; and to improve faculty skills in e-technology and competency based assessment in geriatrics. SOM is the only medical school which now offers eight geriatric OSCE cases and uses “third year peer review,” an idea Basehore is investigating as part of her doctoral research. “There is no other medical school doing peer review like this. It’s eye-opening but definitely beneficial.” In fact, it has worked so well, giving the students real perspective on theirs and classmates’ performances, but in a non-threatening, emotionally supportive way, that “we’re going to keep the peer-rating,” she says. “I’ve had students tell me it’s been one of their most valuable learning experiences.”
In addition to the peer rating process, students participate in a small-group faculty-guided feedback session the next day in which each case is discussed and they have a chance to have their questions answered. The students watch the videos and use checklists and scoring rubrics to evaluate each others’ recorded patient encounters. “They value the opportunity to learn and practice using these simulations,” says Sima Bennett, MPH, RD, CEAC director. “In breaking the bad news, for instance, they can try out words, phrases, body language and conversational flow in advance of having to do this very difficult task with a real patient. Besides, OSCEs are a fabulous way to test their skills. Paper and pencil exercises can only get as far as testing knowledge” — which is not enough for the real world.
Pulling out a blank sheet of paper, Bennett quickly draws what looks like a pyramid.
“This is Miller’s Triangle,” she explains. Divided into four horizontal segments, the bottom of the pyramid is Knows, one level up is Knows how, next up is Shows how and at the top, all in caps is DOES. “Basically, this is a graphic presentation of levels of competence,” Bennett says, Knowing the material is only a start. In role-playing or an OSCE simulation, the student should be able to show how a particular skill is done. “When all of the pieces come together,” Bennett adds, the DOES part takes place in the real world with a physician being able to act independently in a complex situation and do the right thing — which isn’t always completely predictable.
Take the situation which so impressed Libby Weisberg. Her character, Edna Grayson, had hurt her back before eating breakfast that morning. When one student doc offered to give her pain medication immediately, Edna cautioned the young man that it might upset her empty stomach.
“Let me get you something to eat right away,” he said, taking both of her hands into his. “Then we’ll take care of your pain.”
“What a bedside manner,” Libby says. “I wept real tears.”