Study setting. Medical students at the UMMSM participate in a longitudinal curriculum in Geriatrics, Pain Medicine, and Palliative Care that starts in the preclinical years (years 1 and 2) with a home visit program in which students interact with active older adults in the community and culminates with a 4-week required Geriatric and Palliative Medicine Clerkship in 1 of the clinical years (years 3 or 4), during which students work with more complex and frail older adults, including persons in a long-term care setting. With grant support from the Donald W. Reynolds Foundation (Las Vegas, NV), a team of geriatrics educators at the UMMSM developed a competency-based curriculum for 5 geriatric syndromes including dementia, delirium, falls, polypharmacy, and pressure ulcers. The delivery of this curriculum was spread over the 4 years of medical school training.
Curriculum development and implementation. For each of these syndromes, a team consisting of geriatricians, content experts from nursing or allied health disciplines, and instructional designers developed instructional and assessment activities. Members from the authors’ team led an earlier collaborative effort by medical schools in the state of Florida (the Florida Consortium for Geriatric Medicine Education) to develop medical student competencies for 10 geriatric syndromes. The specific learning objectives chosen for the curriculum were based on these competencies. For the pressure ulcers component, the learning objectives were as follows: 1) Given a case scenario, identify the factors that increase risk for skin breakdown; 2) Given descriptions of different types of wounds, identify the most likely diagnosis; and 3) Describe general measures for pressure ulcer prevention and management.
The authors’ development team determined how much emphasis should be placed on each syndrome and the appropriate level at which each of the components of this competency-based curriculum should be introduced. For example, because falls are more common than pressure injuries, a more expanded curriculum was developed for this syndrome. Some of the Falls’ components also were introduced earlier in the preclinical years when students work with more mobile and active older adults. The pressure ulcers curriculum was determined to fit best in the clinical years along with the dementia and delirium curriculum because students rotated through inpatient venues where they routinely encounter these syndromes.
The pressure ulcers curriculum included a preceptor-led didactic (case-based PowerPoint presentation), online study resources, clinical experiences, and a brief online competency assessment. A nurse practitioner with wound care expertise delivered the presentation on pressure ulcers and other skin lesions for each group of students. The presentation was revised during 1 of the quality improvement (QI) phases, but the final product specifically addressed the 3 learning objectives stated previously. Students were presented with a case and asked to identify risk factors. They were taught how to classify and distinguish among Stage 1 through Stage 4 pressure ulcers, unstageable wounds, deep tissue injuries, skin tears, diabetic ulcers, venous ulcers, and arterial ulcers. The presentation also covered prevention and management strategies. The PowerPoint presentation, which contained practice exercises for wound classification, was available on the institution’s online Geriatrics University (GeriU) platform for students to review afterwards. This learning platform is utilized by medical students throughout their 4-year geriatrics training and comprises all of the learning resources of the competency-based curriculum.
For their clinical experience, students rotated through several clinical venues at the Miami VA Health Care System, including Hospice, Post-Acute Care, and Long Stay Units. Students were supervised by geriatricians, geriatric medicine fellows, and nurse practitioners. Students participated in daily rounds with the team on each of the units and as a team assessed and discussed the management of any wounds present. Students were assigned individual patients to follow and were encouraged to perform routine complete skin assessments as part of their physical exams, but exposure to pressure ulcers and other skin lesions and involvement in wound assessment and care varied. No standardized methods or tools were established for this clinical component of the curriculum. To provide a standardized component, each student was assigned an older spinal cord injury resident to evaluate in the long-term care setting using the Braden Scale. They initially evaluated these patients individually and then rounded as a team with a geriatrician and met afterward for debriefing.
At the end of their third week of training in the Geriatrics and Palliative Medicine clerkship, students completed an online, case-based competency assessment covering dementia, delirium, and pressure ulcers. The pressure ulcers component was approximately 10 to 15 minutes and consisted of 3 parts that were closely aligned with the 3 learning objectives for the curriculum. In part 1, students were given a case of a patient with diabetes, late-stage Alzheimer’s Disease, and multiple complications and asked to list all risk factors for skin breakdown. In part 2, students were asked to list general strategies for the prevention and management of pressure ulcers. The format for these 2 parts was short answer. In part 3, students were given 7 descriptions and images of different wounds and asked to select the most likely diagnosis from a list of 10 options using an extended matching format. For parts 1 and 2, potential responses for the open-ended questions for which credit would be received (10 risk factors and 9 management strategies in the initial phase) were identified.
Faculty familiar with the curriculum determined a preliminary performance standard for this competency assessment after reviewing the performance of a pilot group of students. Although 3 separate components/learning objectives were specified, investigators opted to set the standard based on the combined score for the 3 components rather than set individual standards for each component. This approach was less complex and made it more feasible for students to receive remediation. Any student not achieving this standard was asked to review the PowerPoint presentation and the Braden Scale before undergoing reassessment.
QI of the curriculum occurred at 2 main time points during faculty retreats where broader review of the clerkships was undertaken. After phase 1 of curriculum implementation (~14 months), the scoring categories for the short answer questions were refined and 1 scoring category was added for both the risk factor and prevention/management questions. Outcome data were reviewed with the nurse practitioner giving the lecture, so she was aware of areas with which students had more difficulty. After phase 2 (~10 months), the instructional activities (in particular, the PowerPoint) were revised to be more closely aligned with the learning objectives and the assessment. The questions in the competency assessment remained the same throughout. After each phase, performance standards were raised (see Table 1). In raising the standard, consideration was given to the feasibility (staff time required for reassessment) and the acceptability (on the part of students) of the remediation and reassessment plan. A remediation rate of 15% or less was considered suitable for this training environment. Although students provided no separate evaluation of the pressure ulcers competency curriculum, they were able to comment on it as part of their overall clerkship evaluation.
Data collection and analysis. Data for this project came from students who completed the curriculum between 2010 and 2014. For these analyses, data from all years and phases were combined in a single Excel sheet. All student names were removed; data for 19 students who completed the competency assessment during the reported time period but for whom data were missing in the Excel sheet were excluded. These students were administered a paper version of the assessment and their data were never recorded in the Excel sheet. Descriptive statistics (frequencies, means, ranges) were applied for the scores in each of the curriculum phases, and average scores were compared across phases by performing an analysis of variance test.
Because this study involved a standard educational intervention, it was deemed exempt from full review by the institution’s review board.