As a medical student, my experience of specialist services for older people was limited to two visits to the geriatric medicine unit.

We were shown some “good cases”. I do recall that one of the patients had Huntingdon’s Chorea, but not much more. When I returned to work in the teaching hospital as a registrar, exposure to geriatric medicine had advanced so that half the medical students had tutorials on the “Geriatric Giants”, whilst a few students were actually attached to a “Geriatric Medicine” firm. In other medical schools, the situation has been different, with all students having formal attachments to geriatric medicine departments, typically of a few weeks duration. During that time students would be taught the principles of geriatric assessment and rehabilitation, and the basics of multi-disciplinary team working. There were two principal aims – to teach the fundamentals to all students, and to enthuse the enlightened with the delights of a career in geriatric medicine or related specialties.

The Anxieties of Change
At recent meetings of the BGS Training Committee and of the Association of Professors of Geriatric Medicine, concern has been expressed about the present status of the teaching of geriatric medicine at the undergraduate level, which appears to be under threat. The anxieties centred on three main areas – the role of Academic Departments in Geriatric Medicine in teaching, the relatively low emphasis on the issues of older people within General Medical Council Guidelines, and the reliance on non-geriatrician mentors to inspire students about older people when supervising problem-based learning.

Role of Academic Departments
There are many medical schools that have failed to appoint to Chairs in geriatric medicine or have been “considering” the future of professorships within the specialty. Nottingham, Birmingham, St George’s and Liverpool have all recently had Professors of Geriatric Medicine, but now do not. Of the new medical schools, only Keele and Warwick have Professors of Geriatric Medicine. Traditionally, departments in medical schools have had a broad academic remit that has included undergraduate education, postgraduate training, MD/PhD student supervision and research. Most medical schools now are closing smaller departments and amalgamating them into larger, primarily research focussed units. At Keele all medical school researchers are now in one of three Institutes. The main driver for this change is to try and ensure the highest quality of research, thus achieving a high score in the next Research Assessment Exercise (RAE). Although the details of the next assessment are not finalised it is likely that there will be an even more selective distribution of research funding than was the case at the last RAE in 2001. The evidence suggests that bigger units do better than smaller units. Whether one likes it or not, the quality of the undergraduate educational experience is of lesser financial importance to a medical school given that there is still a two-to-one oversupply of applicants with the necessary Advanced level requirements of 2 As and a B.

The approach we have adopted at Keele is that the major responsibility for delivering the curriculum should rest with senior lecturers in medical education, drawn from a variety of disciplinary backgrounds, who have this task as their major academic responsibility. Such post-holders will be expected to undertake post-graduate training in medical education, at least to Diploma level.

Tomorrow’s doctors
Last year the General Medical Council produced an updated version of their key document “Tomorrows Doctors”: www.gmc-uk.org/ med_ed/default.htm. Relevant points include the view that the core curriculum that all students take should be reduced to 65-75% of the course, with the remainder being “student-selected”. The anxiety here is that the proportion of time devoted to compulsory attendance at geriatric medicine would be reduced. This is coupled with the clear view that the medical student can not be expected to learn everything and that factual information should be kept to a minimum. On the other hand, the ability to offer innovative and stimulating special study options in the remainder of the course may act as a counterbalance.

Geriatric Medicine is not mentioned specifically in “Tomorrow’s Doctors”. However, the importance of understanding the particular problems of vulnerable groups, including the disabled and those with chronic conditions, is stressed repeatedly. Older people are mentioned specifically. There is a requirement to respect patients regardless of their lifestyle, culture, beliefs, colour, gender, sexuality, disability, age, or social or economic status. Young doctors must understand human development and areas of psychology and sociology relevant to medicine, including growing old. Graduates must also be able to take account of patients’ understanding and experience of their condition, particularly vulnerable groups such as older people. Visiting an older person has been identified as good practice in early clinical involvement.

Problem based learning
Many medical schools have introduced problem-based learning as the major method of knowledge acquisition. Each week there is a problem e.g. an older person with dementia which the students collectively try and understand, utilising a variety of learning opportunities. Problem-based learning tutors may come from a range of backgrounds. Their role is to facilitate student-learning rather than to impart knowledge. The argument has been advanced at the meetings mentioned earlier in this article that it is essential that a geriatrician directs learning about geriatric medicine rather than leave this to clinicians from other disciplines who, although they may be trained in problem-based techniques, may still impart negative attitudes.

Next steps
There are clearly differences of view about the way forward, the two contrasting views being that all students must have a compulsory attachment to a geriatric medicine unit, or on the other hand, geriatric medicine is best taught by including issues of ageing and disability throughout the curriculum. The Association of Professors of Geriatric Medicine wish to undertake a survey of the present status of undergraduate geriatric medicine teaching, its organisation and the role of academic departments in devising, co-ordinating and delivering locally based curricula. We would hope to obtain a 100% response from Medical Schools. This information would be supplemented by a separate survey of the views of the members of the Training Committee and the Association of Professors on the way forward for the next decade. I have been asked by the Association of Professors to lead on this and I would be delighted to hear from anyone who has something to say on the subject.

Peter Crome
Deputy Head of the Medical School
and Professor of Geriatric Medicine,
University of Keele