Firdous Jahan (1)
Shaikh M Naeem (2)
Muhammad A Siddiqui (3)
Muhammad Moazzam Khan (4)


(1) Firdous Jahan
Department of Family Medicine
Oman Medical College
Sohar, Oman
(2) Shaikh M Naeem
Department of Family Medicine
Oman Medical College
Sohar, Oman
(3) Muhammad A Siddiqui
School of Health Sciences
Queen Margaret University
Edinburgh, UK
(4) Muhammad Moazzam Khan
Department of Family Medicine
Oman Medical College
Sohar, Oman

Correspondence:
Firdous Jahan
Department of Family Medicine
Oman Medical College
Sohar, Oman
Email: firdous@omc.edu.om

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Background
Geriatrics refers to the clinical aspects of aging and the comprehensive health care of older persons. Evidence from several studies and national surveys indicates that families are the major care providers for impaired older adults. As fertility rates decline, the proportion of persons aged 60 and over is expected to double between 2007 and 2050. A survey of US medical schools showed that 71% percent of schools either had geriatrics as a medical student clerkship or as part of a required clinical rotation [1-2]. Ageing is characterized by progressive and heterogeneous decline in physiological reserve of all organ systems. There are an estimated 101,145 60-plus people in Oman, representing 5.2 per cent of its population. Five per cent of these are bed-ridden [3-4].

Every elderly person has unique and specific needs. Ministry of Health (MOH) Oman runs a comprehensive assessment program to determine the immediate needs of an individual. This defines whether the person needs health or social intervention or both. Globally the number of elderly is expected to increase three-fold by 2050 [5]. This rise of the aging population has had an impact on the practice of medicine, as the unique needs of the elderly require the presence of a multidisciplinary and comprehensive medical approach [6]. The need for geriatric education has been repeatedly cited in the United States where, according to one study, every third patient seen by a medical student is elderly [7]. Teaching geriatrics in medical schools leads to improvement in geriatric knowledge, skills and attitudes of undergraduate medical students [8].

Evaluation and treatment of elderly patients requires specific knowledge, attitudes, and skills that are acquired across the continuum of medical education. Development and implementation of new geriatrics experiences has been undertaken throughout the medical school and residency curriculum [9]. Geriatric/Palliative care education in the undergraduate medical curriculum found considerable evidence that current training is inadequate in dealing with end of life issues, most strikingly in the clinical years. Reforming existing health care curriculum to incorporate palliative care education is often faced by many challenges on a number of levels [10]. There is a strong need to incorporate geriatric palliative care education into primary health care education such that there is an overlap between primary health care and palliative care. The attitudes and competencies required to provide high-quality care overlap substantially with those required to provide excellent primary care [11-12].

To strengthen and make it more effective in terms of teaching and experiential learning of geriatric /palliative care in family medicine few steps are already being done. Thus, a process of needs assessment, identifying gaps in knowledge, consultations with the curricula reformers and strategic planning is thought to be an effective catalyst for curricular change [13-14]. Geriatric care is an integral part of teaching and learning in family medicine. Caring for patients with a chronic or terminal illness is an opportunity to use knowledge and skills as part of a team and to give patients the time and the opportunity to discuss some of their deepest fears and anxieties. Cure may not always be a possibility but empathy and care will always be required, and the doctors of the future need to be aware of this.

Goals of family medicine program are to have a competent clinician in respect of diagnosis and providing evidence-based cost-effective management of conditions commonly met at the primary health care level. The purpose of this study was to evaluate the attitudes, knowledge and perception of medical students about elderly patients before and after implementation of a new geriatrics curriculum and to assess perceived attainment of objectives in geriatric module.

Methods
A favorable ethical opinion was obtained from the Oman Medical College ethics committee at the beginning of study.

Curricular Design
A detailed study of curriculum design and planning was then undertaken. The student-centered, problem-based, integrated model seemed most applicable in our setting and was adopted. Key topics were identified through an overview of American Association of Medical Colleges' list of common geriatric competencies. We integrated a geriatric course into an existing curriculum and described the necessary steps required to implement it. The overall aim was to introduce a geriatrics education program within the existing curriculum [13-15].

The course content was reviewed by experts, course coordinators and academic vice dean. Exit level and specific enabling objectives of the geriatric program were made. Teaching/learning strategies were devised and consisted of small group tutorial sessions, case based scenarios, role play, simulated history taking and a few large class format sessions.

Curricular Implementation
Teaching/learning strategies were devised and consisted of small group sessions. The new module was incorporated in the existing eight week family medicine rotation in year 6 which is the first clinical year. In all, five groups of students rotate through family medicine for eight weeks through the year, with this class having a total of 70 students. The geriatric course objectives for this year were to familiarize students with history taking and physical examination and use of common geriatric assessment tools in elderly patients. In addition basic knowledge of aging physiology and pharmacology were also incorporated in this rotation.

Prior to the introduction of geriatrics in the family medicine rotation, faculty development initiative was taken. Family medicine faculty underwent a basic two hour training session on teaching a problem based geriatric history and physical examination method. Besides this reading materials were provided as additional learning resources.

For students, two tutorial sessions were conducted to cover the basics of aging physiology and pharmacology and small group sessions in which problem based scenarios were used to practice history-taking in the context of aging physiology and pharmacology. Geriatric assessment and use of common geriatric tools was taught in a tutorial and then reinforced in small group case based discussions. Each student rotates to geriatric clinic in a government primary care clinic and had opportunity to assess patients. Opportunistic learning in terms of history taking and geriatric assessment was also provided to students in their clinical sessions during encounters with elderly patients throughout their eight week rotation.

Learning Outcomes and Core Competencies in Geriatric Module
o Acquire knowledge of the demography and epidemiology of ageing;
o Recognize the scientific basis of geriatric medicine and the differences in medical care of older patients;
o Develop foundational competencies in performing important aspects of a geriatric assessment;
o Recognize and appreciate physiologic diversity and its clinical significance in elderly patients;
o Establish the interactions between medical diagnoses, functional impairment, and medications;
o Interact with patients and their caregivers using a bio-psychosocial approach;
o Develop a clear understanding of important basic ethical principles governing care of elderly patient;
o Explore healthcare services for the elderly and healthcare financing for the elderly with specific reference to Oman.

List of Teaching Methodologies and Topics in Geriatric Module
Small Group Interactive Workshops/Tutorials

o Approach to the older person and Principles of geriatric medicine
o Physiology of ageing and functional impairment
o Cognitive and behavioral issues in ageing
o Common medical problems in old age/ Prevention, rehabilitation and care
o Principles of geriatric pharmacology / Prescribing in older persons
o Health promotion and disease prevention in older persons
o Nutritional needs & dental/oral hygiene
o Health care services for the elderly in Oman

Once in 8 week rotation: visit to Elderly care center

o Clinical skills in geriatrics: history taking and physical examination

Once in a week clinical rotation at Geriatric clinic

o Clinical skills in geriatrics: history taking and physical examination
o Approach to geriatric patients' problems in primary care

Curriculum Evaluation
Student's feedback on this curriculum was taken to further refine the curricular content and strategies as necessary. Two study instruments were used to assess the course. Student knowledge was assessed via a single best option test which was given to all students as a pre-test prior to the introduction to geriatrics. The UCLA geriatric knowledge test, a validated questionnaire used in previous studies, was reviewed for pre-test development. Keeping in line with the overall objectives of history taking and assessment skills for students, a modified pretest was designed. The questionnaire consisted of questions on aging demographics, aging physiology (cardiovascular and central nervous system), aging pharmacology, history taking, nutritional, functional, and gait assessment. The same questions were given (in a different order) to the students at the end of the geriatric sessions as a post test. Scores were reported as the total number of correct responses.

Attitudes toward geriatrics were measured using a geriatric attitude questionnaire adapted from the 14-item UCLA Geriatrics Attitudes Scale [16]. The scale was designed to assess general impressions about older people, perceived value of older people, distributive justice of societal resources toward older people, attitudes toward caring for older patients, perceived potential benefits of treating older patients, and personal economic concerns about caring for older patients. The additional two questions were used to assess attitudes toward working with elders and to evaluate attitudes regarding elders' perceived level of trust in discussing sensitive issues with medical providers. A self-administered evaluation form was also distributed at the end of the rotation to all students. The overall quality of teaching was included in the feedback form and a global rating for the overall module was also assessed. At the end of the rotation all students were asked to fill in the feedback form. This form consisted of nine questions related to the course objectives rated on a forced choice format (a variant of the Likert scale) questionnaire with five choices ranging from 1 ('not achieved') to 5 ('outstandingly achieved'). Space was also provided at the end of the form for additional comments. Student name on the course evaluation form was optional. No extra resources or funds were used.

Statistical Analysis
Statistical analysis was performed using SPSS (IBM SPSS Statistics 20.0). Data were expressed in frequencies, mean and percentages. Each participant's individual score was calculated for pre and post question by assigning 1 for correct and 0 for the wrong response. Mean scale scores for the pre and post questionnaire of each scale were evaluated for significance difference using the paired t-test for hypothesis testing.

Results
A total of 70 students participated in the study. Age ranged from 21 to 25 years with mean of 22.84 ± 1.03. 14.3% were male and 85.7% were female students. Table 1 shows student's pre and post-test geriatric teaching correct responses. Significant difference was found regarding geriatric teaching between student's pre and post correct responses (p <0.001, 95% CI: 5.228-13.24). Similarly, significant difference was observed between pre and post-test knowledge MCQ correct response (p <0.001, 95% CI: 12.39-23.39). The mean scale score for students basic understanding of geriatrics was significantly higher after completion of education program compared with scores prior to training (p < 0.001, 95% CI: 3.01-4.87) with an increase of 3.943 in the mean scale score. In the same way the mean scale score of students' knowledge of geriatrics was statistically higher after completion of education program compared with scores prior to training (p < 0.001, 95% CI: 3.13-4.5) with an increase of 3.829 in the mean scale score. Similarly, significant difference was found between pre and post responses among both male and female students. All students were also satisfied with the quality of teaching with 90% rating it as good or higher. Most students (89%) rated that the overall objectives were clear and achieved. Table 3 shows the students' perceived attainment of objectives from geriatric module at the end of rotation.

Table 1: Student's Pre and Post-Test Geriatric Teaching Correct Responses among 70 Students - n (%)

Click here for Figure 1. Students Geriatric Teaching Correct Pre and Post-Test Responses with significant difference

Table 2: Pre and Post-Test Knowledge MCQ Correct Response among 70 Students - n (%)

Click here for Figure 2. Students' Knowledge MCQ Correct Pre and Post-Test Responses with significant difference

Click here for Table 3: Students' Perceived attainment of objectives from geriatric module at the end of rotation - n (%)

Discussion
There has been a rise in the elderly population throughout the world including Oman because of good living standards. The unique needs of the elderly require a multidisciplinary and comprehensive medical approach for medical care and health promotion. This is imperative to have structured undergraduate and postgraduate medical curriculum to train our future doctors how to handle these population [16].
The knowledge scores improved considerably in students who attended the geriatrics course in their first clinical year. This change was similar to improvement in student scores reported in other schools where geriatrics was introduced [17]. Effective teaching and learning methods for geriatric competencies are mandatory to enhance knowledge in geriatric medicine [18-19].(Table I, Figure I) Different areas of knowledge also showed improvement; the same finding is also reported in literature that students were successful in fulfilling objective, which was to bring about an improvement in students' knowledge and attitudes in geriatrics [20].

Using pre and post rotation testing, we were able to demonstrate significant knowledge acquisition on a variety of topics pertaining to geriatric medicine and care of the older patient. Various research studies have shown the same result [21-23](Table II, Figure II). This study'sresults have shown overall level of confidence and competency in students and better empathic response towards geriatric population [24-25].

Student's perception regarding geriatric care was improved after they finished the rotation. The overall course was well-received by students, and teaching strategies were considered good or better by a strong majority of students. There were a small number of students who rated the course unsatisfactory in terms of achievement of objectives. This was also reflected in the course evaluation scores where students rated achievement of objectives in teaching and learning physiology and pharmacology slightly lower than the other areas. As reported in literature students may have some negative attitudes towards geriatric medicine that need to be addressed appropriately [26-27].(Table III).
One of the important points in students' feedback was their report of difficulty in students' ability to generate a problem list in geriatric patients as well as using a tool for geriatric assessment. Basic understanding and exposure to geriatrics can develop a good and effective curriculum for undergraduate medical students. Teaching and learning focused on geriatric issues as well as assessment after module will further improve the outcome [28-29]. Increase in geriatric population in Oman needs a focused and structured undergraduate as well as postgraduate curriculum to train our future doctors [30].

Future research should address the issue of translating acquired knowledge in geriatric medicine into demonstrated clinical skills, when caring for the elder population. Future research may involve identification of the ideal curriculum models in geriatrics that provide support to the students' learning and developing and validating instruments to measure effectiveness of curricular innovations.

Conclusion
Medical students who received education during their module showed improvement in levels of knowledge about geriatrics. This study has demonstrated that a combined didactic and clinical program successfully increased students' knowledge in Geriatric Medicine. Adding a student-based approach and strengthening assessment are future steps towards improving this curriculum. Changing population demographics mandate not only the need for more specialists in geriatric medicine, but also primary care physicians should have an adequate knowledge of the principles of caring for older patients. This must be accomplished with a mandatory rotation in medical schools.

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