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Currently there are approximately 890 geriatricians in California, or one geriatrician per 4,000 Californians 65 years of age or older. (1) For years geriatricians have been calling for inclusion of geriatric curriculum into the mainstream of American medical education without much response. As the Alliance For Aging Research notes in its recent publication, Medical Never-Never Land: Ten Reasons Why America is Not Ready for the coming Age Boom, the current shortage of health professionals trained in geriatrics is a “crisis that is already here.”(2) In addition, one-third of Americans now pass through a nursing home before they die. “Although many individuals aged 65 and over will be admitted for short stays for rehabilitation or skilled nursing needs, 55% of those admitted may stay for at least 1 year, and 21% may stay 5 years or longer.” About one-fifth of Americans die in a nursing home. (3) This figure is increasing as nursing homes attempt to lower their rates of hospital transfer for residents at the end of life, to allow for peaceful deaths "at home" rather than in an acute-care facility. The number of Americans who spend their final days or years in a nursing home is only expected to increase as the baby-boom generation ages.

In 2000, the California State Legislature addressed this crisis by passing the Geriatric Medical Training Act of 2000, (4) noting that training in geriatric care would be required for licensure as a physician, and geriatric training in California medical schools should be greatly enhanced by September, 2003. In response to this legislation the Academic Geriatric Resource Programs on the six health science campuses of the University of California (San Diego, Irvine, Los Angeles, San Francisco, Berkeley, and Davis) have developed and implemented required geriatrics curriculum in their medical schools.

As early as 1984, the California State Legislature through AB 2614 called for education and continuing education programs in geriatrics and gerontology for health science students and the general public as well as teaching nursing home programs in which the quality of institutional long-term care would be improved. Such a program is now in place in the UC Berkeley – UC San Francisco Joint Medical Program (JMP) located in the UC Berkeley School of Public Health. With funding from UC Berkeley's Academic Geriatric Resource Program, the JMP has responded to these legislative mandates and demographics in two ways. First, it has embarked on an aggressive path toward innovative uses of problem-based, case-oriented learning, and will infuse one-third of the cases with geriatric content. Second, by academic year 2005 – 2006 all JMP students will undergo one-third of their face-to-face encounters with patients in a continuing care retirement community (CCRC). All first-year JMP students began these encounters during the current 2003 – 2004 academic year.

Development of the Experiential Geriatrics Learning Project

A teaching continuing care retirement facility development committee was established during academic year 2002 – 2003 to develop a clinical care setting in which students from the JMP would complete part of their clinical training. This interdisciplinary committee is comprised of the following individuals

The Administrator from Salem Lutheran Home
A Post-Doctoral Fellow from the UC Berkeley Center for Medicine, Humanities, and the Law
The COO from Mercy Retirement & Care Center and Salem Lutheran Home
The Academic Coordinator from UC Berkeley’s Resource Center on Aging
A geriatrician from the UCSF Division of Geriatrics, San Francisco VA
A law student from the UC Berkeley School of Law
The Program Director of Contextual Education at the Pacific School of Religion
The geriatrician/medical director at Mercy Retirement & Care Center and Salem Lutheran Home
An Assistant Clinical Professor , Gerontology Program- UCSF School of Nursing
A Medical Student from the UCB/UCSF Joint Medical Program
A Clinical Professor & UC Berkeley’s Director of the Resource Center on Aging
The Eden Alternative Coordinator for Elder Care Alliance
A Graduate Student from the UCSF-UC Berkeley Joint Program in Medical Anthropology
An Assistant Clinical Professor from the Berkeley School of Optometry
A Senior Lecturer/Field Consultant from Berkeley’s School of Social Welfare
As noted by Lipsitz, (5) such a setting is ideal because:

The nursing home [and more broadly a Continuing Care Retirement Community—CCRC]
provides unique educational opportunities…including practice in physical diagnosis
and history taking, unimpeded by the exigencies of acute illness; exposure to unusual
physical findings; extensive experience in cognitive and functional assessment; management
of geriatric syndromes such as falls, incontinence, and dementia; exposure to geropsychiatry
and rehabilitation; experience in family dynamics and interdisciplinary teamwork;
discussion of ethical issues and advance directives; and appreciation of the importance of
quality, not just quantity, of life.
The following objectives guided the TCCRC committee’s first-year developmental process, and continue to do so:

To have a TCCRC functioning for first-year JMP students by academic year 2003 – 2004.
To have a TCCRC functioning for first and second-year JMP students by academic year 2004 – 2005.
To have a TCCRC functioning for all JMP students by academic year 2005 – 2006.
To continue to plan, develop and implement and oversee during academic years 2003 – 2006,
a multidisciplinary clinical training site within the TCCRC/NH for health
professional students including but not limited to those in Optometry and Social Work.
Salem Lutheran Home, a care community under the umbrella organization of Elder Care Alliance in Oakland CA was identified as the major site at which clinical training would occur and committee meetings would be held. As the planning year developed, two additional sites, Mercy Retirement Center, and Piedmont Gardens, also in Oakalnd, were added. These site were chosen for two reasons. First, the committee felt it important that students interact with and learn about both well, independent elders and frail elders. Within a continuum of care from independent living, assisted living, nursing home and dementia care, a CCRCs rather than a nursing home alone, provides this opportunity. Second, the committee felt students should be exposed to exemplary facilities, the concept of which they can carry with them into their practice of medicine.

During academic year 2002 – 2003 the Teaching CCRC Development Committee worked as a task force to design and implement the sites. During academic year 2003 - 2004, first-year JMP students attended an orientation at Salem on September 3rd, 2003, and did their clinical work throughout the year at Salem, Mercy & Piedmont Gardens. Now second-year students (academic year 2004 - 2005), they will do more advanced clinical work at these facilities, and some will see patients at the Center for Elders Independence (CEI) . On September 7, 2004, first-year JMP students attended their orientation at Salem. They too will be seeing patients during the current (2004 - 2005) year at Salem, Mercy, Piedmont and CEI and throughout their three years at Cal.

The Committee continues to meet regularly to further develop and implement the above objectives. In addition to the 24 JMP students involved in this project, Optometry students and nursing students also are seeing patients at these sites. The committee hopes to have a social work student on site soon. Additionally, Beth Dungan, Post-Doctoral Fellow from the UC Berkeley Center for Medicine, the Humanities, and Law has led discussion groups with residents at Salem on images of aging, and Elizabeth Pohlman, graduate student from the UCSF-UC Berkeley Joint Program in Medical Anthropology has written a participant observation about the process of being on the committee and has lead groups of elders at Salem on "what does it mean to be old". A Barbee Fellow from UC Berkeley's Boalt Law School is also on the committee.

If you would like further information about this project please contact Desi Owens at: desiowens@berkeley.edu

(1) Wright, R, CA State Assemblyman, AB 2810, 2000.The Geriatric Medical Training Act of 2000.
(2) Alliance For Aging Research, Medical Never-Never Land: Ten Reasons Why American is Not Ready for the coming Age Boom, February, 2002
(3) Reuben et al., “Primary Care of Long-Stay Nursing Home Residents: Approaches of Three health Maintenance organizations,” Journal of the American Geriatrics Society, 1999 47:131-138.
(4) Ibid.
(5) Lipsitz LA. “The teaching nursing home: an educational and economic resource for geriatric training.” Amer J Med 1994;97(4A):245-265.

 
     
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