EDUCATION AND TRAINING
Effect of Extracurricular Geriatric Medicine Training: A Model
Based on Student Reflections on Healthcare Delivery to
Elderly People
Linda M. Goldenhar, PhD, E. Gordon Margolin, MD,w and Gregg Warshaw, MDz
Although many professional and accrediting bodies have
identified competencies for medical students pertaining to
caring for older patients, including understanding the basics
of the healthcare delivery system, the highly structured cur-
riculum in medical school provides few opportunities for
these competencies to be achieved. One possible solution is
to let students participate in geriatrics-related extracurric-
ular educational and clinical activities and ask them to re-
flect on their experiences. This article presents the results of
a qualitative analysis of student reflections from participat-
ing in such a program implemented at the University of
Cincinnati College of Medicine. One hundred thirty of 321
student journal entries (collected over 3 academic years)
containing any mention of the healthcare system were
qualitatively analyzed. The themes and resulting model that
emerged from the data includes three distinct levels of
healthcare delivery: individual, organizational, and sys-
tems. Each level is presented and explained using illustra-
tive student quotes. As a whole, the model indicates that
students in this innovative extracurricular experience
gained important knowledge about how medical care is
provided to elderly people. The model developed may pro-
vide additional structure for future medical students as they
reflect on their early encounters with the complex health
and social forces affecting the quality of care received by
older adults. J Am Geriatr Soc 56:548552, 2008.
Key words: student reflections; healthcare delivery;
journaling
T he heavily structured curriculum in most U.S. medical
schools offers few opportunities for students to be-
From the Office of Medical Education; wDepartment of Internal Medicine;
z
Department of Family Medicine, Division of Geriatrics, University of Cin-
cinnati College of Medicine, Cincinnati, Ohio.
Address correspondence to Linda M. Goldenhar, PhD, Assistant Dean for
Medical Education, University of Cincinnati College of Medicine, 231 Albert
Sabin Way ML 0552, Cincinnati, OH 45267. E-mail: linda.goldenhar@
uc.edu
DOI: 10.1111/j.1532-5415.2007.01554.x
JAGS 56:548552, 2008
r 2007, Copyright the Authors
Journal compilation r 2008, The American Geriatrics Society
come familiar with, much less understand, the complex
healthcare delivery system in which they will work. A few
educational interventions have recently been implemented
that help provide those opportunities,13 but none of these
efforts emphasize education about the healthcare system as
it pertains to health care for elderly people. The burgeoning
growth of this population demands that medical students
understand the system in which they will be providing that
care.4
The American Geriatrics Society (AGS) and other pro-
fessional and accrediting bodies (Association of American
Medical Colleges, Accreditation Council for Graduate
Medical Education, American College of Physicians, Amer-
ican Academy of Family Physicians) have identified a num-
ber of competencies pertaining to healthcare delivery for
elderly people. These include understanding healthcare fi-
nancing and available community resources, adaptation to
care in alternative living situations, long-term care facilities,
willingness to work with other disciplines, and issues sur-
rounding end-of-life care (e.g., advance directives, physi-
cian-assisted suicide). These issues, typically addressed in
residency training,57 should be incorporated into the con-
tinuum of the educational process, starting with medical
students, but given the current medical school curricula, it is
hard to imagine how students will start making progress
toward realizing these competencies.
One way is to provide geriatrics-related extracurricular
activities and then ask students to reflect on their experi-
ences in an on-line journal. This article presents the results
of a qualitative analysis of journal entries from such a pro-
gram. The University of Cincinnati institutional review
board approved this study, including the student consent
form.
METHODS
In 2003, the University of Cincinnati College of Medicine
began a 4-year longitudinal geriatrics education program
called the Geriatric Medicine Student Scholars (GMSS)
program. The overarching goal is to expose an interested
group of medical students, beginning in their first year and
continuing through their fourth, to a variety of extracur-
ricular activities designed to enhance their understanding of
0002-8614/08/$15.00
JAGS MARCH 2008VOL. 56, NO. 3 STUDENT REFLECTIONS ON HEALTHCARE DELIVERY TO ELDERLY PEOPLE 549

Healthcare Delivery for Elderly People

Individual Level Organizational Level Systems Level

Who delivers the care? When is care delivered? What are the barriers to and
What kind of care is being delivered? Where is care delivered? facilitators of healthcare delivery?

Individual Care Sites

Physicians Provider Training
(Physicians offices, private homes, nursing (Shortage)
(Time vs technology, communication) homes, assisted living, hospitals)
Financing
Family Community and Government Agencies (Government, individual/family)
(Caregiving, stress)
Legal & Ethical or Moral End-of-Life Care
Social Networks (Advance directives, physician-assisted
(Support) suicide)

Figure 1. A model based on student reflections on the delivery of health care to elderly patients: individual, organizational, and
systems levels.

the complex health and social challenges facing older
adults. The three primary aspects of the programFmen-
toring, didactics and reflective journalingFwere described
in an earlier article and are therefore described only briefly
here.8
Mentoring
The GMSS mentors (practicing geriatricians) met regularly
with the medical students that they were mentoring to help
them understand the realities and significance of providing
care to elderly people.
Didactics
Monthly AGS student chapter meetings and special dinners
were held during which topics such as end-of-life ethical
and legal considerations and hospitalnursing home inter-
face issues were presented by and discussed with geriatrics
experts.
Reflective Journaling
All GMSS students are required to complete eight reflective
journal entries each academic year using an on-line pro-
gram with a semistructured format designed for the GMSS
program. The goal is for them to reflect on the aging-related
extracurricular activities provided by the GMSS program,
such as experiences with their mentors, with other mentors,
or with other GMSSs students. They are also free to write
on other issues such as aging-related personal experiences,
aging-related curricular activities, or general thoughts
about aging.
ANALYSIS
Three hundred twenty-one journal entries collected from 27
students over 3 years (academic years 2003/04, 2004/05,
2005/06) were downloaded for review and analysis. At the
end of the first reading, the authors agreed that an over-
arching theme that they called healthcare delivery for el-
derly people was emerging. All entries containing one or
more reflections about the healthcare delivery system were
extracted from the original 321. Entries not reflecting the
codes were removed, leaving 130 journal entries (40% of
the original 321; to obtain a more comprehensive under-
standing of the other topics students reflected on, see8). Us-
ing a final coding dictionary, the authors independently
coded entries. They then met to review, discuss, and finalize
their coding decisions. At the end of the coding process, it
became apparent that the individual codes could be
grouped into three higher-order levels of the healthcare de-
livery system: individual (47 entries), organizational (52
entries), and systems (31 entries). The model shown in
Figure 1 presents these levels and their components.
RESULTS
The model, although not a comprehensive representation of
how health care is delivered to elderly patients, depicts the
aspects of geriatrics-related healthcare delivery of which
these students gained knowledge by participating in the
GMSS program. For each level and corresponding compo-
nent, sample quotes are presented to illustrate the students
depth of understanding gained and progress made toward
achieving desired competencies related to healthcare deliv-
ery for elderly people.
Individual Level
The focus at the individual level is upon who is delivering
care to elderly people and issues involved in providing that
care. The three types of individuals most often mentioned
were physicians, family members, and members of broader
social networks.
550 GOLDENHAR ET AL.
Physicians
The primary issues pertaining to physician care identified by
students were the complexity of providing care to older
patients, the importance of communicating clearly, how
critical it is to spend time with the patient and family mem-
bers, and how vital it is to work with all members of the
medical team to ensure proper care. The following quota-
tions illustrate these specific issues.
Communication and Time
I already knew that geriatric patients could have lots of problems,
but I learned that it really does take more than a normal doctor
visit to make them better. Dr. . . . said that he often schedules his
geriatric patients at the end of the day so that he can spend more
time with them if he needs to. This is definitely a strategy that I
plan to use when I have my M.D.
As we age things start to slow down and we start to appreciate a
slower paced lifestyle. It strikes me how in contrast that is with the
working style of most physicians. Doctors buzz into the exam-
ining room, speak a mile a minute, fill out some prescription and
shove the patient out the door. It makes me wonder how any
patient, and especially elderly patients, feel satisfied from the
physician experience and more importantly, what they actually
learn about their health from their doctors and remember all those
instructions.
We learned that the woman had just recently lost her husband. I
expected the Dr. to give her condolences and move on . . . Instead,
she . . . talked to her about normal grief & how to differentiate
between that and symptoms of depression . . . I was very im-
pressed . . . and it certainly made me feel much better about be-
coming a doctor and being able to treat elderly patients well.
Teamwork
I sat in on evaluations with three patients, all of whom were quite
different and required vastly different needs. I was impressed with
the collaboration between the medical team. During each visit a
social worker and a nurse accompanied the physician into the
exam room for a joint consultation.
Family
The complex and difficult role of caregiving by family
members also became apparent to the students as they par-
ticipated in the mentoring relationship.
. . . The caregivers are often times forgotten. . . . They are respon-
sible for the care of a patient without the resources or tools avail-
able to a doctor and . . . often times without the proper knowledge
or instruction to give proper quality care.
I saw the wife of another patient . . . She came in for counseling.
She did not have a medical complaint. Her chief complaint was
that she was very stressed out and complained of being depressed
but at the same time she could not bring herself to put her husband
in a nursing home.
Social Networks. Students, through their GMSS expe-
riences, also became aware of how important social net-
MARCH 2008VOL. 56, NO. 3 JAGS
works were in the lives of elderly people, including
providing health care and assuring quality of life.
Luckily, this patient was in a caring environment and her dete-
rioration had been noticed by good friends and peers. . . . It is
scary to think of the patients who do not have such a social en-
vironment, who could quickly deteriorate and become dysfunc-
tional without anyone noticing it.
When I entered her home to deliver her meal, she asked me to
open a carton of milk and pour it on her cereal for her. . . . I
couldnt help but wonder what other tasks she needed (but was)
waiting for the delivery person to arrive so that they might help
with some particular task.
Organizational Level
At the organizational level, the student reflections focused
on where health care is delivered to elderly patients, in-
cluding specific medical delivery sites and in the community.
Individual-Care Sites
The sites mentioned most often were doctors offices, hos-
pitals, individuals homes, and nursing homes or assisted
living facilities. The reflections included advantages and
disadvantages associated with providing care at the partic-
ular sites and how improvements might be made.
Physicians offices
. . . things that were obvious like making sure you have an elevator
if your office is not on the ground floor. . . other points . . . such as,
. . . many geriatric patients have a hard time rising from the seated
position and having a soft chair would hinder their ability to get
up . . . but it was something that I had never really thought about
before.
I remember how troublesome it was for (grandmother) to go to
the doctors. Since she was barely able to walk, one of my parents,
aunts or uncles would always have to take the day off to accom-
pany her. And most weeks she had multiple appointments with
multiple doctors. I cant imagine what other obstacles elderly pa-
tients face when trying to visit the doctor. How about those pa-
tients with medical equipment and those who dont have family
near by? Home care would have been such a godsend for my
family.
Patients Home
When a doctor does a home visit, he/she can learn more/different
information. . . . For example, (s/he) can ask to see the patients
medications, see what kind of lifestyle the patient leads . . .
including diet, support system, hygiene . . . Learning about
the patients habits and lifestyle is probably one of the most im-
portant things in correctly and efficiently alleviating a patients
problems.
It is important to evaluate whether there are obstacles in a
patients home that could result in a fall such as wires, floor rugs,
etc. . . . The better the lighting, the more likely the patient will
avoid these obstacles. Home visits can also help the clinician
evaluate the patients activities of daily living. Is the home clean?
This will give the doctor a clue about the patients function.
JAGS MARCH 2008VOL. 56, NO. 3 STUDENT REFLECTIONS ON HEALTHCARE DELIVERY TO ELDERLY PEOPLE
Nursing Homes
. . . Residents were so alive and the staff really tried to treat them
with dignitya . . . cant help but wonder whether [this was] be-
cause of the money they were spending . . . If this facility was
unique because it catered to the well-off, . . . I cant help but
wonder what other nursing homes would be like for the average
income-earning family.
I was amazed that patients are sent to the nursing home from the
hospital with inadequate documentation of the hospital care they
had received. This seems to be an injustice to the patient who is
being cared for as well as the doctors who are continuing their
care. It just seems that in this day in age, with such a vast amount
of communication technology available, that the hospital staff
does not take the extra effort to spend the small amount of time
needed to tell the nursing home about the patient.
Community and Governmental Agencies
There are probably many resources, but how does one find out
about these things? If she were a battered woman, I would give her
hotline numbers. If she were homeless, I would help her find a
shelter. But she is old and frail, and I dont know who she calls.
One of the most valuable portions of this rotation has been the
exposure to some of the community resources available for the
geriatric population and their family and caregivers . . . I feel like
having exposure to these places at the end of my fourth year is a
little sad because it would have been so nice to know about them
before starting any clinical work.
Systems Level
The GMSS students reflected on three primary topics at the
systems level: the shortage of physicians to provide geriatric
care, healthcare financing (individual assets and govern-
mental programs), and legal, ethical, and moral issues re-
lated to end-of-life care.
Physician Training
A number of students expressed concern about the lack of
interest by their fellow students in becoming geriatricians as
well as the lack attention given to geriatrics during their
training.
When the researchers asked if there were any students interested
in gerontology only one raised their hand. The class laughed at
that person . . . went on to say that in the past twenty years the
number of gerontologists in this country has gone down fifteen
percent . . . This attitude is unacceptable and creating a dangerous
situation in todays healthcare system.
Healthcare Financing
The students expressed serious concern about the financial
aspects of health care for elderly people, whether individual
finances or governmental programs.
He gave her samples and arranged for her to apply for free med-
ication through the drug company. He let her know about a drug
assistance plan that she may qualify for . . . Based on the [nurses]
reaction, I would say that . . . getting the free medication from the
551
drug company is a nuisance which makes me wonder how many
physicians opt not to use this service.
The Medicare Plan D prescription drug plan confuses me. And if I
am confused . . . Are the seniors who are considering Plan D ac-
tually able to access the information? . . . I assume they get in-
formation directly from Medicare, but from examining their
website, they do not always present information in a very clear
manner. Many Medicare recipients will probably rely on their
families to help them figure out the best plan . . . Im concerned
about the seniors who are confused and do not have friends/fam-
ily to help through these plans.
I saw a woman whose blood pressure was controlled with three
medications. She was able to afford two, . . . but the third was so
expensive that she began to take it every other day. When we saw
her, her BP was so high that we considered a change of medica-
tion. She explained that it was a question of finance . . . A tough
situationFpay your bills and buy food, or pay your bills and buy
medicine.
End-of Life CareFLegal and Ethical or Moral
Many of the students reflected on end-of-life care issues,
specifically addressing the legal (advance directives) and
ethical or moral issues (e.g., physician-assisted suicide).
. . . anecdotes of a widow recounting the trouble she went through
with her husbands several years of debilitation. Her candor made
the stories all profound. Especially the part about how advance
directives would be completely ignored unless the paperwork is in
handFanytime an emergency care crew there to resuscitate a
DNR patient. Spouses have incomplete legal authority over their
significant others without the durable power of attorney.
It might be interesting to hear about the role that advance direc-
tives play from the physicians standpoint. Do the limitations in-
voked by the advance directive frustrate the physician? Are there
times when the literal reading of the advance directive may not
refer to a certain circumstance? Can the family ever overrule the
advance directive?
Physicians can make a huge impact on the families of geriatric
patients by bringing end-of-life care issues to discussion. Not only
does early introduction of such topics make decision-making eas-
ier, . . . it provides an emotional preparation for the unthinkable.
If the family is more comfortable making decisions and knows the
wishes of their loved one better, then they are more likely to honor
their wishes . . . the physician will be better able to honor the
wishes of the family and patient if several decisions have already
been discussed.
My mentor brought up an interesting point. He said it is at least
conceivable if not expected that one day people will begin to
protest palliative care similarly to the way people protest abor-
tions now. . . . I had never considered it before.
DISCUSSION
Todays medical students will spend the majority of their
future careers providing care to older adults, yet many
552 GOLDENHAR ET AL.
medical schools do not require much, if any, geriatrics
training. According to the AGS report, medical schools
should include substantial geriatrics training to ensure
competency in caring for older persons, including having
ample experience with healthier older persons in commu-
nity settings to improve their attitudes toward caring for
older adults.9 The AGS estimates that the clinical years
should include at least 15 lecture hours, 4 weeks of rotation,
and 9 weeks of longitudinal clinic time.10
The John A. Hartford Foundation funded 40 medical
schools to expand their geriatric medicine student curric-
ulum.11 Although they differed in their approach, the com-
mon learning objectives included understanding the
interrelationships of disease, lifestyle, and social issues;
learning about healthcare systems and insurance; and un-
derstanding the ethical issues in geriatric care. These same
topics were common areas of reflection by the GMSS stu-
dents.
Although it was not the intent that GMSS students gain
a comprehensive understanding of healthcare provision to
elderly people, the analysis of the journal entries and their
organization into a conceptual model confirm that the
GMSS program provided them with experiences that en-
couraged awareness of and reflection on the issues of
healthcare delivery; multiple students mentioned each AGS
competency described earlier in one way or another.
Not all of the students reflected on all of the compo-
nents in the model, but when viewed as a cohort, through
their reflections, the GMSS students exhibited an under-
standing of many of the complexities of providing care to
elderly patients. The model could be shared with medical
students early in their training to use as a framework for
understanding what they will see and experience as student
physicians. The challenge for medical educators is to broad-
en medical students understanding of how health care is
currently delivered to the elderly population and how, as
physicians of the future, they might improve upon itFat
the individual, organizational, and systems level.
ACKNOWLEDGMENTS
We wish to thank Ms. Elizabeth Gothelf for her coordina-
tion of the Geriatric Medical Student Scholars program and
all the GMSS faculty mentors for their participation. Their
dedication to geriatrics and medical student education al-
lowed these student scholars to learn and grow in ways that
would not otherwise have been possible. We would also like
MARCH 2008VOL. 56, NO. 3 JAGS
to thank the geriatric medical student scholars for their in-
sightful reflections on their experiences in the program.
Conflict of Interest: The editor in chief has reviewed the
authors personal and financial conflict of interest checklist
and has determined that none of the authors have any con-
flicts related to this article.
Author Contributions: Linda M. Goldenhar, as eva-
luator on the GMSS project, conceptualized, developed,
and administered the reflective journaling as the method for
evaluating the GMSS program. She conducted confirmatory
qualitative analysis on journal entries, and worked with
Drs. Margolin and Warshaw on interpreting the results,
developing the model, and preparing the manuscript. E.
Gordon Margolin conducted confirmatory qualitative anal-
ysis on journal entries and worked with Drs. Goldenhar and
Warshaw on interpreting the results, developing the model,
and preparing the manuscript. Gregg Warshaw conducted
confirmatory qualitative analysis on journal entries and
worked with Drs. Goldenhar and Margolin on interpreting
the results, developing the model, and preparing the manu-
script.
Sponsors Role: None.
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