Teaching Geriatrics in Medical Education II

Department of Ageing and Life Course and IFMSA

In response to the global demographics challenges, WHO launched a new programme on ageing and health in 1995 designed to advance the state of knowledge about how ageing impacts on public health, health care in old age and gerontology through special training and research efforts, information dissemination and policy development1.

The programme’s perspectives focus on the following: • approaching ageing as part of the life course rather than compartmentalizing health promotion and health care for older people; • concentrating on the process of healthy ageing and the promotion of long-term health; • respecting cultural contexts and influences; • adopting community-based approaches by emphasizing the community as a key setting for interventions, taking into account that many health problems need to be dealt with outside the health sector; • recognizing gender differences; • strengthening intergenerational links; • respecting and understanding ethical issues related to health and well-being in old age

In all countries and in developing countries in particular, measures to help older people remain healthy and active are a necessity, not a luxury.

To promote active ageing, health systems need to take a life course perspective that focuses on health promotion, disease prevention and equitable access to quality primary health care and long-term care.

It is time for a new paradigm, one that views older people as active participants in an age-integrated society and as active contributors as well as beneficiaries of development.

Ageing and Life Course, WHO

Our mission is to offer future physicians a comprehensive introduction to global health issues. Through our programming and opportunities, we develop culturally sensitive students of medicine, intent on influencing the transnational inequalities that shape the health of our planet.

IFMSA (International Federation of Medical Students Associations) Mission Statement

Contents

Acknowledgements Background

The TeGEME II Study

Methodology • Coding • Participants • Confounding factors • Type of analysis o Table 1: Number of Medical Schools and Medical Schools Participation per Country Results • Americas o Bolivia o Chile o Panama o Peru • Europe o Bulgaria o Czech Republic o Finland o Germany o Malta o Norway o Romania o Spain o Switzerland o United Kingdom • Asia o Lebanon o Hong Kong o Malaysia o Pakistan o Thailand • Africa o Ghana o Nigeria o South Africa o Sudan o Tanzania Discussion

Appendices

Appendix I: ASD Table for all Countries Appendix II: Medical Schools for all Countries Appendix III: Case Study – Ghana Appendix IV: Case Study – United Kingdom Acknowledgements

The Teaching Geriatrics in Medical Education II Study was conducted between March 2005 and August 2007. The study report was assembled by Dr Nidhi Gupta (UK), and co-written and coordinated by Dr Nidhi Gupta, Dr Manuela Moraru (Romania), and Dr Jo Lyn Chooi (UK), and co- written by Dr Colin Brown (UK). The study was supervised by Ms. Ingrid Keller (Associated Professional Officer with WHO/ALC) and Dr. Alexandre Kalache, Coordinator WHO/ALC.

Additional IFSMA support: Dr. Nikola Borojevic (Croatia), Dr. Jacco Veldhuyzen (the Netherlands) and Dr. Arttu Makipaa (Finlnd), Dr. Wael Shamseddeen (Lebanon) and Dr. Usman Ahmad (Pakistan).

The support of all the Standing Committee for Medical Education Directors, and those active members who helped with the project in its early stages, is much appreciated. The results from Africa were collated by Dr. Ntobeko Nutsi (South Africa).

The data collection would have been impossible without the support all of the National Focal Points (in bold) and Local Focal Points in the participating countries. Our appreciation goes to:

Europe: Bulgaria: Rishabh Kedia; Czech Republic: Marek Nemek, Petr Houska, Lenka Bosanska, Jan Latta, Mariana Zarubova, Tereza Luzna, Magdalena Klimesova, Andrea Svinkova Tomas Indruch, Zuzana Elbertova, Michal Lesko Amir Zolal, Mirka Casova Lucia Frcova, Matej Smizansky, Hana Lattova; ;k, Tuuli Savolainen, Ossi Kaijanen, Sara TornbergنFinland: Suvi Vainiom Germany: Malte Braunroth, Jan Hilgers, Thorsten Hornung, Jan Baier, Philipp Schweinfurt; Malta: Philip Amato Gauci; Norway: Rita Helleren, Sigrid Bjrondal, Camilla Smedtorp, Hansen Torstein Schroder, Renee B. Alstad; Portugal: Francisco Botelho, Nono Fereira Francisco; Romania: Sebastian Manoleasa, Maria Opritoiu, Cristina Apostol, Silvia Pop, Alexandra Moraru; Spain: Manuela Moraru, Aida Rodriguez Sainz, Elsa de la Fuente Briongos, Nuria Millán guez Cubillo, Sandra AudiيGarcía del Real, Xoana Barros Freiria , Beatriz Rodr Lapiedra, Diego Jarast; Switzerland: Camille Piguet; United Kingdom: Colin Brown, Aurélie Hay-David, Nicholas Foster, Bilal Jamal, Catherine Grier, Jasmin Ohlsson, Celine Vousden, Nabihah Sachedina, Balvinder Sagoo, Raguwinder Bindy Sahota, Phillip Williams, Catherine Fletcher, Ciarán Trolan, Nishamali Jayatileke, Leigh Bissett, Ben Lawton, Aleem Sachedina.

Americas: Bolivia: Cristian Ayala Carreo; Chile: Maricarmen Andrade and Jose Manuel Burgueno Rivera; Daniela Andrea Meza Benavides, Leonardo Hernan Santander Hess, Alicia Francisca Muos Araneda; Panama: Tathiana Castillo, Yarisel Carrasco, Kevin Cedeo; Peru: Vanessa Karina Valderrama Victoria, Yael Saavedra Valiente, Alfredo V. Laguna Urdanivia. Asia: Lebanon: Wael Shamseddeen; Hong Kong: Chiu Ka Fung Peter, Maggie Mok, Jack Tsang; Malaysia: Yeenwan Choong; Pakistan: Usman Ahmad Raza, Fahd Anzaar, Abdullah Muhammad Rana, Durreshahwar Khursheed, Ayesha Khan, Bakht Taj, Saadia Wahid, Fahad Nauman Safir, Samar Zia, Muhammad Omar Butt, Bilal Kiran, Salman Gohar, Sabeen Shah, Mohammad Tariq Ali, Waseem Mohammad, Fahad Ajmal, Faris Khan; Thailand: Poranee Ganokroj, Nacha Harinrak , Aekarach Ariyachaipanich, Piyasak Vitayaburananont.

Africa: We would also like to thank all of the coordinators and participants from Ghana, Nigeria, South Africa, Sudan and Tanzania. Background

Global population ageing is an important challenge and opportunity to be addressed by virtually all countries. Population ageing changes the nature of demands on health care systems, which will have to accommodate the needs of the older population as well the care-needs of other population age groups. This will be especially the case in less developed countries, where health systems capacity is already stretched and under-resourced.

Throughout the 21st century health professionals will increasingly be required to be familiar with old age care whatever the specialty they choose, because routine practice will increasingly include older patients. Thus, the basic principles of the special care-needs of older persons should not be of exclusive concern to specialists. The ALC has developed a fifteen-point template which has all the components.

Undergraduate Medical Education 1requires equipping healthcare professionals of tomorrow for the challenges of an ageing population. 1

In an attempt to assess how Geriatric Medicine is being taught world-wide, the WHO Ageing and Life Course Programme (ALC) devised a study, the Teaching Geriatric in Medical Education study I (TeGeME I), and in December 1999 invited the International Federation of Medical Students’ Associations (IFMSA) to be a close collaborator in its implementation.

The main goal of the TeGeME I study was to gain insight on if and how ageing issues are incorporated into the medical curriculum world-wide. WHO strongly advocates that all future medical doctors need to be well trained in ageing issues and in care of older persons, since most future doctors will see increasing numbers of older persons in daily practice. From the data obtained from 36 countries, the conclusion was that the majority of the health care systems were not prepared to provide adequate care to a growing older population even though a steep increase in the older population is predicted for decades to come.

In 2002 the Teaching Geriatrics in Medical Education Study II (TeGeME II) was devised to explore further the area of Geriatric Teaching and Medical Students' Attitudes. Again, the IFMSA was a close collaborator in its implementation and coordination.

The main goal of the TeGeME II study was to gain an insight into how clinical medical students view the older generation, relating their opinions to the extent of Geriatric training received and their personal and social interactions with the older generation. Today’s students need to acquire knowledge about how to treat older persons from an interdisciplinary point of view. WHO has established a firm partnership with IFMSA with the ultimate aim of fostering the adoption of Geriatric Medicine in the medical curriculum worldwide.

One of the main features of the world population over the last few decades has been rapid increase in the absolute and relative numbers of older people in both developing and developed countries. This trend will accelerate over the next two or three decades. The total number of older people (defined as 60 years of age and over) world-wide is expected to increase from 605 million in 2000 to 1.2 billion by the year 20252. Currently, about 60% of older persons live in the developing world. This number is expected to increase to 75% (843 million) by the year 2025 and 85% in 2050. Figure 1 shows the proportional increase of older persons among the total population for selected developing countries.

1 World Health Organisation. International Association of Gerontology and Geriatrics: Geriatric Medicine: basic contents for Undergraduate Medical Students 2 United Nations, World Population Prospects: the 2000 update

3 Source

In 2000, for the first time, there were more people aged 60 and older than children under 14 in a number of developed countries such as Germany, Japan and Spain.3 Population ageing could be compared to a silent revolution that will impact on all aspects of society. It is imperative that we prepare ourselves in the most appropriate way as the opportunities and the challenges created by population ageing will fundamentally change the way societies are structured.

Rapid ageing in developing countries In 1950 the average life expectancy at birth (LEB) in most of the developing world was around 40 years. By 2000 it had increased to 64 years and it is projected to reach 71 years by 20252. With the exception of those Sub-Saharan countries, which have been hit hardest by the HIV/AIDS epidemics, the LEB has constantly increased in all developing countries over the last few decades. For example, in India LEB for both sexes increased from 53 years in 1975 to 64 years in 2000 and is expected to reach 72 years by 2025. Respective figures for Thailand are 61, 70 and 77 years and for Brazil 60, 68 and 74 years2. Already over 40 countries in the developing world have a LEB of 70 years or over2.

These rapid increases in LEB reflect sharp declines in mortality rates, particularly through the prevention and/or treatment of diseases associated with premature death. The advent of specific treatment for a range of infectious diseases, such as, tuberculosis, respiratory infections and gastroenteritis in childhood, in addition to immunization programmes against many others such as diphtheria, poliomyelitis and measles, contributed to the survival of millions of children to adulthood throughout the developing world within the last 50 years. These adults are now ageing. Furthermore, life expectancy of older adults in developing countries is not much smaller than that in the high- income countries. For instance, life expectancy at the age of 60 in Canada in 2010 is predicted to be 25/21 for women/men; respective figures in Mexico are 22/21, Japan is 27/22, China 20/17 and 4 Thailand20/17 again .

3 Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. World Population Prospects: the 2004 revision. World Urbanization Prospects: the 2003 revision 4 Organization for Economic Co-operation and Development (OECD), Health Data Database, Paris, 1998 Obviously, for countries to age it is necessary that large proportions of their populations survive into old age. However, the speed of the process is even more influenced by what happens at the bottom of the age distribution, affecting the number of young individuals in the population. The recent trends in this respect have taken demographers by surprise: the speed of decline of fertility rates since the 1970s in developing countries could not have been predicted in the 1970s. Once again, interventions based on medical technology were instrumental. The availability of modern contraceptive methods has made it possible to have sharp fertility rate declines in only a few years. For example, in Brazil the fertility rate was 5.8 and in 2002 2.2.

World-wide trends in life expectancy at birth and in fertility rates are summarized in Figures 2 and 3. In both cases, the vast differential between developed and developing countries are rapidly decreasing. Figure 2

Figure 3

The combined effect of this shift from high to low mortality and from high to low fertility (commonly referred to as the demographic transition) is population ageing: fewer children enter the population while more individuals survive into old age.

The epidemiological transition Population ageing will increasingly bring important challenges to health care policy makers. This is particularly so because of the changing pattern of diseases, translated into changing causes of death and morbidity - commonly referred to as the epidemiological transition. This term describes the increasing importance of disease and death attributable to non-communicable diseases (NCDs) happening simultaneously with to a decrease in the importance of infectious diseases. While obviously welcome, the gradual shift away from infectious diseases towards NCDs poses a different sort of challenge for developing countries. According to WHO estimates, in 1990 about 50% of the burden of disease in developing countries was attributable to communicable diseases, around 40% to NCDs (including neuropsychiatric diseases) and the remaining share attributable to external causes (mostly injuries). By 2020 a very different picture will have emerged: NCDs and injuries are expected to be responsible for over three-quarters of the disease burden in developing countries and newly- industrialized countries (Figure 4).

Source 5,6

That is not to say, however, that infectious diseases will have disappeared in the foreseeable future. While they are expected to decrease in importance as a cause of morbidity, resources will continue to be required for both the treatment and the prevention of infectious diseases. At the same time NCDs will increase in both prevalence and cause of death in most of the developing countries. Hence, the term double burden of disease has been used to reflect what will emerge as a dominant feature of public health within the next few decades in the majority of developing countries.

5 Guralnik JM, LaCroix AZ, Everett DF, Kovar MG. Ageing in the eighties: The prevalence of co-morbidity and its association with disability. Advance data from vital and health statistics. No. 170. US National Centre for Health Statistics, 1989 6 WHO, Evidence, Information and Policy Cluster, Global Burden of Disease database, 2000

The challenge for health systems The increasing percentage of older persons in the population leads to significant changes in the demands on health care systems. This is particularly important in countries where only incipient health insurance or social security systems exist. New and innovative plans for community health care and long term care for the aged are urgently required to counteract factors such as urbanization, changes in family structure and participation of women in the paid work force. Further, as health care systems in developing countries become increasingly challenged by the double burden of disease, the ensuing issues become particularly complex. Primary health care workers, in particular, will be required to be well-trained in prevention and treatment of NCDs. This training should embrace a multi-disciplinary perspective.

Particular attention should be given to the special care-needs of older persons, reflecting the fact that they include medical conditions unique to this age group. For example, comorbidity is diagnosed in the USA in more than 50% of older people6 and severe walking disabilities are seen in approximately 10% of older individuals7. Additionally, when choosing the dosage of medication for older patients, health care providers need to take the age of the patient into consideration as well as the risks of polypharmacy and iatrogenic disease (the result of a lack of appropriate consideration of side effects)8. Further, cognitively impaired patients might fail to remember to take their medications, or take an inappropriate dosage. Some older patients may also be in special need for care of their emotional and spiritual well-being, in particular when loved ones, especially spouses, may have died.

There are at least 30 different "Geriatric syndromes" including social, mental and physical problems which can only be well attended by specially trained health care providers. This includes nurses, doctors, social workers, caregivers and policy makers acting at all levels starting from primary health care to the specialized unit at a tertiary hospital, rehabilitation and long-term care facilities, as well as in the office of the local or national health care authorities. At present, only through well-designed educational programmes in Geriatrics and gerontology can a well- planned infrastructure to support older people's care be developed.

For all the above reasons, the demand for knowledge of “older age care” will increase as the number of older persons increases throughout the world – in the developed countries which are continuing to age, and in the developing world which is ageing rapidly.

This will be particularly so if societies and individuals do not incite themselves to achieve health through the process of active ageing. In this respect, ALC has been actively promoting the concept of “active ageing”, which is defined as: the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. In addition, the life-course perspective has been central to ALC efforts to hang the paradigm of health and ageing, as it is illustrated in Figure 5.

Figure 6 shows the three determinants of active ageing.

7 Rantanen T, Guralnik JM, Ferrucci L, Leveille SG, Fried LP. Coimpairments: strength and balance as predictors of severe walking disability, J of Gerontology, Medical Sciences, 1999, Vol. 54A, No. 4, M172 – M176 8 Maelly & Duggan. The pharmacology of ageing, in: Pathy, (ed.) Principles and Practice of Geriatric Medicine, Second Edition, John Wiley and Sons, 1991

Figure 5

9 Source

Functional capacity (such as ventilatory capacity, muscular strength, and cardio-vascular output) increases in childhood and peaks in early adulthood, eventually followed by a decline. The rate of decline, however, is largely determined by factors related to adult lifestyle – such as smoking, alcohol consumption, levels of physical activity and diet. The gradient of decline may become so steep as to result in premature disability. However, the acceleration in decline may be influenced at any age through individual as well as policy measures. Smoking cessation and small increases in the level of physical fitness, for example, reduce the risk of developing coronary heart disease. Conditioning by social class also affects functional capacity -- poor education, poverty, and harmful living and working conditions all make reduced functional capacity more likely in later life. For those who become disabled, provision of rehabilitation, adaptations of the physical environment and specific interventions e.g. cataract surgery, can greatly reduce the level of disability. Quality of life should be a major consideration throughout the life course. Changes in living environment can vastly improve quality of life. Gains are obtained by supporting the ‘care unit’ – in most case the family and close friends. Through appropriate environmental changes such as adequate public transport in urban environments, lifts, ramps, and adaptations in the home – the disability threshold can be lowered. Such changes can ensure a more independent life well into very old age.

Figure 6 - The three determinants of Active Ageing

9 World Health Organisation, Ageing and Life Course Programme, 2000, [email protected] The TeGEME II Study ALC strongly believes in medical students as agents of change and natural leaders in reforming medical education. Taking this into consideration, and prompted by the speed at which the global population is ageing, WHO and IFMSA continued their collaboration and launched Teaching Geriatrics in Medical Education Study II (TeGEME II), a study focusing on medical students’ attitudes towards the older population and determining whether their views correlates with the degree of Geriatric teaching received and their level of social and familial contact with the older generation.

Teaching Geriatrics in Medical Education I looked into the actual Geriatric content of undergraduate medical education and its emphasis in undergraduate training.

Methodology A single questionnaire was designed by the IFMSA and WHO, incorporating the Age Semantic Differential Scale developed by Rosencranz and McNevin (1969)10, an instrument to measure attitudes towards populations of all ages, using 32 opposite adjective pairs on a 7 point scale. Additional information was sought focusing on the age, sex of the student, year of clinical study, degree of Geriatric teaching received and information regarding the level of familial contact with the older generation.

The questionnaires were then translated from English into Spanish, French and Portuguese by the IFMSA and these were validated by the WHO. The translations into Bulgarian, Norwegian, Finnish, Czech, Romanian and German languages were also carried out by IFMSA members from the native countries and validated internally.

One person was named the National Focal Point (NFP) for the TeGeME study in each country participating to our study. The NFP was the main national collaborator who became the liaison person for WHO and IFMSA, respectively for the coordinators of the study. They were responsible for the co-ordination, organisation and supervision of all TeGeME II activities within the country. Each NFP received from the coordinators of the study the questionnaire and detailed protocols about how to proceed. They were then asked to find and recruit local representatives from as many medical schools in their countries as possible. Those local representatives are referred to as Local Focal Points (LFP).

In order to receive credible results, the questionnaire has been translated in the majority of the countries participating to our study. It was the NFPs duty to organize the translation process. They had to assign the translation task to two persons unaware that they have the same task (and if possible, who did not know each other at all). After the initial translation process, the two versions were compared, and differences were discussed with both translators before a final a decision was made for the best form of translating each item. The translated questionnaire was then validated by asking several medical students to complete it, comment on its clarity and describe what additional explanations were required. The translated questionnaire, in its’ final form, was then sent to the WHO for a second validation, and then used for further data collection.

In addition, the NFPs answered any enquiries from the WHO and IFMSA and ensure that the LFPs met the deadlines.

Data Collection It was the LFPs duty to distribute the questionnaires among the students in their faculties. The data had to be collected only from medical students in the clinical years. To ensure a representative sample

10 Rosencranz HA, McNevin TE. A factor analysis of attitudes toward the aged. Gerontologist 1969: 9; 55-59 was obtained, the LFPs were asked to obtain at least 20% of all students in the clinical years in each medical school, and not less than 100 participants per school (unless there were less than 100 students in the clinical years in that particular school). Such non-statistical framework for size determination was accepted because we were interested in a descriptive and qualitative analysis. Although we did not follow a statistical framework of sampling, students filling in the questionnaires had to be chosen as randomly as possible. There were several ways the LFPs have chosen to select the surveyed students, depending on / considering the particularities of each school. Examples of these include:

- approaching randomly selected students during lectures, ensuring that all students in each clinical year were included in the selection and none would be picked up twice; - approaching randomly selected students during exams where all students form one particular year were supposed to be present; - mailing the questionnaire to randomly chosen students from a the list of all students in the clinical years (where this was accepted by the internal rules of the university and after previous commitment to ensure confidentiality); this method, even if proposed to the LFPs was not used in any of the medical faculties participating in the present study.

Coding All questionnaires were coded using MS Excel by the international coordinators, and NFPs, using an MS Excel Matrix that was designed by the IFMSA with detailed coding-guidelines in a codebook that guided the reader step-by-step through every question of the local questionnaire and gave precise instructions on how to code the individual answers. Coding the questionnaires involved transferring the information given in the questionnaires into definable variables of numeric and text values. Each of the seven-point Rosencranz scale was assigned a number of equal numeric values from 1 to 7. Each country was coded and analysed separately.

Type of Analysis 1. To analyse the data, the programmes Microsoft Excel and SPSS 11.0 were used. 2. A descriptive and then a non-parametrical analysis was performed for each sample, dividing the data from the ASD scale in 3 groups of variables, as established by Rosencranz and McNevin10. These 3 groups are: a) I – I Instrument – Ineffective, that measures views about older persons’ ability to be self directed and adaptive to change; b) A – D Autonomous – Dependant, that measures views about an older person’s ability to contribute to society; c) PA – U Personal Acceptability – Unacceptability, that measures views about the personal acceptability of elderly people and their ability to interact socially.

An example of one of the questions with the associated assigned numeric values:

Intelligent Unintelligent 1 2 3 4 5 6 7

The value of the participant for each characteristic were then combined with the values for the other participants from the same country and these were averaged to find the ASD, the average stratified score, which was then used to determine the opinion of the participant population. Lower scores in each of the groups indicated more positive attitudes in all dimensions. Scores lower than 4 indicate positive attitudes towards the focus population.

Participants Data was collected from 8761 medical students from 24 countries, on four continents. The degree of participation varied from country to country. It proved especially difficult to obtain data from all medical schools in countries which had a high number of them (e.g. Japan and USA). A complete list of all participating countries and the number of schools per country is provided in Appendix 1.

Confounding Factors There are a number of factors in the study which require adjustment in the interpretation of the results. One of the most important aspects is that not all universities took part in the study, in some instances only a handful. Hence, the representation these institutions have on the impression of the whole undergraduate medical system may be limited to a certain extent.

Number of Medical Schools and Medical Students’ Participation per Country

Country Number of Medical Number of Clinical Schools Participated Medical Students Participated EUROPE 47 4655 Bulgaria 2 133 Czech Republic 7 612 Finland 6 625 Germany 5 450 Malta 1 116 Norway 4 504 Romania 3 395 Spain 6 626 Switzerland 1 91 United Kingdom 12 1103 ASIA 15 1430 Lebanon 1 101 Hong Kong 2 221 Malaysia 1 103 Pakistan 8 851 Thailand 3 154 AMERICAS 12 1587 Bolivia 1 200 Chile 4 878 Panama 3 260 Peru 4 249 AFRICA 7 1035 Ghana 2 199 Nigeria 1 97 Sudan 1 82 Tanzania 1 105 South Africa 2 552 Total 8707

Results: Africa

Ghana

There are two medical Schools in Ghana, both of whom participated in the study. There is no Geriatric faculty or Geriatric wards in the affiliated hospitals. Geriatrics is not taught; the reason stated is that: “older persons are not a priority and as a result Geriatrics is not included in the national medical curriculum”.

The University of Ghana reports the intention to create a Geriatric sub-unit under internal medicine soon. The population of people aged 60 years and over accounts for 5% of the total population and is expected to rise to 7% by 2025.

Characteristics of Ghanaian medical students Number of participants 199 Average age of participants 25 % of Males 70.5% % of Females 29.5% Lived with grandparents for >5 years 39.2% % Undertaken Geriatric training 2% % Participants stating no Geriatric training present 30.7% % Considered Geriatric specialisation 6.7% % Of those who have had Geriatric training, who 0% have considered Geriatric specialisation % Of participants considering specialisation who 69% have lived for >5 years with grandparents

More than two thirds of the surveyed Ghanaian students were males. 69% of the students who have considered specializing in Geriatrics had lived with their grandparents for more than 5 years.

Age Semantic Differential ASD Differential Score Instrumental – Ineffective (I – I) 4.85 Autonomous – Dependent (A – D) 4.43 Personal Acceptability – 3.69 Unacceptability (PA – U) Overall ASD Score 4.22

The overall ASD indicates negative views of the older population, but the PA – U score was slightly lower indicating that there are some positive views regarding the older generation.

ASD I-I A-D PA-U ASD Overall 4.85 4.43 3.69 4.22 Lived with grandparents > 5 years 4.89 4.33 3.64 4.19 Lived with grandparents < 5 years 4.83 4.47 3.69 4.23 Considered specialisation 4.69 3.94 3.30 3.86 Did not consider specialisation 4.88 4.47 3.74 4.27

The ASD for those who lived with their grandparents was only slightly more positive than those who had not; however, the numbers in this group were not significant to be able to extrapolate to the general population under study. The only significant p-value for participants who had considered a career in Geriatrics was in the A-D (0.033). There were only 4 students who answered positive in the category of receiving Geriatric training and as such cannot be compared to those that have not received training in Geriatrics.

Nigeria

The University of Lagos, College of Medicine, took part and has a total of 1860 medical students of which only 97 students participated, only 5.2% of the student population.

Characteristics of Nigerian medical students Number of participants 97 Average age of participants 22 % of Males 78.4% % of Females 21.6% Lived with grandparents for >5 years No answers % Undertaken Geriatric training 6.2% % Participants stating no Geriatric training present 24.7% % Considered Geriatric specialisation 9.5% % Of those who have had Geriatric training, who 30% have considered Geriatric specialisation

Almost three quarts of the surveyed Nigerian medical students were males. Only 30% of the students who have considered a future career in Geriatrics had received specific training in this field.

ASD I-I A-D PA-U ASD Overall 4.61 4.39 4.02 4.29 Lived with grandparents > 5 years 4.51 3.78 3.66 3.93 Lived with grandparents < 5 years 4.68 4.53 4.10 4.38 The ASD indicates a negative view of the older generation. All the ASD scores were lower in those that had considered Geriatrics as a specialty, however, this difference is not significant (p-values: I-I 0.84; A-D 0.052; PA-U 0.31 and ASD 0.18)

Due to the small numbers in each category it is difficult to ascertain the true population values and hence the medical students’ opinions.

South Africa

Two universities in South Africa took part: Stellenbosch University, Cape Town and University of Cape Town Medical School. The former has a Geriatric sub-unit under internal medicine. Geriatrics is an obligatory subject during the undergraduate course and postgraduate specialisation in Geriatrics is offered as part of specialization in internal medicine. The postgraduate Geriatrics course is 40 hours course taught in one block over 2 weeks which includes lectures, bed-side teaching and interaction with other health care professionals. South Africa’s over- 60 population currently stands at 5.9% but this is expected to rise to 11.5% in the year 2025.

Characteristics of South African medical students Number of participants 552 Average age of participants 22 % of Males 46.9% % of Females 53.1% Lived with grandparents for >5 years 33.5% % Undertaken Geriatric training 34.7% % Participants stating no Geriatric training present 8.7% % Considered Geriatric specialisation 10.5% % Of those who have had Geriatric training, who 31% have considered Geriatric specialisation % Of participants considering specialisation who 43% have lived for >5 years with grandparents

ASD I-I A-D PA-U ASD Overall 4.36 4.02 3.55 3.91 Lived with grandparents > 5 years 4.23 3.96 3.37 3.78 Lived with grandparents < 5 years 4.41 4.00 3.56 3.92 Considered specialisation 4.27 3.70 3.27 3.67 Did not consider specialisation 4.37 4.00 3.56 3.91 Students with Geriatric training 4.34 4.05 3.59 3.93 Students without Geriatric training 4.37 4.00 3.53 3.90

35% had training in Geriatric Medicine, much higher than the 19.7% of students with Geriatric Medicine training in the total survey population. No significant difference in attitudes in the proportion of medical students with co-residence with their grandparents was observed in comparison with the total survey population. The ASD scores for medical students living with their grandparents were all lower (more positive) than those that had not. However, only I – I had a significant p-value (0.038). The ASD scores for those who have received training in Geriatrics were lower than those who had not, and all were significant except I-I (p-values I-I 0.366; A-D 0.013; PA-U 0.016 and ASD 0.034) The ASD scores for medical students that had considered training in Geriatrics were equivocal to those that had not, indicating that their views were similar.

Sudan

Little is known regarding the medical curricula of Sudan and the presence of Geriatrics in that curriculum. 5.3% of Sudan’s population are over 60, in the year 2025 the percentage will be 7.7%. Characteristics of Sudanese medical students Number of participants 82 Average age of participants 24 % of Males 35.1% % of Females 63.9% Lived with grandparents for >5 years 40% % Undertaken Geriatric training 12.7% % Participants stating no Geriatric training present 35.1% % Considered Geriatric specialisation 13.2% % Of those who have had Geriatric training, who 50% have considered Geriatric specialisation % Of participants considering specialisation who 100% have lived for >5 years with grandparents

Almost two thirds of the participating Sudanese students were females. All Sudanese medical students who have considered specializing in Geriatrics have had training in this field.

ASD I-I A-D PA-U ASD Overall 4.05 3.59 3.03 3.47 Lived with grandparents > 5 years 3.90 3.62 2.99 3.41 Lived with grandparents < 5 years 4.17 3.58 3.08 3.53 Considered specialisation 3.73 3.88 3.24 3.54 Did not consider specialisation 4.07 3.47 3.00 3.43 Students with Geriatric training 3.88 3.88 3.68 3.79 Students without Geriatric training 4.09 3.53 2.89 3.40

A greater proportion of Sudanese students have lived with their grandparents in comparison with the total population surveyed, 40% vs. 36% respectively A smaller proportion of Sudanese students had taken a course in Geriatric Medicine in comparison with the total population surveyed, 6.7% vs. 19.7% respectively. A greater proportion of Sudanese students had an “intention to specialise” in Geriatric Medicine in comparison with the total population surveyed, 13.2% vs. 9.7% respectively, even though most had no previous training in this field. The overall ASD score of 3.47 indicates that Sudanese medical students have a positive view of the older generation. The overall ASD score for medical students that were living with their grandparents was lower that those that had not and hence the former had a more positive view of the older generation. Except for I - I category, the ASD scores were higher for medical students that had considered specialising in Geriatrics, compared with participants who had not. However, these differences were not significant at 5% level. The number of students was less than 100 and hence we cannot relate it to the population under investigation. However, from the few results obtained the results indicate a positive view of the older generation.

Tanzania

Little is known regarding the medical curricula of Tanzania and the role that Geriatrics is in medical education. 4.8% of the population in Tanzania are currently aged 60 and over. In the year 2025, 6.0% of the population will be over- 60.

Characteristics of Tanzanian medical students Number of participants 105 Average age of participants 27 % of Males 65.7% % of Females 34.3% Lived with grandparents for >5 years 38.5% % Undertaken Geriatric training 1.9% % Participants stating no Geriatric training present 23.3% % Considered Geriatric specialisation 9.6% % Of those who have had Geriatric training, who 0% have considered Geriatric specialisation % Of participants considering specialisation who 40% have lived for >5 years with grandparents

• The average age of 27 was higher than in other African countries. • None of the Tanzanian students who have considered specializing in Geriatrics previously participated in any Geriatrics course. Tanzania has no Geriatrics teaching during medical degree training.

ASD I-I A-D PA-U ASD Overall 4.21 4.28 4.19 4.22 Lived with grandparents > 5 years 4.21 4.23 4.14 4.18 Lived with grandparents < 5 years 4.19 4.30 4.22 4.24 Considered specialisation 3.97 3.47 3.81 3.76 Did not consider specialisation 4.20 4.42 4.27 4.29

All the results are over 4.0 indicating negative views of the older generation. The ASD scores for Tanzanian medical students who had and had not lived with their grandparents were equivocal, with little differentiation. The ASD scores for the Tanzanian students who have considered a career in Geriatrics were all lower that the ones of the rest of the Tanzanian medical students surveyed. Only the A – D category had a significant p-value (0.010), with a significantly more positive ASD score for the students who have considered specialising in Geriatrics. 1.9% of participants said they had Geriatric training, however, this will not have been formal teaching as there is none in the medical curricula in Tanzania. Overall there are negative attitudes amongst the Tanzanian medical students.

African Analysis

Both universities of South African participants had Geriatric departments and as such 67% of all students who had had Geriatric training were from South Africa. Also, the greater number of South African student participants would have affected this result. 5.2 % of the total population in Africa are currently over 60. By the year 2025, this will have become 6.4%.

Characteristics of African medical students Number of participants 1035 Average age of participants 25 % of Males 70.5% % of Females 29.5% Lived with grandparents for >5 years 39.2% % Undertaken Geriatric training 2% % Participants stating no Geriatric training present 30.7% % Considered Geriatric specialisation 6.7% % Of those who have had Geriatric training, who 26% have considered Geriatric specialisation % Of participants considering specialisation who 51% have lived for >5 years with grandparents

More than two thirds of the African medical students participating in our study were males. More than half of the African students who have considered a career in Geriatrics had lived with their grandparents for more than 5 years.

Age Semantic Differential ASD Differential Score Instrumental – Ineffective (I – I) 4.44 Autonomous – Dependent (A – D) 4.12 Personal Acceptability – 3.64 Unacceptability (PA – U) Overall ASD Score 4.00

In examining single attributes, African medical students viewed older persons as more dependent (4.7), conservative (5.0), old-fashioned (4.9), inflexible (4.7), weak (4.6) and unhealthy (4.6), i.e. the A-D ASD scores were high and hence more negative. However, the PA-U ASD scores were lower and hence more positive, i.e. generous (2.9), friendly (2.8), neat (3.4), trustful (3.4) and pleasant (3.0), in comparison with the general population. No notable differences for gender were observed. Sudan had the lowest overall ASD scores in the continent at 3.47 while Nigeria had the highest at 4.29.

Overall ASD scores for Africa

6.00

5.00

4.00

3.00 ASD scores

Scores 2.00

1.00

0.00 AFRICA South Ghana Nigeria Sudan Tanzania Africa Countries

ASD for medical students living with grandparents ASD Lived with Lived with grandparents >5 grandparents < 5 years years or not at all I-I 4.37 4.46 A-D 4.05 4.10 PA-U 3.54 3.63 ASD 3.91 3.99

Students who had co-resided with their grandparents in their formative years were significantly (p<0.001) more likely to express the “intention to specialise” in Geriatric Medicine. Of the 92 students who had the “intention to specialise” in Geriatric Medicine, 51% had lived with their grandparents for 5 years, in comparison with the total survey population (36%).

ASD for medical students considering Geriatric specialisation ASD Considered Did not consider p-value specialising in specialising in Geriatrics Geriatrics I-I 4.24 4.46 0.060 A-D 3.74 4.15 <0.001 PA-U 3.36 3.67 0.001 ASD 3.86 4.27 <0.001

The relationship between “intention to specialize” and co-residence with grandparents is two way: students who had lived with their grandparents for longer than 5 years were more likely to consider specialisation in Geriatric Medicine, while students who intended to specialise had more positive attitudes towards older persons.

ASD for medical students’ training in Geriatrics SD Received training Did not receive in Geriatrics training in Geriatrics I-I 4.30 4.48 A-D 4.03 4.13 PA-U 3.61 3.65 ASD 3.92 4.02

Medical students who had received training in Geriatrics had more positive views of older people, but only just. The differences between the ASD scores of these two groups were not statistically significant. Results: Asia

Hong Kong

Both medical schools in Hong Kong participated in the study. The over 60 population of Hong Kong is expected to double between 2000 and 2025 from 14% to 28%. The Chinese University (CU) has a traditional curriculum, while the University of Hong Kong (UHK) has a problem-based curriculum. A national curriculum does not exist.

CU has an independent Geriatric faculty and a ward. UHK has a ward and Geriatrics is taught by Internal Medicine . In both schools Geriatrics is mandatory and post-graduate studies are offered. The content at UHK covers a broad range of aspects including “acute and chronic rehabilitative Geriatrics.” A life-course perspective is covered through “special sessions on 'Ageing' and 'Paediatrics & Adult Medicine' in the 4th year”. At CU, a class called ”Common presentation of illness in the older people, prescribing, age-related physiological changes, nutrition, rehabilitation, modes of service delivery, end of life issues and palliative care” is offered. Both schools offer a block course with lectures, bedside teaching and at UHK, problem-based learning. Field visits to older peoples’ homes are offered. There is interaction with nurses, psychiatrics and social workers. At CU there is also interaction with therapists, and at UHK with volunteers.11

Characteristics of Chinese medical students Number of participants 221 Average age of participants 23.5 years % of Males 43.5% % of Females 56.5% Lived with grandparents for >5 years 29.0% Clinical year differential 1st Year 73% 2nd Year 20% 3rd Year 7% 4th Year 0% % Undertaken Geriatric training 29.4% % Participants stating no Geriatric training present 9.1% % Considered Geriatric specialisation 42.1%

More women than men took part. Twice the percentage that had undertaken Geriatric training had considered Geriatric specialisation.

ASD I-I A-D PA-U Overall 4.55 4.04 3.88 Lived with grandparents > 5 years 4.32 3.87 3.90 Lived with grandparents < 5 years 4.65 4.11 3.87 Considered specialisation 4.43 3.99 3.82 Did not consider specialisation 4.69 4.09 3.93 Students with Geriatric training 4.67 4.17 3.98 Students without Geriatric training 4.55 4.0 3.85

11 Global Survey on Geriatrics in the Medical Curriculum, WHO/NMH/NPH/ALC/02.7

The overall ASD score indicated a slightly negative view of older people, 4.12. The most positive category was PA – U and the most negative view was in I – I. PA – U ASD scores were equivocal for those who had and had not live with their grandparents for more than 5 years. In the other two categories, students that had lived with their grandparents for more than 5 years had more positive ASD scores than those that had not. Students considering specialisation in Geriatrics had more positive ASD scores in all three categories than those that had not. Students having received training in Geriatrics had more negative ASD scores than those that had not. This may reflect the quality of the training received.

Lebanon

The over 60 population is currently 8.5%, but expected to rise to 13.5% by 2025. Only one of the four medical schools participated, but 101 of the 150 clinical medical students in Beirut medical school participated. A national curriculum does not exist and the curriculum type differs among the schools. Geriatrics is under Internal Medicine at the university. In Beirut Arab Geriatric Medicine is a mandatory course of 20-40 hours covering socio-psychological aspects of old age.

Characteristics of Lebanese medical students Number of participants 100 Average age of participants 21.4% % of Males 73% % of Females 27% Lived with grandparents for >5 years 27% Clinical year differential 1st Year 45% 2nd Year 55% 3rd Year 0% 4th Year 0% % Undertaken Geriatric training 4% % Participants stating no Geriatric training present 54% % Considered Geriatric specialisation 6%

A significant number of the students were male, reflecting cultural sensibilities.

ASD I-I A-D PA-U Overall 4.35 3.78 3.46 Lived with grandparents > 5 years 4.24 3.72 3.41 Lived with grandparents < 5 years 4.39 3.93 3.61 Considered specialisation 3.98 3.91 3.13 Did not consider specialisation 4.38 3.78 3.52 Students with Geriatric training 4.58 3.69 3.45 Students without Geriatric training 4.39 3.82 3.48 The overall ASD scores were positive, with the most negative being in the I – I category. The most positive view was in the PA – U category. The overall ASD was 3.80, a generally positive view. Medical students who had lived with their grandparents for more than five years had more positive ASD scores than those that had not. In the A – D category, medical students that had considered specialisation in Geriatrics had poorer views of older people. In the other two categories, they had more positive views than those that had not considered specialisation. The I – I and PA – U ASD scores were equivocal for medical students who had and had not received training in Geriatrics. In the A – D category, the ASD score was more positive in those that had received training.

Malaysia

Malaysia has 12 medical schools, 7 of which are government run and 5 of which are privately owned. Only 1 medical school, the International Medical University participated in this study. There is no national curriculum for medical education, neither is Geriatrics a mandatory subject. Geriatrics is not a well established subject in Malaysia and tends to be taught within the scope of Internal Medicine. The current percentage of the population over 60 is 6.5% but this is expected to rise to 13.3% in 2025.

Characteristics of Malaysian medical students Number of participants 103 Average age of participants 22.9 years % of Males 42.7% % of Females 57.3% Lived with grandparents for >5 years 40.8% Clinical year differential 1st Year 57% 2nd Year 28% 3rd Year 15% 4th Year 0% % Undertaken Geriatric training 10.7% % Participants stating no Geriatric training present 61.7% % Considered Geriatric specialisation 14.6%

Only 10% of medical students had undertaken training, whilst nearly two-thirds stated that no training was available.

ASD I-I A-D PA-U Overall 4.36 3.93 3.59 Lived with grandparents > 5 years 4.43 3.88 3.60 Lived with grandparents < 5 years 4.31 3.96 3.58 Considered specialisation 4.14 3.86 3.49 Did not consider specialisation 4.46 3.96 3.63 Students with Geriatric training 4.42 3.99 3.36 Students without Geriatric training 4.49 3.92 3.46

The overall ASD score was positive at 3.90, a generally positive view. The most negative ASD score was in the I – I category; the lowest in the PA – U category. The ASD scores for those who had lived with their grandparents for more than five years and those that had not were equivocal. The ASD scores for medical students who had considered training in Geriatrics had more positive ASD scores than those that had not. The ASD scores for medical students who had received training in Geriatrics and those that had not were equivocal.

Pakistan

There are 33 medical schools in Pakistan with approximately 32 000 students. There are no specialist Geriatric courses available with no specific undergraduate Geriatric courses. There is also no provision for specialised post-graduate training in Geriatrics.

With regards to Geriatric provision within the health system, there are no specific Geriatric wards for the care of elderly patients and these are treated in the same ward as general medicine. There are some Geriatric CME (continuous medical education) points available, and awareness is growing, but slowly and it is in its infancy. 5.7% of the population is currently over 60 but this percentage will increase to 8.2 by the year 2025.

Characteristics of Pakistani medical students Number of participants 851 Average age of participants 22.5 years % of Males 44.7% % of Females 55.3% Lived with grandparents for >5 years 48.9% Clinical year differential 1st Year 11% 2nd Year 26% 3rd Year 33% 4th Year 30% % Undertaken Geriatric training 4.7% % Participants stating no Geriatric training present 51.1% % Considered Geriatric specialisation 8.9%

Around half of students stated that no Geriatric training was available, and less than 5% had undertaken Geriatric training.

ASD I-I A-D PA-U Overall 4.21 3.70 3.27 Lived with grandparents > 5 years 4.05 3.71 3.22 Lived with grandparents < 5 years 4.34 3.70 3.31 Considered specialisation 4.30 3.80 3.31 Did not consider specialisation 4.21 3.72 3.28 Students with Geriatric training 4.11 3.85 3.44 Students without Geriatric training 4.14 3.72 3.29

The overall ASD score was positive (3.65), with the most negative score only at 4.34. This may reflect a culture of living in extended families. The A – D and PA – U ASD scores were equivocal between those who had and had not lived with their grandparents for more than five years. The I – I score was significantly lower in those who had. The ASD scores were slightly more negative in those who had considered training in Geriatrics compared to those that had not. Apart from I – I, the ASD scores for medical students receiving training in Geriatrics were higher, and hence more negative, than those that have not received training.

Thailand

There are 13 medical schools in Thailand, only 2 of which participated in this study. Geriatrics is taught by a variety of methods in a combination of problem based learning, integrated teaching blocks and more conservative discipline based styles, but is not a compulsory subject. The population over 60 currently constitutes 9.2% of the total population but this is predicted to rise to 19.2% by the year 2025.

Characteristics of Thai medical students Number of participants 236 Average age of participants 21.9 years % of Males 43.1% % of Females 56.9% Lived with grandparents for >5 years 67.0% Clinical year differential 1st Year 47% 2nd Year 39% 3rd Year 14% 4th Year 0% % Undertaken Geriatric training 67.0% % Participants stating no Geriatric training present 8.1% % Considered Geriatric specialisation 18.6%

Over two-thirds of students had undertaken training in Geriatrics, whilst less than a fifth stated there was no training available.

ASD I-I A-D PA-U Overall 4.52 3.66 3.31 Lived with grandparents > 5 years 4.52 3.69 3.34 Lived with grandparents < 5 years 4.52 3.60 3.26 Considered specialisation 4.38 3.53 3.09 Did not consider specialisation 4.52 3.68 3.35 Students with Geriatric training 4.41 3.66 3.28 Students without Geriatric training 4.70 3.69 3.26 Students with Geriatric training 4.41 3.66 3.28 Students without Geriatric training 4.70 3.69 3.26

The overall ASD score were positive (3.75), with the most negative score for the I – I category, the other two having ASD scores below 4.0. The most positive ASD score was in PA – U. The ASD scores for medical students living with their grandparents for more than five years were equivocal to the medical students that had not. The ASD scores for medical students considering Geriatric specialisation were all more positive than those that had not. Apart from I – I category, the ASD scores were equivocal with respect to medical students receiving training in Geriatrics compared to those that had not.

Asian Analysis

Medical schools from five countries in the Asian continent participated in this study. 10.2% of the total Asian population will be over 60 by the year 2025.

Number of participants 1408 Average age of participants 22.4 years % of Males 48.4% % of Females 50.6% Lived with grandparents for >5 years 20.9 Clinical year differential 1st Year 29.4% 2nd Year 32.4% 3rd Year 27.4% 4th Year 10.2% % Undertaken Geriatric training 28.2 % Participants stating no Geriatric training present 19.2 % Considered Geriatric specialisation 14.7 % Of those who have had Geriatric training, who 24 have considered Geriatric specialisation % Of participants considering specialisation who 24 have lived for >5 years with grandparents

Age Semantic Differential

ASD Differential Score Instrumental – Ineffective (I – I) 4.32 Autonomous – Dependent (A – D) 3.77 Personal Acceptability – 3.40 Unacceptability (PA – U) Overall ASD Score 3.76

Asian medical students on the whole had very positive attitudes towards older people. However, Asian medical students did not view older persons as being independent members of society as reflected by the I- I scores which were higher than 4, a view common to all participating countries.

Females in Asia constituted 52.88% of the medical student population, which would have been greater, except that Lebanon had a significantly lower female medical student population.

Overall ASD scores for Asia

4.30 4.20 4.10 4.00 3.90 3.80 ASD scores

Scores 3.70 3.60 3.50 3.40 3.30 ASIA Thailand Lebanon Pakistan Hong Kong Malaysia Countries

Overall Pakistan had the lowest ASD scores, indicating the most positive attitudes towards older people among all the participating Asian countries. Hong Kong had the highest ASD scores. This may reflect the culture and society, but will be further explored in the discussion.

ASD for medical students living with grandparents ASD Differential Lived with Not lived with p-value grandparents grandparents I – I 4.22 4.42 0.000 A – D 3.73 3.80 0.091 PA – U 3.33 3.46 0.002 Overall ASD Score 3.69 3.83 0.000

46.79% of students had lived with their grandparents for more than 5 years. These students had more positive attitudes towards older persons than those who had not, this will be further explored in the discussion.

The overall ASD score was significantly lower, indicating better attitudes in the group who had lived with their grandparents. In all other categories attitudes were better amongst this group compared to the other. All differences were significant except in the A-D category.

ASD for medical students’ training in Geriatrics ASD Differential Received training Did not receive p-value in Geriatrics training in Geriatrics I – I 4.22 4.42 0.015 A – D 3.73 3.80 0.222 PA – U 3.33 3.46 0.207 Overall ASD Score 3.69 3.83 0.082

Only 18.4% of the students had undergone a form of Geriatric training. Thailand was an exception in that a majority of their students (66.95%) had received training in Geriatrics despite the fact that it is not a mandatory subject there. Except for a lower score in the I-I category amongst the students who had trained in Geriatrics, none of the scores were significantly different.

ASD for medical students considering Geriatric specialisation ASD Differential Considered Did not consider p-value specializing in specializing in Geriatrics Geriatrics I – I 4.36 4.34 0.708 A – D 3.83 3.77 0.465 PA – U 3.49 3.40 0.156 Overall ASD Score 3.83 3.77 0.235

None of the results were significantly different. Results: Europe

Bulgaria

There are five medical schools in Bulgaria, of which two participated (Pleven and Varna). The curriculum is conservative and national objectives in medical education exist, but Geriatric Medicine is not mentioned. Geriatrics is not taught formally, because of a lack of trained staff. The small number of surveyed students made an extrapolation for the population under study difficult.

The proportion of those aged over 60 years is expected to grow by 26% between 2000 and 2025, rising from the present 22% to 28%.

Characteristics of Bulgarian medical students Number of participants 133 Average age of participants 22.6 years % of Males 49% % of Females 51% Lived with grandparents for >5 years 58.6% Clinical year differential 1st Year 35% 2nd Year 32% 3rd Year 23% 4th Year 10% % Undertaken Geriatric training 1.5% % Participants stating no Geriatric training present 30.8% % Considered Geriatric specialisation 3.0% % Of those who have had Geriatric training, who 0% have considered Geriatric specialisation % Of participants considering specialisation who 100% have lived for >5 years with grandparents

All students who have considered a career in Geriatrics had lived with their grandparents for more than 5 years.

ASD I-I A-D PA-U ASD Overall 4.34 4.44 3.50 4.00 Lived with grandparents > 5 years 4.90 4.48 3.54 4.01 Lived with grandparents < 5 years 4.40 4.37 3.45 3.98 Considered specialisation 3.75 4.2 3.11 3.66 Did not consider specialisation 4.34 4.40 3.49 3.99 Students with Geriatric training 3.50 4.06 2.93 3.41 Students without Geriatric training 4.33 4.40 3.55 4.01

The overall ASD score was equivocal, 4.00. However, the highest score was in A – D score, indicating that medical students viewed in the majority that the older generation were dependent and did not have the capabilities to be autonomous. With the high I-I score it is noted that they viewed the older generation as being ineffective and non- useful rather than being dynamic members of society. The only significant difference was in the I-I category. The overall tendency was towards a more negative view in those who had lived with their grandparents for 5 or more years, however, due to the low number of medical students who fell into this category, these results cannot be extrapolated to the population under investigation. Those who had not considered specialising in Geriatrics had greater or equivocal scores compared to those who had considered Geriatrics as a career specialty. But a valid comparison was difficult, as the number of students who had considered specializing in Geriatrics was very low (only 3% of the surveyed Bulgarian students had considered Geriatrics as a possible future career for them). Those who had received training in Geriatrics had significantly lower scores than those who had not, possibly indicating training in this field determined better views of the older generation. However, due to the numbers who fall into this category, it means that further research into this area is required.

Czech Republic

All 7 medical schools in the Czech Republic took part in the study.

Charles University in the Czech Republic have worked extensively in the area of Geriatrics. They provide a Geriatrics course that is recognised by the European Commission and is run throughout Europe.12

Teaching activities cover a broad professional spectrum: Undergraduate teaching of Geriatrics for medical students; Geriatric nursing for students of Baccalaureate Nursing Studies; Gerontology for Ergotherapy and Physiotherapy Baccalaureate and Master Degree students; Social Gerontology has been introduced in 1992 into the curriculum for medical students.

As a result Geriatrics is a major component of the medical curricula of medical students as well as allied health professionals. 18.3% of the population of the Czech Republic were aged 60 and above in the year 2000, this will increase to 28.7% in the year 2025.

12 European Masters Gerontology (EuMaG) Characteristics of Czech Republic medical students Number of participants 612 Average age of participants 22.8 years % of Males 39.5% % of Females 60.5% Lived with grandparents for >5 years 28.6% Clinical year differential 1st Year 28% 2nd Year 28% 3rd Year 28% 4th Year 16% % Undertaken Geriatric training 30.7% % Participants stating no Geriatric training present 20.9% % Considered Geriatric specialisation 11.4%

Medical Schools in Czech Republic Number of Participation clinical students Charles University in Prague, Medical Faculty in Hradec Kralove 590 21.5% Charles University in Prague, Medical Faculty in Pilsen 515 9.7% Charles University in Prague, First Faculty of Medicine 1250 8.9% Charles University in Prague, Second Faculty of Medicine 641 10.5% Charles University in Prague, Third Faculty of Medicine 527 14.2% Palacky University in Olomouc, Faculty of Medicine 611 16.4% Masaryk University in Brno, Faculty of Medicine 560 14.6% Total 4694 13.0%

ASD I-I A-D PA-U ASD Overall 4.70 4.39 4.13 4.36 Lived with grandparents > 5 years 4.68 4.43 4.07 4.35 Lived with grandparents < 5 years 4.70 4.38 4.19 4.37 Considered specialisation 4.31 4.24 3.80 4.07 Did not consider specialisation 4.76 4.42 4.18 4.41 Students with Geriatric training 4.60 4.31 3.99 4.24 Students without Geriatric training 4.74 4.41 4.18 4.44

The overall attitudes of Czech Republic medical students with regards to the older generation proved to be less positive than the other European medical students, with an overall ASD score of 4.36 and the highest SD score of I – I of 4.70. The lowest was in the Personal acceptability score of 4.13, but which is still above 4.0. The ASD scores for those who had and had not lived with their grandparents for more than five years were equivocal, with little difference between the two groups. Again the scores for those who had considered specializing in Geriatrics were lower than the scores of those who had not. Hence, those who had considered a career in Geriatrics had better opinions regarding the older generation compared with those who had not. The ASD scores were all significant at the 5% level ( I-I <0.007; A-D 0.010; PA-U <0.007 and ASD 0.004) The Czech medical students that had not received training in Geriatrics had higher scores compared to those that had, however only statistically valid for PA-U. This indicates that students had more positive overall attitudes towards older people if they had trained in Geriatrics, and the difference could particularly be seen with regards to the older people’ personal acceptability. The overall ASD scores were above 4.0 indicating a global negative view of older people in these categories. (p-values I-I 0.056; A-D 0.074; PA-U 0.003 and ASD 0.004)

Finland

Finland has 5 medical schools, of which all five participated in the study. The curriculum type differs throughout the country. All of the schools teach Geriatrics as a mandatoty subject, thus all have a full coverage in the curriculum, and some even include a Life Course Perspective approach.

With the exception of the University of Oulu, all medical schools (4 out of 5) hold an independent Geriatric unit in the faculty; Turku and Helsinki also hold independent Geriatrics wards. The University of Oulu also hold a sub-ward (under Internal Medicine ). In Turku, the University has an agreement with the Geriatric hospital of the city to organise Geriatric teaching, research and post-grad studies.

The duration of the Geriatrics courses are from 20 to 40 hours; only in Tampere is there a longer course. Students usually study almost all aspects of ageing (with the exception of the paediatric and surgical aspects).

Widely common class types are bed-side teaching, problem-based training and field visits to homes, nursing homes and community centres. Generally there is interaction between various other health personal, mostly nurses but also gerontologists and psychologists. In all 5 medical schools, post-graduate studies in Geriatric Medicine are offered. 19.9% of the Finnish population were aged 60 and above in the year 2000, this will increase to 30.8% in the year 2025.

Characteristics of Finnish medical students Number of participants 625 Average age of participants 25.0 years % of Males 31.5% % of Females 68.5% Lived with grandparents for >5 years 4.6% Clinical year differential 1st Year 26% 2nd Year 28% 3rd Year 28% 4th Year 18% % Undertaken Geriatric training 20.2% % Participants stating no Geriatric training present 12.6% j% Considered Geriatric specialisation 9.6% % Of those who have had Geriatric training, who 32% have considered Geriatric specialisation % Of participants considering specialisation who 7% have lived for >5 years with grandparents Of the 1350 clinical students in Finland, 625 participated, a total of 46.3%. The female participation represented two thirds of the total surveyed Finish students.

ASD I-I A-D PA-U ASD Overall 4.25 3.38 3.42 3.67 Lived with grandparents > 5 years 4.02 3.44 3.27 3.53 Lived with grandparents < 5 years 4.26 3.48 3.43 3.68 Considered specialisation 4.10 3.20 3.08 3.40 Did not consider specialisation 4.27 3.52 3.46 3.70 Students with Geriatric training 4.37 3.55 3.52 3.77 Students without Geriatric 4.22 3.47 3.40 3.65 training

Apart from the ASD I – I score, the rest are below 4.0 and are quite low, with the overall score being 3.67, indicating positive views of the elderly. The medical students who had lived with their grandparents for over 5 years, had lower I – I scores than those that had not, 4.26 versus 4.02, this difference being statistically significant at the 5% level (p-value<0.05). The ASD scores and hence perceptions of older people, for those who had considered Geriatrics as a future career were all below those of those who haven’t considered it (p-values I-I 0.029; A-D <0.001; PA-U <0.007 and ASD <0.001) Only one fifth of students had undertaken Geriatric training whilst 12.6% stated there was no Geriatric training offered, even thought in all medical schools of Finland, it is an obligatory part of undergraduate medical training (p-values I-I 0.012; A-D 0.296; PA-U 0.023 and ASD 0.027). Unlike other countries in, the perceptions of medical students of the elderly were greatly improved amongst those that had received training in Geriatrics compared to medical students who had not received any training.

The students from Finland on the whole had positive views of the elderly, compared to other countries and reveal that once they have received training, they have better perceptions.

Germany

5 of the 37 medical schools in Germany took part in the study.

There is a national curriculum for medical education in Germany, that since 2004 includes Geriatrics as a mandatory subject, but did not include it at the moment of the collection of our data. No school had an independent unit for Geriatrics in the faculty, but 29% of university hospitals have an independent Geriatric ward.

In Germany, 24% of schools have at least one Geriatrics sub-unit in the faculty (80% under Internal Medicine , 40% under general medicine or psychiatry, and 20% under neurology or orthopaedics). One- third of schools have a sub-ward (under Internal Medicine , neurology, general medicine or psychiatry).13

13 Global Survey on Geriatrics in the Medical Curriculum, WHO/NMH/NPH/ALC/02.7

Aspects of ageing that are covered by the majority of the schools are the physiological, general clinical, pharmacological and neurological aspects. With 23% of its population currently older than 60 years of age and it is expected to grow to 33% by 2025.

Characteristics of German medical students Number of participants 450 Average age of participants 24.4 years % of Males 37.3% % of Females 62.7% Lived with grandparents for >5 years 23.6% Clinical year differential 1st Year 12% 2nd Year 55% 3rd Year 18% 4th Year 15% % Undertaken Geriatric training 22.0% % Participants stating no Geriatric training present 26.7% % Considered Geriatric specialisation 8.4% % Of those who have had Geriatric training, who 26% have considered Geriatric specialisation % Of participants considering specialisation who 32% have lived for >5 years with grandparents

ASD I-I A-D PA-U ASD Overall 4.50 3.89 3.93 4.08 Lived with grandparents > 5 years 4.51 3.91 3.94 4.09 Lived with grandparents < 5 years 4.50 3.88 3.93 4.08 Considered specialisation 4.25 3.75 3.60 3.83 Did not consider specialisation 4.53 3.89 3.60 3.96 Students with Geriatric training 4.44 3.86 3.98 4.07 Students without Geriatric training 4.52 3.90 3.92 7.08

The overall ASD score is slightly higher than 4, and it can be considered as equivocal. The highest score was in the I-I category, signifying that German medical students did not think of older people as being significantly effective individuals. Although the scores in the A- D and PA-U categories were lower than 4, they were only marginally lower. Students who had lived with their grandparents had similar scores to those who had not. The ASD scores were high, with the highest again being in the I-I category. This meant that both groups of medical students did not think of older people as being functionally effective members of society. Students who had considered a career in Geriatrics had significantly lower ASD scores than the students who had not (p-values I-I 0.002; A-D 0.137; PA-U <0.001 and ASD <0.001). However, I-I scores were still higher than 4, even in the group of students who wished to pursue a Geriatrics as a speciality. There were equivocal results in ASD score between the students who had received training and those who had not. The I-I scores were the highest once more, and the ASD scores in the remaining categories were also high, although less than 4. The overall ASD score was high in both groups.

Malta

There is only one medical faculty in Malta, Pieta with 240 students. The length of the medical course is fixed at 5 years with the last 3 years being clinical. A national curriculum does exist and Geriatrics is a mandatory component of the curriculum and is taught in the 7th term. It is taught in a discipline based traditional manner. The components taught include everything but pathology. 14 hours a week are dedicated to Geriatrics and consist of weekly lectures and bed-side teaching. However there is no interaction with senior patients and no visits are arranged to older people in the community.

There is an independent Geriatric ward at the teaching hospital and an independent Geriatric Unit within the faculty. The proportion of people over 60 accounted for 16% in the year 2000 and is expected to rise to 28.9% in 2025.

Females constitute 60% of the total number of medical students.

Characteristics of Maltese medical students Number of participants 114 Average age of participants 21.8 years % of Males 42.3% % of Females 51.7% Lived with grandparents for >5 years 12.1% Clinical year differential 1st Year 25% 2nd Year 42% 3rd Year 33% 4th Year 0% % Undertaken Geriatric training 5.2% % Participants stating no Geriatric training present 16.4% % Considered Geriatric specialisation % Of those who have had Geriatric training, who 26% have considered Geriatric specialisation % Of participants considering specialisation who 32% have lived for >5 years with grandparents

ASD I-I A-D PA-U ASD Overall 4.59 3.99 3.65 4.12 Lived with grandparents > 5 years 4.67 4.02 3.29 4.03 Lived with grandparents < 5 years 4.57 3.98 3.69 4.13 Considered specialisation 4.39 3.74 3.25 3.81 Did not consider specialisation 4.62 4.04 3.73 4.16 Students with Geriatric training 3.80 3.35 2.85 3.34 Students without Geriatric training 4.63 4.02 3.70 4.13 The I – I score was the highest at 4.59, with lower scores in PA – U and A – D. The overall score due to the high I – I SD score of 4.59 brings the overall SD score above 4.12, however, this masks the lower values of the other two. The scores indicate an overall positive perception of the elderly. Medical students who had lived with their grandparents for over five years during their formative years had better ASD scores for the PA – U grouping, compared with those that had not (all p-values indicating non-significance) Medical students who had considered Geriatrics as a future career had better views of the elderly than those that had not, with statistically significant difference in all dimensions (p- values I-I 0.022; A-D 0.010; PA-U <0.001 and ASD 0.019). Again those that had received training in Geriatrics had significantly lower scores that those who had not. PA – U score for those receiving training was 2.85, the lowest score obtained.

Maltese medical students had generally positive opinions of the elderly, as reflected by the individual ASD scores, despite the overall ASD score being 4.12.

Norway

There are 4 medical schools in Norway and all 4 participated in our study. The length of the medical course is 6 years, with the last 3 years being clinical. There are no national objectives for medical school curricula; nevertheless, Geriatrics is mandatory in all the medical schools. Depending on the medical school, 20- 40 hours a week are allocated for this subject. Teaching is offered in a variety of methods, including lectures, bedside teaching and visits. However, interaction with other related healthcare personnel, apart from some contact with nursing staff, is limited. A life- course perspective is offered at all the schools. Besides the clinical aspects of Geriatrics, the lessons also cover psychosocial and ethical aspects. Independent faculties and hospital wards for Geriatrics are available at 2 of the 4 medical schools.

19.5% of the population was over 60 in 2000, but this will rise to 26.7% in the year 2025.

Characteristics of Norwegian medical students Number of participants 504 Average age of participants 24.9 years % of Males 34.9% % of Females 64.1% Lived with grandparents for >5 years 8.7% Clinical year differential 1st Year 39% 2nd Year 24% 3rd Year 17% 4th Year 20% % Undertaken Geriatric training 52.8% % Participants stating no Geriatric training present 19.4% % Considered Geriatric specialisation 17.7% % Of those who have had Geriatric training, who 76% have considered Geriatric specialisation % Of participants considering specialisation who 7% have lived for >5 years with grandparents Throughout the country, 50- 55% of students were female. More than three quarters of the participating Norwegian students who have considered a career in Geriatrics had lived with their grandparents for more than 5 years.

ASD I-I A-D PA-U ASD Overall 4.41 3.62 3.39 3.75 Lived with grandparents > 5 years 4.33 3.67 3.46 3.76 Lived with grandparents < 5 years 4.42 3.64 3.39 3.75 Considered specialisation 4.37 3.54 3.13 3.60 Did not consider specialisation 4.42 3.67 3.47 3.79 Students with Geriatric training 4.45 3.63 3.37 3.75 Students without Geriatric training 4.36 3.64 3.41 3.74

Norwegian students have positive views of older people as reflected in their low ASD scores. The highest score was the I-I score which was 4.41. However, the scores were low in the A-D and PA – U categories indicating that Norwegian students considered older people to be autonomous and to have attributes which were sociably acceptable. There was no clear difference in attitudes between students who had lived with their grandparents and those who had not. Although I-I scores were lower in students who had lived with older people, overall ASD scores were equivocal. There were significant differences in overall ASD score between those who wished to specialise in Geriatrics and those who did not. The attitudes were more positive amongst students wishing to pursue Geriatrics as a discipline. The students wishing to specialise in Geriatrics also found older people to be more personally acceptable than the rest of the Norwegian students surveyed. In the remaining categories, there was no significant difference in scores (p-values I-I 0.793; A- D 0.099; PA-U <0.001 and ASD 0.003) Students who had trained in Geriatrics had similar overall ASD scores to those who had not. Both groups had positive attitudes towards older people. The highest scores were in the I-I category but the A-D and PA-U categories had low scores.

Romania

Romania has 10 medical schools in total, 3 of which participated in this study. There is no national curriculum therefore each school is responsible for developing their own curriculum. Geriatrics is mandatory in only one medical school that participated in our study (“Iuliu Hateganu” Medical University in Cluj-Napoca) and optional at the “Carol Davila” Medical University in Bucharest. Where it is taught, it is in a combination of discipline based and integrated teaching blocks.

75% of the medical students are female. The medical course lasts 6 years, with the final 3 years being clinical. 19.1% of the population are currently over the age of 60, and this is expected to rise to 23.9% in the year 2025.

Characteristics of Romanian medical students Number of participants 395 Average age of participants 23.4 years % of Males 33.5% % of Females 66.5% Lived with grandparents for >5 years 45.3% Clinical year differential 1st Year 26% 2nd Year 25% 3rd Year 31% 4th Year 18% % Undertaken Geriatric training 12.7% % Participants stating no Geriatric training present 31.7% % Considered Geriatric specialisation 12.7% % Of those who have had Geriatric training, who 22% have considered Geriatric specialisation % Of participants considering specialisation who 51% have lived for >5 years with grandparents

Two thirds of the participating Romanian students were females.

More than half of the surveyed Romanian students who have considered specializing in Geriatrics

had lived with their grandparents for more than 5 years.

ASD I-I A-D PA-U ASD Overall 4.82 3.16 3.82 4.20 Lived with grandparents > 5 years 4.64 4.04 3.65 4.04 Lived with grandparents < 5 years 4.97 4.26 3.96 4.33 Considered specialisation 4.63 4.11 3.51 3.99 Did not consider specialisation 4.89 4.22 3.93 4.28 Students with Geriatric training 5.01 4.56 4.01 4.45 Students without Geriatric training 4.81 4.15 3.87 4.21

Although the A-D and PA-U scores were low, the score in the I - I category was very high, leading to an overall ASD score of above 4. This shows that Romanian medical students had negative views of older people as effective members of society. There were significant differences between students who had lived with their grandparents and those who had not in all 3 dimensions (p-values I-I <0.001; A-D <0.001; PA-U 0.002 and ASD <0.001 The scores for the group who had lived with their grandparents were consistently lower than the group who had not in all categories including the overall ASD score. However, apart from PA-U, the scores were higher in all categories amongst the students who had cohabited with their grandparents. The scores were consistently lower amongst the group of students who had considered Geriatric specialisation. All differences were significant except for the A – D score. The scores in all categories were higher amongst the students who had received training in Geriatrics. These findings might be due to the exposure to sick old people during this training, the contacts with healthy elderly in the community not being included into the medical curricula in Romania (p-values I-I 0.003; A-D 0.001; PA-U 0.154 and ASD 0.017). The I-I score was the highest score at 5.01, indicating negative views of the older generation.

Spain

There are 27 medical schools in Spain, of which 6 participated. The proportion of female to male students ranges from 57% (Cordoba) to 75% (Santiago). The studies consist of fixed 3 years of pre-clinical followed by 3 years of clinical studies. About half of the Spanish medical schools have Geriatrics as a mandatory component of the course. Amongst the schools that have Geriatrics, half have a traditional curriculum, the other half an integrated one. Teaching is through a combination of lectures, bedside teaching, problem- based learning and field visits to the hospital. Generally there is interaction with other health personnel, mostly nurses, gerontologists and dieticians. About half of them have a Geriatric ward, and most of the schools have a Geriatric sub-ward.

3 of the participating medical schools include Geriatrics into the curricula, all as mandatory subject. The percentage of the population above 60 is expected to rise 7.1%, from 21.1% in 2000 to 28.6% in 2025.

Characteristics of Spanish medical students Number of participants 626 Average age of participants 22.6 years % of Males 31.2% % of Females 68.8% Lived with grandparents for >5 years 26.7% Clinical year differential 1st Year 35% 2nd Year 31% 3rd Year 32% 4th Year 2% % Undertaken Geriatric training 16.3% % Participants stating no Geriatric training present 20.6% % Considered Geriatric specialisation 22.0% % Of those who have had Geriatric training, who 32% have considered Geriatric specialisation % Of participants considering specialisation who 30% have lived for >5 years with grandparents

ASD I-I A-D PA-U ASD Overall 4.60 3.92 3.70 4.01 Lived with grandparents > 5 years 4.51 3.87 3.63 3.94 Lived with grandparents < 5 years 4.63 3.94 3.72 4.04 Considered specialisation 4.47 3.77 3.43 3.82 Did not consider specialisation 4.64 3.96 3.77 4.07 Students with Geriatric training 4.49 3.88 3.55 3.91 Students without Geriatric training 4.64 3.90 3.72 40.3

The general ASD score of 4.01 indicates an equivocal view of the older generation that is neither overly positive nor negative. The highest score was for I – I that is high at 4.60. The lowest score was for PA – U at 3.70. Those who had lived with their grandparents for more than five years had lower ASD scores than those who had not, with statistically significant difference for the I – I grouping (p-values I-I 0.049; A-D 0.344; PA-U 0.609 and ASD 0.060).

ASD Considered Did not consider p-value specialising in specialising in Geriatrics Geriatrics I-I 4.47 4.64 0.017 A-D 3.77 3.96 0.013 PA-U 3.43 3.77 0.000 ASD 3.82 4.07 0.000

The Spanish medical students who had considered specializing in Geriatrics had significantly lower scores that those who haven’t considered it, in all 3 dimensions (p-values I-I 0.017; A-D 0.013; PA-U <0.001 and ASD <0.001).

Again, the students that had training in Geriatrics had lower scores compared with the rest of

surveyed Spanish students, with statistically significant difference.

Switzerland

There are 5 medical schools in Switzerland, of which only one, the University of Geneva, participated in our study. During undergraduate training in Geneva, some Geriatric teaching through Problem Based Learning Sessions and special taught courses is available and as such is integrated into the curriculum. With no choice offered to students, 50% of the clinical students undertake clinical practice in a Geriatric hospital. These students tend to become more open-minded towards elderly patients. The two options are advertised as ‘Internal Medicine with Geriatrics’ and ‘General Medicine with Geriatrics’.

The population over 60 in Switzerland will expand from 19.9% in 2000 to 31.4% in 2025.

Characteristics of Swiss medical students Number of participants 91 Average age of participants 25.8 years % of Males 52.8% % of Females 46.2% Lived with grandparents for >5 years 20.9% Clinical year differential 1st Year 0% 2nd Year 1% 3rd Year 96% 4th Year 3% % Undertaken Geriatric training 37.4% % Participants stating no Geriatric training present 0% % Considered Geriatric specialisation 9.9% % Of those who have had Geriatric training, who 56% have considered Geriatric specialisation % Of participants considering specialisation who 11% have lived for >5 years with grandparents

Due to the low participation at country level and to important differences in medical education methods in Switzerland, our findings can only reflect the current situation among the medical students in Geneva.

ASD I-I A-D PA-U ASD Overall 4.19 3.60 3.64 3.78 Lived with grandparents > 5 years 4.14 3.53 3.53 3.70 Lived with grandparents < 5 years 4.20 3.62 3.66 3.80 Considered specialisation 3.77 3.41 3.49 3.55 Did not consider specialisation 4.26 3.65 3.68 3.83 Students with Geriatric training 4.21 3.71 3.65 3.82 Students without Geriatric training 4.17 3.54 3.63 3.86

More than half of the surveyed Swiss medical students who have considered specializing in Geriatrics, received training in this field. The overall ASD score was lower than 4, indicating positive attitudes towards older people. The highest score was in the I-I category. ASD scores were low in both groups established by sorting the total sample considering the co- residence with grandparents as criteria, although lower in the group who had lived with their grandparents. The highest scores were once more in I-I categories in both groups. ASD scores were low in both of these groups.

United Kingdom

There are 32 medical schools in total in the UK, 12 of which participated in this survey. National objectives for medical education exist, which include an understanding of human development and areas of psychology and sociology relevant to growing old, as well as understanding palliative care issues, learning how to deal with vulnerable patients, and end of life issues such as withholding treatment. It is usually taught within the clinical years in teaching blocks, in a variety of methods ranging from didactic teaching to Problem Based Learning Sessions. Undergraduate training is also provided in Special Study Modules dedicated to Geriatrics. Detailed information about Geriatrics teaching in the UK medical schools which participated in our study is included in Appendix V. The over 60 population in the UK stood at 15.9% in the year 2000 and will rise to 19.8% by the year 2025.

Characteristics of UK medical students Number of participants 1103 Average age of participants 22.7 years % of Males 41.2% % of Females 58.8% Lived with grandparents for >5 years 14.5% Clinical year differential 1st Year 34% 2nd Year 38% 3rd Year 26% 4th Year 2% % Undertaken Geriatric training 40.1% % Participants stating no Geriatric training present 15.8% % Considered Geriatric specialisation 18.9% % Of those who have had Geriatric training, who 56% have considered Geriatric specialisation % Of participants considering specialisation who 17% have lived for >5 years with grandparents

More than half of the participating students from the UK were females. More than half of the British medical students participating in our study who have considered a career in Geriatrics have received training in Geriatrics.

ASD I-I A-D PA-U ASD Overall 4.23 3.74 3.47 3.46 Lived with grandparents > 5 years 4.20 3.75 3.43 3.74 Lived with grandparents < 5 years 4.23 3.74 3.48 3.77 Considered specialisation 4.03 3.67 3.21 3.66 Did not consider specialisation 4.28 3.77 3.51 3.80 Students with Geriatric training 4.16 3.69 3.42 3.70 Students without Geriatric training 4.27 3.77 3.50 3.79

The Overall ASD scores are indicative of the positive attitudes that British medical students have towards older people.

ASD Differential Score Instrumental – Ineffective (I – I) 4.45 Autonomous – Dependent (A – D) 3.88 Personal Acceptability – 3.66 Unacceptability (PA – U) Overall ASD Score 3.94

Scores were lower amongst students who had lived with their grandparents for more than 5 years, compared with the ones who haven’t. Even so, the differences aren’t statistically significant.

Students who were considering Geriatrics as a possible career had significantly lower scores in every category except for the A – D (p-values I-I <0.001; A-D 0.073; PA-U <0.001 and ASD<0.001). Scores were significantly lower in every category amongst students who had undergone Geriatric training, compared with the ones who have not (p-values I-I 0.011; A.D 0.037; PA-U 0.053 and ASD 0.010).

European Analysis

Europe had the highest number of participants amongst all the continents with 4655 students from 10 countries. The majority of the countries were from Western Europe, with 1103 of the surveyed European students studying in the UK. As a continent Europe will have 21% of its population over 60 by the year 2025.

Characteristics of European medical students Number of participants 4655 Average age of participants 22 years % of Males 37.3 % of Females 62.7 Lived with grandparents for >5 years 20.9 Clinical year differential 1st Year 29.4% 2nd Year 32.4% 3rd Year 27.4% 4th Year 10.2% % Undertaken Geriatric training 28.2 % Participants stating no Geriatric training present 19.2 % Considered Geriatric specialisation 14.7 % Of those who have had Geriatric training, who 24 have considered Geriatric specialisation % Of participants considering specialisation who 24 have lived for >5 years with grandparents

Age Semantic Differential ASD Differential Score Instrumental – Ineffective (I – I) 4.45 Autonomous – Dependent (A – D) 3.88 Personal Acceptability – 3.66 Unacceptability (PA – U) Overall ASD Score 3.94

The majority of medical students were female. All countries except Switzerland had more females than males, with the majority being over 60% female. Although Geriatrics is not mandatory in the majority of medical schools, most countries have some form of undergraduate Geriatric training provided, with the exception of Bulgaria.

The low overall ASD score indicates positive attitudes towards older people. The I-I score was the highest and, being higher than 4, indicates that older people were considered by the European medical students not to contribute much to society. High I-I scores were a recurring theme amongst the medical schools in Europe, and is a point for further discussion in the next section.

Overall ASD scores for Europe

6

5

4

3 ASD scores

Scores 2

1

0

UK Spain Malta Norway Finland Bulgaria EUROPE Romania Germany Switzerland Czeck Republic Countries

The UK had the lowest ASD scores in Europe while the Czech Republic had the highest. The difference in ASD scores between the two countries was 0.90.

ASD for medical students living with grandparents

ASD Lived with Lived with p-value grandparents grandparents < 5 >5 years years or not at I-I 4.47 all 4.44 0.060 A-D 4.01 3.85 <0.001 PA-U 3.68 3.65 0.054 ASD 4.00 3.93 <0.001

Scores in all categories, including the overall ASD scores, were significantly higher amongst the group of students who had cohabited with their grandparents, when compared with the ones who haven’t. This strongly suggests that in Europe, students who had lived with older persons for a considerable amount of time had more negative views of older persons when compared to their counterparts who had not. This is another point which will be referred to in the discussion section.

ASD for medical students considering Geriatric specialization

ASD Considered Did not consider p-value specialising in specialising in Geriatrics Geriatrics I-I 4.26 4.46 <0.001 A-D 3.72 3.89 <0.001 PA-U 3.37 3.67 <0.001 ASD 3.72 3.95 <0.001

Students who had considered Geriatrics as a speciality had significantly lower scores in all categories than those who had not. This therefore suggests that European students who had considered pursuing a career in Geriatrics had better views of older people than those who did not.

ASD for medical students’ training in Geriatrics

ASD Received training Did not receive p-value in Geriatrics training in Geriatrics I-I 4.38 4.48 <0.001 A-D 3.81 3.91 <0.001 PA-U 3.58 3.69 <0.001 ASD 3.87 3.97 <0.001

Training in Geriatrics appeared to have a positive impact on European medical students as suggested by the lower scores in the group of students who had received training, except from Romania. The scores were significantly lower in all categories. Results: Americas

Bolivia

There are 10 medical schools within Bolivia, of which 7 are not recognised by the Panamerican Federation of Associations of Medical Schools (Source: Institute of International Medical Education). The university which participated is not recognised.

Bolivia’s over-60 population currently stands at 6.7%, this will increase to 9.5% in the year 2025.

Characteristics of Bolivian Medical Students Number of participants 200 Average age of participants 23.5 years % of Males 44% % of Females 56% Lived with grandparents for >5 years 48% Clinical year differential 1st Year 7.5% 2nd Year 53.5% 3rd Year 39% % Undertaken Geriatric training 2.5% % Participants stating no Geriatric training present 15.5% % Considered Geriatric specialisation 26% % Males considering Geriatric specialisation 33% % Females considering Geriatric specialisation 67% % Of those who have had Geriatric training, who 60% have considered Geriatric specialisation % Of participants considering specialisation who 54% have lived for >5 years with grandparents

More females considered Geriatric specialisation than males. Of those who had some form of Geriatric training, a majority (60%) have considered Geriatric specialisation compared to the average of all medical students. 50% of clinical medical students participated in the study.

ASD I-I A-D PA-U ASD Overall 4.31 3.79 3.31 3.71 Lived with grandparents > 5 years 3.97 3.62 3.01 3.91 Lived with grandparents < 5 years 4.47 3.84 3.36 3.81 Considered specialisation 4.02 3.54 3.04 3.46 Did not consider specialisation 4.41 3.90 3.40 3.82 Students with Geriatric training 4.47 4.82 4.04 - Students without Geriatric training 4.31 3.76 3.24 -

The overall ASD score is 3.71, indicating that the view of medical students from Bolivia is positive towards the older generation. The lowest score is in PA – U; i.e. medical students find the older generation to be trustful, friendly and exciting. The highest score was in I – I, indicating that they view the older generation to be more unhealthy, old-fashioned and passive. Medical students that lived with their grandparents for over five years had lower ASD scores than the average. The difference ranges from 0.22 to 0.50. All students who had lived with their grandparents for more than five years had lower scores than the average and all those who had not, had higher scores than the average. With p-values all below 0.001, these are significant results and at the 5% level, unlikely to be due to chance. Medical students, who had not considered a specialisation in Geriatrics had higher ASD scores than those who had considered specialisation, hence had more negative views. Medical students that had received training in Geriatrics had higher ASD scores than those that had not. Hence their views were more negative than those that had not completed a course in this field. The highest score was in A – D section which looks at, amongst most things, the organisation, security and self-reliance of the older generation. This maybe due to the skewed view that is obtained when caring for the sick older person, as they are less able to look after themselves and due to the nature of disease manifestation in the older person, medical students may feel less well-disposed towards the older person once having cared for them in a hospital setting. But as the number of the students who fall into this group is low (2.5%) it is difficult to generalize this supposition. Again the lowest score was in the PA –U section, but still above 4.00 which indicates that whilst older people were personally acceptable, there was still some negative views present.

Chile

There are 7 medical schools in Chile. Apart from these 7, there are an additional 3 which are not recognised by the Panamerican Federation Associations of Medical Schools (source: International Institution of Medical Students). The medical schools taking part are all recognised by the association. 11.6% of Chile’s population are currently over-60, this figure will become 20.3% by the year 2025.

Characteristics of Chilean Medical Students Number of participants 878 Average age of participants 24 years % of Males 47% % of Females 53% Lived with grandparents for >5 years 22% Clinical year differential 1st Year 33% 2nd Year 18% 3rd Year 29% 4/5th Year 20% % Undertaken Geriatric training 39% % Participants stating no Geriatric training present 0% % Considered Geriatric specialisation 19% % Of those who have had Geriatric training, who 23% have considered Geriatric specialisation % Males considering Geriatric specialisation 40% % Females considering Geriatric specialisation 60% % Of participants considering specialisation who 31% have lived for >5 years with grandparents More females considered Geriatric specialisation than males. Of those who had some form of Geriatric training 23% have considered Geriatric specialisation compared to the average of all medical students, only 19%.

ASD I-I A-D PA-U ASD Overall 4.56 3.88 3.51 3.91 Lived with grandparents > 5 years 4.35 3.79 3.41 3.78 Lived with grandparents < 5 years 4.67 3.90 3.50 3.94 Considered specialisation 4.38 3.97 3.24 3.70 Did not consider specialisation 4.60 3.91 3.57 3.96 Students with Geriatric training 4.54 3.87 3.57 3.88 Students without Geriatric training 4.57 3.88 3.54 3.92

The overall ASD score was 3.91, which indicates a positive view of the older generation. The highest score was again the I – I score which was at 4.56. The medical students who had lived with their grandparents for over 5 years had lower scores than those who had not in all three categories; however, the ASD scores were not greatly different. All differences (between the ASD scores of these two groups) are significant at the 5% level. The ASD scores for the medical students who had and had not considered Geriatric specialisation were equivocal for I – I and A – D, and not significantly different to indicate a different in opinion. The scores for PA – U were greatly different indicating that those who had considered Geriatrics had better personal opinions of older people. Medical students who had received training in Geriatrics had equivocal scores in all three categories.

Panama

Panama has 3 medical schools with integrated curricula and no national curriculum. All 3 medical schools participated in our study.

University Number of students in Percentage participation clinical year University of Panama 400 25% Columbus University 100 60% University Latin a de Panama 150 66%

Overall participation was 50.3%, i.e. half the clinical faculty. Columbus University reports that it specializes in Geriatric and emergency medicine, thus it has an independent Geriatric unit in the faculty and a ward in the hospital. In Columbus Geriatrics is mandatory, taught in the 10th term, and contains all aspects of old age medicine as well as a life course perspective. Weekly lectures (32 hours), bedside teaching (50 hours), and problem based learning (5 hours) are included. Field visits, work on the ward (5 hours), and interactions with nurses, psychiatrists, dieticians, clinical gerontologists and volunteers are included (Keller et al, WHO, 2002).

In Panama currently only 8% of the population are over 60 years of age, yet by 2025 this number is expected to rise by 90% to reach 15%, a significant sector of society.

Characteristics of Panama Medical Students Number of participants 260 Average age of participants 25 % of Males 43% % of Females 57% Lived with grandparents for >5 years 36% Clinical year differential 1st Year 28% 2nd Year 22% 3rd Year 37% 4th Year 13% % Undertaken Geriatric training 6% % Participants stating no Geriatric training present 38%14 % Considered Geriatric specialisation 19% % Of those who have had Geriatric training, who 63% have considered Geriatric specialisation % Males considering Geriatric specialisation 47% % Females considering Geriatric specialisation 53%

More females considered Geriatric specialisation than males. Of those who had some form of Geriatric training, a majority (63%) have considered Geriatric specialisation compared to the average of all medical students, 19%.

ASD I-I A-D PA-U ASD Overall 3.96 3.31 3.00 3.36 Lived with grandparents > 5 years 3.07 2.93 2.79 3.09 Lived with grandparents < 5 years 4.11 3.53 3.12 3.51 Considered specialisation 3.61 3.23 2.09 3.19 Did not consider specialisation 4.04 3.33 3.03 3.40 Students with Geriatric training 3.67 3.26 3.11 3.31 Students without Geriatric training 4.00 3.35 3.00 3.38

All the ASD scores are low, indicating very positive views of older people, with an overall

14 No medical school in Panama provide formal Geriatric teaching during medical school education score of 3.36. The lowest ASD score was in PA – U of 3.00, and the highest score in I – I of 3.96. Panamanian medical students have very positive views of the older generation. Medical students who had lived with their grandparents for over 5 years had significantly lower ASD scores than their counterparts who had not. All differences are statistically significant, with P-values below 0.001. The lowest ASD score was again in the personal acceptability of the older generation. Also, the highest ASD score was the I – I score indicating that medical students did not consider older people to be as effective members of society, however, this score is still low. The ASD scores for medical students considering specialisation were lower in all three categories; the lowest score being in PA – U. All were significant at the 5% level. Medical students who had received training in Geriatrics had in two categories, the I-I and the A- D, lower scores than those who had not received any training. In the category of personal acceptability, there was a lower score in those who had not received any training in Geriatrics. The reason for this lower score is unclear.

Peru

Peru has 22 medical schools in total. All but 4 are recognised by the PanAmerican Federation of Associations of Medical Schools (Source: Institute for International Medical Education, IIME). In Peru, 7.8% of the population is currently over the age of 60, this figure will increase to 12.4% by the year 2025. Characteristics of Peruvian medical students Number of participants 249 Average age of participants 23.5 % of Males 58% % of Females 42% Lived with grandparents for >5 years 41% Clinical year differential 1st Year 32% 2nd Year 26% 3rd Year 22% 4th Year 19% % Undertaken Geriatric training 10% % Participants stating no Geriatric training present 6% % Considered Geriatric specialisation 16% % Of those who have had Geriatric training, who 36% have considered Geriatric specialisation % Males considering Geriatric specialisation 47% % Females considering Geriatric specialisation 53%

More females considered Geriatric specialisation than males. Of those who had some form of Geriatric training, 36% have considered Geriatric specialisation compared to the average of all medical students, 16%.

ASD I-I A-D PA-U ASD Overall 4.33 3.97 3.53 3.88 Lived with grandparents > 5 years 4.33 4.04 3.52 3.89 Lived with grandparents < 5 years 4.34 3.91 3.54 3.87 Considered specialisation 4.36 4.16 3.74 3.91 Did not consider specialisation 4.33 3.94 3.55 3.88 Students with Geriatric training 4.37 4.01 3.39 3.90 Students without Geriatric training 4.34 3.99 3.57 3.87

• The overall ASD score was low at 3.88, however there was a high score in the I – I category, with the lowest in PA – U. Peruvian medical students have a generally positive view of the older generation. • Peruvian medical students who had lived with their grandparents for over five years had a slightly more positive view of the independent nature of the older generation than those who had not 4.04 vs 3.91. The other ASD scores were equivocal. • Apart from I-I, Peruvian medical students thought slightly better of the older generation. • The ASD scores for both groups were equivocal, indicating no significant difference.

Central and South American Analysis

The whole of Central and South America cannot be extrapolated from the above four participants, however some generalisations and applications can be made.

Age Semantic Differential ASD Differential Score Instrumental – Ineffective (I – I) 4.34 Autonomous – Dependent (A – D) 3.74 Personal Acceptability – 3.43 Unacceptability (PA – U) Overall ASD Score 3.84

Overall ASD scores for Central and South America

4.20

4.00

3.80

3.60 ASD scores Scores 3.40

3.20

3.00 AMERICAS Panama Peru Chile Bolivia Countries

Overall the four countries demonstrated their medical students had positive views on the effectiveness of the older generation in their society. However, lower SD scores are seen in the degree of independence and the degree to which the medical students accept the older generation. As a region, the over 60 population currently constitutes 8.8%. This will increase to 14.5% in the year 2025. 52% of medical students were female from the 4 countries. Peru was the only country with fewer females than males. Medical students who had lived with their grandparents for more than five years had lower SD scores than those who had not.

ASD for medical students living with grandparents ASD Differential Lived with Not lived with grandparents grandparents I – I 3.95 4.37 A – D 3.62 3.81 PA – U 3.15 3.41 Overall ASD Score 3.57 3.83

Medical students who had not lived with their grandparents for over five years had lower SD scores and hence more positive views compared to their counterparts. The overall SD scores were still below 4.0 (p<0.001).

ASD for medical students’ training in Geriatrics ASD Received training Did not receive in Geriatrics training in Geriatrics I-I 4.26 4.31 A-D 3.99 3.99 PA-U 3.50 3.34 ASD 3.86 3.76

On average, only 14.4% of the students sampled had had training in Geriatrics, with Bolivia only having 2.5% who had training. Both PA - U and A – D had positive views, but with equivocal results between the two groups. The I – I groups were both negative, with high ASD scores. DISCUSSION

Importance of TeGeME II Attitudes are viewed as a mediating link between clinical competence and clinical performance, meaning that they directly influence a doctor’s actions in practice (Wolschuk et al, 200415). Although extensive selection processes for medical students attempt to ensure that students offered entry into medical student programmes are those deemed by medical school admission committees to have desirable attitudes, it is known that students often become more cynical and lose some of their humanitarian feelings they initially possessed as they progress through their training (Masson and Lester, 200316). This devolution of behaviour during undergraduate training indicates the impact that medical curricula can have on medical students. Undergraduate medical education can become an excellent foundation of good medical practice to better serve the needs of older people. Apart from that it also serves as a method of increasing interest in the subject of Ageing and Geriatric Medicine as a speciality (Duque et al, 200317). The fact that today’s medical students are tomorrow’s doctors is a well recognized one, therefore implying that investment in medical education is worthwhile to ensure continuous improvement in healthcare. Despite this universal view, and the fact that most students will enter careers serving a significant number of Geriatric patients, Geriatrics does not feature prominently in medical education. The influences on medical students' attitudes towards older persons are multiple with complex relationships between the different factors (Cleary et al, 200118) and are not simply reliant on undergraduate medical curricula. Negative perceptions towards older people are known to exist in the general population (Kishimoto et al, 200519), which may influence medical students’ views of older persons. The existence of negative views amongst medical professionals as teachers and role models could also have a significant impact on medical students as the so called "younger generation" of health professionals. The seeds that may cause the development of negative attitudes are thought to be planted in medical school.

Preliminary findings from a study by (Alford et al 200120) speculated this to be primarily due to negative stereotypes and the low priority given to Geriatrics by other healthcare personnel, behaviours which may cultivate detrimental attitudes towards older people. It is known, for example, from existing literature that within the medical profession in EU countries, stigmatisation towards older people and affiliated conditions such as dementia have been found to be especially prevalent (Vernooij-Dassen et al, 200521).

15 Woloschuk W, Harasym P, Temple W. Attitude change during medical school: a cohort study. Medical Education, 2004; 38 (5): 522-534. 16 Masson N, Lester H. The attitudes of medical students towards homeless people: does medical school make a difference? Medical Education, 2003; 37(10):869-872. 17 Duque G, Bergman S, Bergman H. Early Clinical Exposure to Geriatric Medicine in Second-Year Medical School Students - The McGill Experience. Journal of the American Geriatrics Society, 2003; 51(4):544. 18 Cleary LM, Lesky L, Schultz HJ, Smith L. Geriatrics in internal medicine clerkships and residencies: current status and opportunities. American Journal of Medicine 2001; 111(9):738-741. 19 Kishimoto M, Nagoshi M, Williams S, Masaki K, Blanchette P. Knowledge and Attitudes About Geriatrics of Medical Students, Internal Medicine Residents, and Geriatric Medicine Fellows. Journal of the American Geriatrics Society, 2005; 53(1):99-102. 20 Alford C, Miles T, Palmer R., Espino D. An Introduction to Geriatrics for First-Year Medical Students. Journal of the American Geriatrics Society, 2001; 49(6):782. 21 Vernooij-Dassen MJ, Moniz-Cook EM, Woods B, de Lepeleire J, Leuschner A and Zanetti O. Factors affecting timely recognition and diagnosis of dementia across Europe: from awareness to stigma. International Journal of Geriatric Psychiatry, 2005; 20: 377–386. Medical students’ opinions can potentially be influenced by those thought to be in authority as shown by (Kamein et al, 199922) where intentions to pursue a medical discipline were shown to be inversely proportional to the frequency of negative comments that are heard about doctors by other doctors.

Despite all this, it has been found that medical students on average view older people in a positive light (Kishimoto et al, 200519). This does not persist throughout medical school, however, and diminishes throughout undergraduate training (Woloschuk et al, 200415).

The TeGeMe II study tries to address the current attitudes of medical students towards older persons while identifying several potentially influential factors which might contribute to medical students' opinions of older people.

Demographics All participants were themselves in their early to mid-twenties, with the average age of the participating students 24. The total number of participants was 8707. Female participants outnumbered males in Europe and Asia, a possible reflection of the growing number of females in the medical profession in general. The small numbers of participants some African countries rendered much of the data statistically invalid, thus interpretation of data from that continent cannot be readily applied to practice.

Factors identified There were 3 factors that were specifically considered as possible contributions to medical students' attitudes, namely, cohabitation with grandparents for more than 5 years, having undergone training in Geriatrics during the course of the undergraduate medical course, and having considered Geriatrics as a speciality. The impact of residing with grandparents and of Geriatric training was also considered as possible influences to choosing a Geriatric speciality.

Overview Overall the continental analyses revealed that medical students had positive attitudes towards older people as reflected in their low ASD scores, with every continent scoring below 4. However, when individual categories were taken into account, it was evident that the Independent- Ineffective (I-I) scores were always high in every continent and in every variable considered.

The I-I score reflects the ability of older persons to be self-directed and adaptable to change (Rosencranz and McNevin, 196910). It is typified by the items “progressive vs. old fashioned” and “active vs. passive” on the ASD scale. The consistency of the high I-I scores thus suggest that across all the continents, older people were considered to be unable to pursue goals, adapt to change and actively engage the environment (Intrieri et al, 199323). This could quite possibly be a reflection of how negative societal stereotypes of older people form detrimentally lasting impressions.

Asia had the lowest ASD overall score and therefore the most positive attitudes amongst all the continents involved in this study. This may reflect cultural influences, as traditionally in Asia the extended family unit has largely been maintained, meaning that overall more students would have had more early contact with older people in the community, which as mentioned earlier, has positive correlations with better attitudes.

22 Kamien BA, Bassiri M, Kamien M. Doctors badmouthing each other. Does it affect medical students’ career choices? Aust Fam Physician, 1999; 28(6):576-9 23 Intrieri R, Kelly J, Brown M, Castilla C. Improving Medical Students’ Attitudes Toward and Skills with the Elderly. The Gerontologist, 1993; 33 (3):373-378.

Although family units in Africa also tend to include the extended family, Africa had the highest overall ASD score amongst all the participating continents. African medical students may experience additional responsibilities and constraints in living with older relatives. They may also have greater exposure to illnesses and death in older age. Reflecting on the ASD analysis, the African medical students felt that older persons were more dependent (4.7) and unhealthy (4.6). Such attitudes may not necessarily be negative, but rather an interpretation of reality. For example, older persons who are no longer working may be dependent financially on their families, or they may be physically dependent on relatives for mobility. It is worth noting, additionally, that 552 out of the 1035 African students came from South Africa, therefore the data obtained cannot be said to be representative of all 5 countries.

Living with grandparents Evidence in the literature indicates that merely exposing medical students to older people is insufficient to generate positive attitudes amongst medical students, and in fact may create negative views. However, introducing medical students at an early stage in their careers to older people who are not only healthy but also who remain in the community has proven to have very powerfully positive effects. Positive attitudes are more pronounced in medical students who see older people in their element in the community rather than in institutionalized care (Wilkinson et al24, 2002, Medina- Walpole et al, 200525).

Although cohabitation with grandparents cannot be generalised to mean early exposure of students to healthy older persons, it can be assumed that the students in question would have had prolonged exposure to older family members in the community. Older people frequently maintain many functional positions in society including caregiver roles and in some countries many older persons remain economically and socially productive beyond usual retirement ages (Ebrahim and Kalache, 199826). This may cast them in a positive light in the eyes of their family members.

In TeGeME II, living with grandparents was generally related to positive attitudes towards older people. This is consistent with the idea that exposure to older people in the context of the family and the community correlates to more favourable views of older individuals in the eyes of students. The only exception to this were students in Europe, amongst whom living with grandparents created negative attitudes to older persons in every category. This may be related to a mainly Western society where living with grandparents is unusual and may be due to, for example, financial, social and health reasons that result in negative views, rather than positive.

Students in the other 3 continents participating in the study had cultures in which extended family arrangements are typical and this would have been encouraged by those societies, although these trends are also rapidly changing. In Western societies, youth and individualism tend to be given priority by the mass media (Liu et al, 200327) therefore creating even stronger negative societal stereotypes of older persons. The portrayal of older persons in the media as sick and vulnerable or comically grumpy is commonplace and all too easily believed. Thus it is a possibility that even proximity with older persons for extended

24 Wilkinson T, Gower S, Sainsbury R. The earlier, the better: the effect of early community contact on the attitudes of medical students to older people. Medical Education, 2002; 36 (6):540-542. 25 Medina-Walpole A, Heppard B, Clark N, Markakis K, Tripler S. Quill T. Mi Casa o Su Casa? Assessing Function and Values in the Home. Journal of the American Geriatrics Society, 2005; 53 (2):336-342. 26 Ebrahim S, Kalache A. Greater attempts must be made to promote positive roles for elderly people. British Medical Journal, 1998; 316:148. 27 Liu J, Ng S, Loong C, Gee S, Weatherall A. Cultural Stereotypes and Social Representations of Elders from Chinese and European Perspectives. Journal of Cross- Cultural Gerontology, 2003; 18(2):149- 168. periods of time would not have been sufficient to counter the pre-existing negative impressions left by the media.

Training in Geriatrics Geriatric clerkships are intended to help solidify the Geriatric skills knowledge base and sensitize students to a comprehensive and interdisciplinary approach in the care of older persons (Shah et al, 200428). Geriatric training varies widely in method and stage of inclusion in undergraduate training, if it is included at all. Clinical training in Geriatrics earlier rather than later in undergraduate training has been shown to be more beneficial in engendering positive attitudes towards older persons (Wilkinson et al, 200219). The method of training is also important. Students cite that they enjoy alternative training methods such as community based visits more and simulation-based experiences which put them in the shoes of older people (Rao, 200329, Wilkinson et al, 200224, Alford et al, 200120).

Evidence on the efficacy of training in Geriatrics in improving student attitudes towards older people varies widely. A 2005 study indicated that a lack of Geriatric training in the undergraduate curriculum did not necessarily correlate to poor student attitudes towards older persons (Kishimoto et al 200515). However other studies advocate training as a reliable method of ensuring that students develop favourable views of their older patients (McAlpine et al, 200230).

Geriatric training had a positive impact on student attitudes in Europe. In Asia, Africa and South America, training appeared to offer no significant difference in how students viewed older people, however, this may well be due to the fact that the percentages of participants in those continents who had undergone a form of Geriatric training was low, 2%, 18.4% and 14.4% in Africa, Asia and South America respectively.

Poor responses to Geriatric training is also likely to be related to the fact that teaching in Geriatrics is most well developed in European schools when compared to medical schools from the other 3 regions. While a number of developed countries report diverse facilities to teach Geriatrics, countries with their economies in transition lack these advantages (Keller et al, 200231). Many participating countries from Europe were developed Western European countries and the majority from other continents were classed as developing, the results could have been a reflection of the diversity of training worldwide. In high income countries, it is common to have highly developed programmes of teaching, including ward based teaching methods as well as interaction with other disciplines. They are also more likely to have a life course perspective to Ageing in their teaching.

Medical education that incorporates a life course perspective, as well as varied teaching methods are not so common in lower income countries. Geriatrics is not a subject that is well established in most Asian medical schools (Mejumder et al, 200432). In many African countries, Geriatrics is not taught as a separate course in the medical schools, and there is no specialized training in Geriatrics at present (Akanji et al,

28 Shah M, Heppard B, Medina-Walpole A, Clark N. and McCann R. Emergency Medicine Management of the Geriatric Patient: An Educational Program for Medical Students. Journal of the American Geriatrics Society, 2004; 53:141-145. 29 Rao R. Dignity and impudence: How should medical students acquire and practise clinical skills for use with older people? Medical Education, 2003; 37(3):190-191. 30 McAlpine C, Gilhooly M, Murray K. Medical students and Geriatric Medicine. Academic Medicine, 2002; 70:749 750. 31 Keller I, Makipaa A, Kalenscher T, Kalache A. Global Survey on Geriatrics in the Medical Curriculum. Geneva, World Health Organization Publication, 2002. 32 Mejumder M, Rahim A, Rahman S. Geriatric Training in Problem-Based Learning: An Asian Perspective. Journal of the American Geriatrics Society, 2004; 52(6):1038. 200233). These findings point to the importance of well tailored Geriatric training programmes in cultivating positive attitudes towards older persons amongst medical students.

Considering Geriatrics as a speciality A third of current Geriatricians indicate that their decision to pursue a career in Geriatrics was made before or during medical school (Medina- Walpole et al, 200220), a convincing argument for Geriatric educators to endeavour to develop courses that merit student participation and consideration. Unfortunately, in spite of good training programmes, prestige is often an important stimulus influencing choice of career and Geriatrics is a low- profile speciality that lacks visibility both in academia and amongst many of the medical specializations (Beck and Butler, 200434).

Students who cited an intention to specialize in Geriatrics had lower ASD scores and therefore better attitudes to older people than students. This held true in every continent. It is reasonable to expect that students with an interest in older persons’ healthcare would have better views of older persons and therefore would be more interested in specializing in Geriatrics.

In TeGeMe II it was discovered that neither training in Geriatrics nor living with grandparents was hugely instrumental in influencing students’ wishes to specialise in the field. In total, only 39% of students who had trained in Geriatrics and 33% of students who had lived with their grandparents expressed a wish to specialize. Evidence in the literature shows that training in Geriatrics does not significantly increase interest in clinical Geriatrics or Geriatric research, even among students who alter their views to become more positive (Alford et al, 200120) and this was consistent with the findings of this study.

It is reasonable to expect that the learning objectives set out in medical school curricula alone cannot be hugely influential on student career choice. The “hidden curriculum” must also be taken into account – one that includes indirect student observations of role model behaviour and informal interactions (Woloschuk et al, 200415). Awareness of the fact that the medical school curriculum lies outside mere syllabi and lectures is crucial to the realisation that “Geriatric Training” encompasses much more than is implied by its boundaries and therefore it is difficult to fully understand the impact of “training” on students until all aspects of “training” itself are made clear.

Study limitations Not all the students assessed had participated in Geriatric undergraduate training, making it difficult to ascertain the impact of training on student attitude.

Another limitation of this study is the fact that only literature in English was reviewed. Most of the literature on the subject of Geriatrics in medical education is based on curricula in developed countries such as North America, Europe and Oceania and it proved difficult to find literature on Geriatrics and Geriatric education in developing countries.

33 Akanji B, Ogunniyi A, Baiyewu O. Healthcare for Older Persons, A Country Profile: Nigeria. Journal of the American Geriatrics Society, 2002; 50 (7):1289-1292. 34 Beck J, Butler R. Physician recruitment into Geriatrics- further insight into the black box. Journal of the American Geriatric Society, 2004; 52 (11):1959-1961.

Bias may have been introduced by the fact that students who had favourable attitudes towards older persons would have been more likely to participate in the study. It is possible too that the students did not answer candidly for fear that their opinions would be deemed socially unacceptable.

It was also not possible to ensure that each medical student filled in the questionnaire independently. If the students conferred with each other during the completion of the questionnaire, they could have influenced each other and some students may have changed their original answers. Also, the questionnaires were completed at different times in the different countries within a 12-month period. It would have been ideal if all the questionnaires had been completed at the same time. The reliability of the assessment tool has not been ascertained, as this is the first study in which this tool was used.

In many of the continents, the balance of participants from different countries was not equal. The numbers of countries participating in each continent was largely small in most continents apart from Europe. Therefore the results obtained cannot be said to be representative of the continents as a whole. Furthermore, not all the regions of the world were equally represented. For example, North America was entirely excluded and almost no Middle Eastern countries apart from Lebanon participated in the study.

All countries in Asia which participated were classified by the World Bank as middle or low income countries. A more complete picture could have been obtained if high income countries Japan and South Korea had been included in the study to serve as points of comparison. However, with the rapid increase of the older population in developing countries, it is reasonable to focus on these countries as regions whose healthcare systems will have to undergo considerable change to withstand the so called “double burden of disease”.

Implications of study Examining student attitudes toward Geriatric patients from multiple dimensions helps to explain their attitudes better and to design specific intervention strategies for improving attitudes (Lee et al, 200535). TeGeMe II has provided a platform from which to view and compare medical students’ attitudes based on the same potentially influencing factors in their individual geographical locations.

Although this study cannot take into account the diversity of training and cultural influences globally, it offers a unique opportunity to assess the opinions of future health professionals towards older persons on a large scale. It was comforting to see that regardless of training status, level of exposure to older persons and future career aspirations, current medical students had positive opinions towards older persons. Measures should be taken to ensure that this is not diminished by insensitive attitudes picked up at medical school.

The key to positive views could be the mastery of the curriculum from both formal and informal aspects of teaching. This is easier said than done since it is almost impossible to keep track of what students learn via informal communications, whether implied or direct. Student observations of their mentors can convey to them messages of what is perceived to be valued (Woloschuk et al, 200416). It will be difficult to ensure that students always receive positive messages from their mentors. The initial step has to be taken at the grassroots level by working to improve the attitudes of current generation of medical students, who will

35 Lee M, Reuben D, Ferrell B. Multidimensional Attitudes of Medical Residents and Geriatrics Fellows Toward Older People. Journal of the American Geriatrics Society, 2005; 53 (3):489-494 then be tomorrow’s mentors to another set of students. This arduous effort will hopefully facilitate a culture of imparting positive outlooks towards older persons within the medical profession itself.

The rationale behind successfully cultivating and maintaining medical students’ interest in any subject through formal training is to first highlight the importance of the subject to good clinical practice and vary training methods to break monotony.

The former can be achieved by increasing implementation of undergraduate training in Geriatrics. Students often report gaining a multitude of skills from Geriatric clerkship modules such as the need to properly evaluate social supports and living arrangements, the need to obtain information about medications and the need to screen older adults for hidden clinical issues such as depression, poor nutrition, and falls (Shah et al, 200523). A confident grasp of some the greatest challenges faced by the older adult is a useful addition to any medical student’s arsenal of skills regardless of career choice in later stages of a medical career.

Many suggestions have been given to attempt to achieve interesting yet beneficial Geriatric training programmes. Among the ideas were to insert Geriatric Medicine clerkships in modules that were already given emphasis such as emergency medicine. Other suggestions which can be employed to provide stimulating Geriatric clerkships include case study discussions, inviting elders from diverse backgrounds to speak to students and the use of self- assessment tools to allow students to be aware of their own attitudes towards older persons (Xakellis et al, 200436).

Aside from the issues surrounding Geriatric training, this study realizes that the implications of better attitudes amongst students who had lived with their grandparents are multiple. From previous studies as well as anecdotal evidence students have responded well to exposure to older persons in their communities. Such opportunities provide chances to build relationships with older persons and visualize previously unfamiliar psycho- social aspects of elderly healthcare. It also speaks strongly for the fostering of intergenerational solidarity between young and old for the mutual benefit of both parties, whether this is provided in the formal context of the medical school or informally in personal relationships in the community.

Further work With regards to research, longitudinal follow-up studies on student attitudes as they progress through medical school is a more accurate way of assessing how school curricula affect students. This method may also prove useful in assessing how many students who express the wish to specialize actually follow through into the career after completing medical school.

For the purposes of further improvement of medical education, it is worth noting from Europe’s example that student attitudes towards older persons can be improved through well thought out training programmes. This in itself advocates increased implementation of undergraduate Geriatric training.

Medical students spend most of their training on hospital wards and interact with ill and frail older patients with decreased function due to their illness. Their contact with healthy active older individuals is limited in their educational programs. The students are presented with a one-sided view of the older person and this view is reinforced throughout their training. The results of TeGeMe II suggest that early exposure to older

36 Xakellis G, Brangman S, Ladson H, Jones V, Masterman D, Pan C, Rivero J, Wallhagen M, Yeo G. Curricular Framework: Core Competencies in Multicultural Geriatric Care. Journal of the American Geriatrics Society, 2004; 52 (1): 137-142. persons in the context of the community is conducive to the conception of positive student attitudes towards older patients and action should be taken to incorporate more of this type of teaching into medical education.

It is hoped that the data obtained by each country and medical school will be utilized to identify areas for improvement in undergraduate training, tailored to the needs of the individual institution or nation.

Following on from this, it is important to realize that the health service is not solely comprised of doctors and medical students, but instead draws on the skills of all professions allied to medicine for the provision of holistic and appropriate healthcare delivery. If the improvement of healthcare of older persons is the ultimate aim, future projects could include the assessment of attitudes of other health professionals, so as to provide a more comprehensive view.

The WHO and IFMSA advocate inclusion of Geriatric training in undergraduate medical curricula, especially with a Life Course perspective with an emphasis on Active Ageing (WHO, 2002). While TeGeMe II has demonstrated that the attitudes of the many bright, young health professionals who participated in this study do not rest solely on the state of medical curricula, it is a variable which can be altered and therefore efforts should be made to improve it. Appendix I Overall ASD Scores

Country I – I A – D PA – U ASD ASD Score ASD Score ASD Score Score Bolivia 4.31 3.79 3.31 3.71 Chile 4.56 3.88 3.51 3.91 Panama 3.96 3.31 3.00 3.36 Peru 4.33 3.97 3.53 3.88 Bulgaria 4.34 4.44 3.50 4.00 Czech Republic 4.70 4.39 4.13 4.36 Finland 4.25 3.38 3.42 3.67 Germany 4.50 3.89 3.93 4.08 Malta 4.59 3.99 3.65 4.12 Norway 4.41 3.65 3.39 3.75 Romania 4.82 3.16 3.82 4.20 Spain 4.60 3.92 3.70 4.01 Switzerland 4.19 3.60 3.64 3.78 United Kingdom 4.23 3.74 3.47 3.46 Hong Kong 4.55 4.04 3.88 4.12 Lebanon 4.35 3.78 3.46 3.80 Malaysia 4.36 3.93 3.59 3.90 Pakistan 4.21 3.70 3.27 3.65 Thailand 4.52 3.66 3.31 3.75 Ghana 4.85 4.43 3.69 4.22 Nigeria 4.61 4.39 4.02 4.29 Sudan 4.05 3.59 3.03 3.47 Tanzania 4.21 4.28 4.19 4.22 South Africa 4.36 4.02 3.55 3.91

Appendix 2: Participating Medical Schools

EUROPE 44 Medical Schools 10 countries Bulgaria University of Pleven, University of Varna Czech Republic Charles University in Prague, Medical Faculty in Hradec Kralove, Charles University in Prague, Medical Faculty in Pilsen, Charles University in Prague, First Faculty of Medicine, Charles University in Prague, Second Faculty of Medicine, Charles University in Prague, Third Faculty of Medicine Palacky University in Olomouc, Faculty of Medicine, Masaryk University in Brno, Faculty of Medicine Finland University of Helsinki, University of Kuopio, University of Oulu, University of Tampere University of Turku Germany Bonn University Medical Faculty, Koln University Medical Faculty, Mainz University Medical Faculty Leipzig University Medical Faculty, Wursburg University Medical Faculty Malta University of Malta Norway University of Bergen, University of Oslo, Norwegian University of Science and Technology (in Trondheim), Tromso University of Tromsoe Romania Iuliu Hatieganu University, Cluj-Napoca, Victor Papilian University, Sibiu, University of Targu Mures Spain University of Alcalá de Henares, University of Salamanca, University of Santiago de Compostela University of Seville, The Autonomous University of Madrid, Rovira I Virgili University (in Reus, Catalunya) Switzerland University of Geneve United Kingdom University of Aberdeen, School of Medicine; Queen’s University of Belfast, School of Medicine and Dentistry; University of Edinburgh, College of Medicine and Veterinary Medicine; Guy’s, King’s and St. Thomas’ (GKT) School of Medicine; University of Leeds, School of Medicine; University of Leicester, Faculty of Medicine and Biological Sciences; St. Bartholomew’s and the Royal London, Queen Mary’s School of Medicine and Dentistry; Imperial College of Science, Technology and School of Medicine; University of Nottingham, Faculty of Medicine and Health Sciences; University of Oxford, Clinical School of Medicine; University of Southampton, School of Medicine; University of Warwick, Warwick Medical School

AMERICAS 12 Medical Schools 4 countries Bolivia Del Valle University Chile Pontifical Chilean Chatolic University; University of Santiago de Chile; Mayor University, Santiago; de la Frontera University, Temuco Panama University of Panama, Collumbus University, The Latin University of Panama Peru Cayetano Heredia Peruvian University, San Martin de Porres University, Mayor de San Marcos National University, San Fernando Medical Faculty, University of Villareal ASIA 15 Medical Schools 5 countries Hong Kong The Chinese University of Hong Kong, The University of Hong Kong Lebanon American University of Beirut Malaysia Melacca Manipal College Thailand Bangkok Metropolitan Administration Medical College and Vajira hospital, Chulalongkorn University, University of Bangkok Pakistan Khyber Medical College, Peshawar; Khyber College of Dentistry, Peshawar; Gandhara Medical College, Peshawar; Aga Khan University, Karchi; Sindh Medical College, Karachi; Dow Medical College, Karachi; Allarna Iqbal Medical College, Lahore; King Edward Medical College, Lahore

AFRICA 6 Medical Schools 4 Countries Ghana University of Ghana Medical School, Accra; University of Science and Technology, School of Medical Sciences, Kumasi Nigeria University of Lagos, College of Medicine South Africa Stellenbosch University, Cape Town; University of Cape Town Medical School Sudan Unknown Tanzania Muhimbili University College of Health Sciences, Dar-es-Salaam Appendix III

Case study: Geriatric Medicine in Ghana Our cultural belief is that older people are a precious part of our society. There are a few negative aspects to mention though, concerning how we care for older people: when older people are not in hospital, they are not treated as well. When an older person has a disease like stroke, extra time-intensive care is needed when they leave the hospital. But after older patients are discharged from the hospital, giving them satisfactory care becomes difficult, and many older persons die at home from complications. Community homes for older people do not exist in Ghana, and this has led to a reduced standard of care for older people who cannot take care of themselves. Isolation is another major problem as space is not made available for older people to meet, socialize and to discuss their problems. Older people who depend solely on grossly inadequate pensions tend to be unhealthy because of lack of appropriate nutrition. Communities often lack well equipped hospitals, so older people rarely have access to high standard hospitals. Interventions to improve this situation should not only focus on hospital care, but also on the psychosocial aspects of the older person in order to ensure healthy and active ageing. The issue of teaching Geriatrics in the medical schools is gaining ground in the curriculum of the schools. In the medical school where I am being trained (Accra), there is no formal course on Geriatrics, but in our classes and in clinical practice issues that deserve explanation or modification in order to allow appropriate old age care are stressed by the lecturers. For example, topics such as chronic renal failure, diabetes mellitus type 2, and malignancies are taught. In such lectures the main focus is on older people, and these classes are not very different from the lectures in Geriatric Medicine which I had the chance to attend in other countries. I think that, with the increase in the adult and aged population, there will be an increased emphasis on the issue of Geriatrics in Ghana. In the clinical years of my training in Accra, teaching patterns are similar to those in the pre-clinical years. Lectures are given which, in my perception, are lectures on Geriatric Medicine. Some of my lectures are about groups that care for the aged. Hence, through these lecturers more awareness is being raised about the aged. On the wards there is no separate ward for older people, but a general ward for adults. Many of our patients are older people though, and therefore, in practice on the wards we learn about how to modify our treatment plan to suit older patients. The issue of caring for older people is gaining popularity and I believe that we will soon be seeing a ward for Geriatric patients, at least at my medical school. During my community health rotation, I was asked to work on advocating for the improvement of health care for the aged in Ghana. This gave me more insight into the issue. The Ministry of Health has come out with a policy which states that children under 5 years of age, pregnant women, and older people (over 70 years) are entitled to free medical care. This means that the needs of older people are being recognized much more now. In addition, organisations like HelpAge Ghana are being given more attention and support. All the experiences that I have had during my training leave me with the impression that Geriatric Medicine is moving from being a peripheral issue to assume a much more central position in the training of medical students.

References: Global Survey on Geriatrics in Medical Education. WHO/NMH/NPH/ALC/02.7

Appendix IV

Case study: Geriatric teaching in the United Kingdom37 The United Kingdom has a number of medical schools, with no national set curriculum. There are guidelines from the General Medical Council, the regulatory body, but medical schools are free to interpret these in their own manner. This is a selection of UK medical schools and their Geriatric teaching provision.

University of Aberdeen The Geriatrics teaching in Aberdeen begins in Year 2 with a rotation at the Department Of Medicine for the Elderly (DOME). There are four sessions there: in the first there is a tutorial that aims to introduce students to specific aspects to consider of elderly patient care e.g. rehabilitation; the other three sessions are based in the wards and in those students take histories, present and discuss any issues that might be important to consider before their discharge such as home help. In Year 3 there are three lectures which consider the key Geriatric problems. Year 4 aims to tie all the experience together with a week at DOME where students gain more practical experience. There is no specific teaching in Year 5 unless students ask to be attached to the DOME (during a seven week rotation on both a medical and surgical ward).

Barts and the London The official Geriatrics teaching takes the form of one week of old age psychiatry in Year 4 and then 4 weeks of Health Care of the Elderly in Year 5. There is informal/unofficial teaching during a seven week rotation in old age medicine during Year 3, however, only 20 students in the whole year will be attached to this ward (all students are divided into small groups and then allocated to wards on two surgical and two medicine teams). Students are expected to clerk patients to receive teaching on clinical examinations and tutorials on the medical objectives in the core curriculum. These students will be likely to learn about Geriatric Medicine through contact with patients and by talking to doctors on the ward.

University of Edinburgh Throughout all of the medical teaching there is also a continuous thread based on an Ageing and Life Course model, though specific Geriatric Medicine teaching is based in Year 5. The course begins with a three-day course:

● A two-day introduction to the main service and clinical topics in Geriatric Medicine ● A day at St. Columba’s Hospice or Marie Curie Centre (a cancer specialist centre) with lectures and clinical time, learning palliative care.

Thereafter, there is a three and a half week clinical attachment with one of a number Geriatric services across central and southern Scotland. The attachment consists of clerking patients on the ward, attending

37 Personal communication, 2005: Ciaran Trolan, LFP, Queen’s Belfast, Nabihah Sachadina, LFP, King’s College London, Raguwinder Bindy Sahota, LFP, University of Leicester. Other responses through data submission to NFP.

multidisciplinary teaching ward rounds and observing outpatients’ clinics. Emphasis is placed on gaining a wide range of experience from different health care professionals, such as attending occupational therapist home visits.

At the end of the attachment there is a written exam and a final session of case presentations and discussion. The latter is facilitated by a clinician from Geriatric Medicine and someone with specialist expertise in medical ethics. The session is an acknowledgement that difficulties and dilemmas arise in the care of older people; it helps to develop skills to deal with them better. There is also an assessed case report where a specific patient’s illness is discussed from a holistic viewpoint of physical, social and psychological problems and therapies.

Kings College London Students have approximately six weeks of Geriatrics in Year 4 as part of a module on 'Child Health, Development and Ageing' which runs for a total of twelve weeks. During this time there is teaching in old age psychiatry and Geriatric Medicine (two days per week each). At the end of this there is a case-study- style presentation. At the end of the twelve week module there are written exams and an end-of-year clinical exam covering different aspects of care, for example, a falls assessment or discharging an elderly patient. During the Geriatrics attachment there is also teaching from members of the Geriatric multidisciplinary team, such as dieticians, speech and language, physiotherapists and community pharmacists.

University of Leeds In Year 2, teaching is given regarding Geriatrics individuals and populations, family, society & health, looking at how society views aging and the elderly.

In Year 3, with a life-ycle approach, students study the ageing process; theories of aging; normal biochemical process at cellular, body and functional levels as well as the pathological processes commonly associated with ageing and disability. There is also teaching on management of health care, specifically the health and social care needs of older people, services available; personal and societal attitudes to aging and resulting disability. There is also teaching on dying, death and bereavement: biological and social theories of dying and death, diagnosis of death, care of the dying and bereavement.

During Year 4 and Year 5 the only Geriatric-related teaching is that related to clinical experience, in dermatology, genitourinary medicine, infectious diseases, musculoskeletal, oncology palliative care, orthopaedics, plastic surgery, rehabilitation and rheumatology as well as other areas of medicine.

Queen’s University of Belfast (Northern Ireland) Geriatrics is taught as a three week clinical module in conjunction with a General Practice module. There are two days of introductory seminars discussing common conditions and their management in the field of Geriatrics. Placements are throughout centres in Northern Ireland. The majority of these centres have a stroke unit attached to them.

Students are expected to clerk patients, present on interdisciplinary ward rounds, and attend out-patient clinics. Domiciliary visits are also undertaken by students under supervision. Teaching on placement is carried out by all members of the multidisciplinary team and inter-professional education with nursing students is planned for the future. Two cases are written up for assessment along with a pharmacology presentation on how a particular drug group is used in the elderly compared to the general population.

University of Sheffield The Geriatric teaching consists of a few days of ward based teaching, focussing on taking a history of activities of daily living (ADL) which determine the degree of independence present in an older person.

University of Southampton Students are expected to integrate clinical experience with knowledge from biological and social sciences. Elderly care teaching is integrated into the curriculum throughout the degree. During pre-clinical years, subjects including sociology and psychology on ageing and elderly care are taught in the form of lectures, seminars and workshops. Elderly care is a compulsory three week attachment in the first clinical year. During this attachment, students get an opportunity to communicate with patients who may have sensory and /or cognitive impairment. It is also an opportunity to assess the impact of social, economic and cultural factors on health, illness and recovery. The teaching includes ward based clinical experience and case-based teaching and seminars.

During the Year 3, third year psychiatry attachment, students spend two weeks in old-age psychiatry attending outpatient clinics, house visits as well as clerking in-patients. In Year 4, Geriatric teaching is integrated into short clinical attachments including neurology, orthopaedics and rheumatology, dermatology and ophthalmology. In Year 5 students spend ten weeks with general medicine firms. During this period, some students will spend a couple of weeks in Geriatric wards refining skills taught in Year 3.