1. Introduction

1.1 The first publication of "Tomorrow's doctors" by the General Medical Council (GMC) in 1993 [1] heralded a change in the delivery of undergraduate education, with the emphasis shifting from the acquisition of knowledge to a learning process including the development of skills to communicate effectively with patients and colleagues and evaluate data. As a result most medical schools evaluated and restructured their curriculum.

1.2 In their updated guidance in 2003 [2] the GMC emphasise the need for medical graduates to meet the principles of professional medical practice as set out in "Good medical practice" [3] and identified the knowledge, skills, attitudes and behaviour expected of all new graduates.

1.3 All undergraduate curricula must have a core consisting of the essential knowledge, skills and attitudes which students must have by the time they graduate, supported by student-selected components (special study modules) occupying 25-33% of a five year curriculum. These enable students to study topics in more detail, develop self directed learning and become familiar with research and presentation skills.

1.4 In this document the British Geriatrics Society Education and Training Committee (BGSETC) sets out what it believes should be the curriculum in Geriatric Medicine and Gerontology for all medical undergraduates. This document draws on recent GMC guidance [2] and focuses on areas which are of particular relevance to older people and the specialty, and should be considered in addition to basic history and examination skills which form the generic content of all undergraduate curricula. Whilst most of the learning objectives in Geriatric Medicine should be included within the core curriculum, many areas of the ageing and the health of older people can be studied as student-selected components.

1.5 It is important that all new medical graduates are prepared for life-long learning. The core undergraduate curriculum in Geriatric Medicine can be regarded as a basis upon which Foundation Year (FY1 and FY2) and Specialist Training (ST) doctors can build their educational objectives on [4, 5]. However it cannot be assumed that doctors will have further education in Geriatric Medicine and the undergraduate curriculum is designed to ensure that all graduates have the essential knowledge and abilities to manage older people.

1.6 Students and recent graduates should have the following knowledge, skills and attitudes:

2. Knowledge
2.1 The ageing process and theories of ageing. The biological changes associated with ageing, loss of reserve and altered homeostasis and how these may affect pathological processes.

2.2 Evidence-based approaches to enhancing health and active life in old age. Including primary prevention (a healthy lifestyle) and secondary prevention (modifying factors which may reduce the risk of developing other health problems e.g. treating hypertension to prevent vascular disease).

2.3 The diagnosis, analysis and basic management of the specific problems listed below (including the so called "geriatric giants"). These do not occur exclusively in elderly people but are commonly seen in this age group and form the major workload of any service looking after elderly people.

• Multiple problems: physical and mental disease, functional difficulties and inadequate social support.
• Falls
• Mobility difficulties
• Urinary and faecal continence
• Stroke and cerebrovascular disease
• Delirium and dementia
• Depression
• Communication and visual difficulties
• The principles of palliative care and relieving pain, distress and symptom control.
• The cause and prevention of pressure sores.
• Malnutrition
• Parkinson's Disease and Parkinsonism
• Ischaemic heart disease and heart failure
• Chronic Obstructive Pulmonary Disease (COPD)
• Rheumatoid arthritis and Osteoarthritis
• Osteoporosis
• Diabetes mellitus
• Polymyalgia rheumatica and temporal arteritis

2.4 The change in demography and the role older people have in our society. How the proportion of older people in society may influence resource provision, utilization and delivery of care.

2.5 The differences in disease patterns and the presentation of illness in older people including multiple pathology and non-specific presentation.

2.6 Understand the interrelationships of function, health and disability, including the social impact of disability (WHO International Classification of Functioning, Disability and Health (ICF)[6]) and the commonest causes of disability in older people.

2.7 How to appropriately investigate an older person

2.8 How to prescribe medication appropriately for older people, know the indications and side effects of commonly used drugs. Ensure older people are not denied appropriate treatment because of their age. Be aware of the problems of multiple drug therapy and the problems this may cause.

2.9 The process and principles of rehabilitation in hospital and community settings, the importance of functional assessment and what may realistically be achieved. The importance of goal setting in rehabilitation, the roles of other members of the multidisciplinary team and the influence of socio-economic factors.

2.10 Community services available to support frail older people and the importance of planning in the discharge process. The inter-relationships between health and social services and the interface between primary, intermediate and secondary care.

2.11 Criteria for appropriate institutional care for the older people who need it.

2.12 Ethical and legal issues relating to older people including: consent to treatment, capacity to make decisions, safe-guarding finances, withdrawing and withholding treatment, elder abuse and cardio-pulmonary resuscitation decisions.

3. Skills

3.1 Take a history from an elderly person, including information on social support and functional ability. Modifying the approach when dealing with a patient with confusion or a communication difficulty. Recognise the need to take a history from a third party in certain situations and the importance of information provided by relatives/carers.

3.2 Performing a full physical examination of elderly people including those systems often affected by illness in old age (locomotor, nervous and cardio-respiratory systems). Know that some physical signs may be absent or altered in old age.

3.3 Be familiar with commonly used assessment scales in managing older people including those used to:

• Assess mental state e.g. Mini Mental State Examination
• Assess depression e.g. Geriatric Depression Scale
• Assess physical function e.g. Barthel Activities of Daily Living score

3.4 Be able to appropriately investigate an elderly patient and interpret basic x-rays and laboratory data.

3.5. Be able to prescribe drugs appropriately and safely, and evaluate their efficacy.

3.6 Recognise patients with psychiatric illness, and when to refer to Departments of Old Age Psychiatry.

3.7 Recognise which patients may benefit from rehabilitation, and those needing further assessment by other members of the multi-disciplinary team before discharge from hospital, and how to refer to community support services.

3.8 Communicate clearly and effectively with older patients, their relatives and colleagues from a variety of health and social care professions. These skills include:

• The ability to relate to patients, their families and carers. Be able to discuss with them their medical problems, plans for discharge and support, providing sufficient information in a way that is easy to understand.
• The ability to communicate with older people regardless of their background or disability.
• The ability to relate to older people with communication difficulties and to know how communication can be facilitated in these situations.
• The ability to work as a member of a team with colleagues, including General Practitioners, professions allied to medicine and representatives from social services. Recognise the importance of communicating effectively (verbal and written) with other members of the team to optimize patient care and treatment. Recognize the need to keep good medical records, documenting changes in progress and recording conversations with families and carers.
• The ability to communicate with patients and carers in potentially difficult situations such as breaking bad news or bereavement.

3.9 Carry out basic practical procedures safely and effectively, including a bedside swallow assessment.

4. Attitudes

4.1 Understand the importance of maintaining a professional approach to the care of older people.

4.2 Respect older patients' rights regardless of their background, culture, lifestyle, beliefs, race, gender, sexuality, disability, social or economic status. Recognising the negative attitudes which can be displayed towards older people ("Ageism").

4.3 Appreciating the important role of geriatric medicine in elderly care and understanding that an acute hospital is only part of many services available for older people.

4.4 Respect patient confidentiality and recognize the potential problems of communicating with relatives and carers.

4.5 Understand the principles of autonomy, capacity to make decisions and consent to treatment and the need to involve patients in decisions about their own care, including their right to refuse treatment or take part in teaching or research. Understand the “best interest” principle for those lacking the capacity to exercise their autonomy.

4.6 Be aware of the ethical issues which may be involved in caring for older people such as withdrawing and withholding treatment and resuscitation decision making.

4.7 Students should examine their own attitude to old age, death and disability and how this may affect their care of older people.

4.8 Respect the roles and expertise of other health and social care professionals in the care of older people.

4.9 Show an awareness of the political and economic influences on health care.

4.10 Demonstrate sensitivity to the balance between prolongation and quality of life.

4.11 Understand the concept of a "good death"

5. Core Competencies

5.1 The undergraduate curriculum in Geriatric Medicine will enable graduates to develop the following core competencies:

a. Take a history from an elderly person, including information on social support and functional ability and be able to modify the approach in the context of common problems associated with ageing and ill health. Perform thorough physical and mental state examinations.
b. Use this information to formulate a differential diagnosis and problem list and prepare an
initial management plan. Where appropriate the diagnostic formulation should take into account information gained from the members of the multidisciplinary team.
c. Being able to plan safe discharge of older people from hospital by taking into account information gained from members of the multi-disciplinary (sometimes multi-agency) team.

6. Learning Opportunities

6.1 Geriatric Medicine provides excellent learning opportunities for medical undergraduates. Good quality care of older people requires a multi-disciplinary approach and older people may be treated in a variety of different settings. Communication with patients, carers and other professionals is of paramount importance to the optimal care of older people and ethical dilemmas frequently occur in clinical practice. Geriatricians and gerontologists not involved in designing undergraduate curricula should liaise with those who are, promoting the many learning opportunities that the specialty offers.

6.2 It is important that the thread of ageing and the health of older people runs through an integrated medical undergraduate course. The curriculum in Geriatric Medicine can be adapted for different course modules e.g. community or hospital based or means of learning e.g. problem-based.

6.3 The BGSETC recommends that all students should have the opportunity to learn about the treatment and care of older people in a module attached to a specialist department. The attachment should be long enough (at least four weeks) to enable students to see patients respond to treatment and progress with a multi-disciplinary approach to management.

6.4 Some medical schools have found that educating medical undergraduates about teamwork can be enhanced by learning in multi-disciplinary groups with students from other professions allied to medicine such as physiotherapy and occupational therapy.

7. Assessments

7.1 Methods of assessment should support the curriculum and undergraduates must demonstrate that they have met the curricular objectives. Students must be assessed in the core and student selected components of the curriculum.

7.2 There are a variety of different and complementary forms of assessment. The Objective Structured Clinical Examination (OSCE) is a particularly useful method and the Geriatric Medicine curriculum lends itself particularly well to this approach. Assessments can take place at the end of an attachment or module which includes Geriatric Medicine, and/or in the final examinations for a primary medical qualification. Different stations can be incorporated in the OSCE relevant to the specialty curriculum such as history and examination (including mental state), communication skills (using simulators), practical skills (using manikins), treatment/prescribing and discharge planning stations. Many aspects of the curriculum, especially knowledge can also be assessed in specific or medical or psychiatric written exams. A variety of assessment methods can be used, ideally in combination.

7.3 The BGSETC recognises that the curriculum objectives and design will differ between medical schools. The Geriatric Medicine curriculum should be regarded as a framework which can be adapted and modified to suit all undergraduate curricula.

8. References

1. Tomorrow's doctors: Recommendations on undergraduate medical education. General
Medical Council 1993
2. Tomorrow's doctors General Medical Council 2003
3. Good Medical Practice. General Medical Council 2001
4. British Geriatrics Society and Royal College of General Practitioners. Training General Practitioners in Geriatric Medicine. J Royal College Gen Pract 1978; 28: 355-9
5. Core Curriculum for SHOs in General (Internal) Medicine and Medical Specialties. 4th Edition. Federation of Royal College of Physicians 2003
6. The International Classification of Functioning, Disability and Health - ICF. World Health Organisation 2001.

Review date: July 2010 Author : Tash Masud for BGS Education & Training Committee