|Year : 2018 | Volume
| Issue : 1 | Page : 33-40
Should undergraduates be introduced to geriatric training? A pilot study on knowledge, attitude, and perception in medical interns and postgraduate residents from a tertiary care hospital
Alka A Subramanyam, Delnaz Dara Palsetia, Suchita Rajiv Agarwal, Ravindra M Kamath
Department of Psychiatry, TNMC and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||8-May-2018|
Alka A Subramanyam
Department of Psychiatry, 1st Floor, OPD Building, TNMC and BYL Nair Charitable Hospital, Mumbai Central, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: The number of elderly patients is expected to rise. However, the efforts required to integrate this aging population into our health-care system seem to be lacking. An improvement definitely has to be aimed for because the subject of geriatric medicine will personally concern each one of us in the future. Aims: This study aims to assess and compare knowledge, attitude, and perception toward elderly and aging in medical interns and postgraduate residents and compare attitudes toward aging among the different postgraduate branches. Settings and Design: This study was conducted at a tertiary care teaching municipal hospital and medical college. This was a cross-sectional study utilizing self-constructed structured questionnaires. Materials and Methods: Questionnaires on knowledge, attitude, and perception, constructed by the lead researcher and reviewed by an expert panel, were administered to the two groups. The responses were collected and analyzed. Statistical Analysis Used: Chi-square test and means of percentages were used. Results: Both groups showed a positive perception to the needs of the elderly. The interns showed a more negative attitude toward aging compared to the postgraduate students, with the differences being significant (P < 0.05) between the two groups in 16 out of 45 questions. On the knowledge questionnaire, a significant (P = 0.014) difference was seen between the teaching in interns and postgraduates. The analysis also revealed that general medicine and psychiatry had the best scores on the attitude questionnaire. Conclusions: Although the perception of elder-friendly city is same in both groups, interns have a more negative attitude toward aging which could stem from the inadequate knowledge being imparted during the undergraduate medical curriculum. Hence, there is a need to introduce geriatric medicine at an undergraduate level.
Keywords: Ageism, elderly-friendly city, geriatric, medical curriculum, undergraduates
|How to cite this article:|
Subramanyam AA, Palsetia DD, Agarwal SR, Kamath RM. Should undergraduates be introduced to geriatric training? A pilot study on knowledge, attitude, and perception in medical interns and postgraduate residents from a tertiary care hospital. Ann Indian Psychiatry 2018;2:33-40
|How to cite this URL:|
Subramanyam AA, Palsetia DD, Agarwal SR, Kamath RM. Should undergraduates be introduced to geriatric training? A pilot study on knowledge, attitude, and perception in medical interns and postgraduate residents from a tertiary care hospital. Ann Indian Psychiatry [serial online] 2018 [cited 2018 Nov 14];2:33-40. Available from: http://www.anip.co.in/text.asp?2018/2/1/33/232044
| Introduction|| |
By 2050, one-fifth of India's population will be aged (more than 60 years of age).
International studies were able to demonstrate a correlation between medical students' knowledge, attitudes, experience, and interest regarding aging and older people.,,,,
An improved education using different didactic options generally leads to an improved competence and an enhanced attitude toward professional conduct, therapy, and attitude toward patients.
Hence, the purpose of this study is to assess and compare knowledge, attitude, and perception toward elderly in medical interns and postgraduate residents and compare attitudes toward aging among the different postgraduate branches.
| Materials and Methods|| |
The study was conducted at a tertiary care hospital. All postgraduate residents and medical interns willing to give informed consent were included in the study and those not willing to give consent were excluded from the study.
A cross-sectional study was performed.
The permission from the Head of the Institute was taken to conduct the study in undergraduate interns and postgraduate medical students. Questionnaires on knowledge, attitude, and perception were constructed by the lead researcher and reviewed by five psychiatrists (faculty) of the department after which they were used. Previous literature  and researchers' personal experiences were used to form and phrase the questions.
The knowledge questionnaire consisted of nine questions with question three having five subquestions. All the questions were of yes or no format with yes being scored as 1 and no as 0. Range of score was from 0 to 13. Higher score meant more was the knowledge.
The attitude questionnaire consisted of 45 questions. All the questions were yes/no/don't know format questions except the first question. Higher score meant better was the attitude.
The perception questionnaire consisted of 30 questions. All the questions were yes/no format questions. Higher score meant more was the perception.
The same was submitted to the institutional ethics committee for approval. Informed consent was obtained from the participants. Questionnaires were used to gather information. All questionnaires were distributed together to the participants and they were given time to fill the same in the presence of the reviewer. Participation was voluntary. Participation was voluntary. The participants had the right to withdraw at any point of time. A total of 96 participants responded to the questionnaires out of a total of 250 questionnaires distributed. Of these, 43 were medical interns and 53 were postgraduate residents.
Data were tabulated and analyzed using descriptive and inferential statistics using the IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY: IBM Corp.). Chi-square test and means of percentages were used.
| Results|| |
The mean age of medical interns was 23.6 years and of postgraduate residents was 26.4 years.
On the perception questionnaire [Annexure 1] [Additional file 1], most of the participants gave answers indicating that there was a need for more facilities for the elderly in India to make an elder-friendly city. Among the medical interns, the average score on perception questionnaire was 15.76 out of 30 items, and among the postgraduates, it was 18.21 out of 30 items. This indicated that they believed not enough was being done in India for an elder-free city [Figure 1]. The perception of the needs for an elder-friendly city showed no significant differences between the medical interns and postgraduate residents, on any of the 30 questions analyzed. Both showed a positive perception to the needs of the elderly.
|Figure 1: Average scores on the perception questionnaire, comparing undergraduate interns with postgraduate students|
Click here to view
The average score on attitude questionnaire [Annexure 2] [Additional file 2] was 15.73 for interns and 23.71 for postgraduates out of a total of 45 [Figure 2]. The interns showed a more negative attitude toward aging compared to the postgraduate students toward the elderly, with the differences being significant (P < 0.05) between the two groups in 16 out of 45 questions. These included questions based on their decision-making capacity, social life, and attitude toward health problems and dealing with them. For example, 44.2% of medical interns and 11.3% of postgraduate residents were of the opinion that “old people do not work.” Similar gaps were seen on questions like, “Old people who wear makeup or dress up, look odd,” “Most old people are depressed,” and “Opinions of old people are based on rudimentary ideas and do not carry importance in modern times.” Both the groups showed their negative attitudes toward aging while replying to 16 out of 45 questions, which included questions based on their cognitive abilities, physiological changes, rigid thinking, and physical abilities. For example, 56% of all participants reported that “Old people do not change their routine.” Similar negative attitudes were also seen toward financial dependence, sexual life, and assigning roles to them such as babysitting.
|Figure 2: Average scores on the attitude questionnaire, comparing undergraduate interns with postgraduate students|
Click here to view
On the knowledge questionnaire [Annexure 3] [Additional file 3], the average scores were 6.28 and 6.58 out of 13 items for interns and postgraduates, respectively [Figure 3]. About 79% of postgraduates reported that they had been taught about the geriatric population in their medical curriculum, versus 55.8% of interns, the difference being significant (P = 0.014). Similarly, 72% of medical interns reported that history taking for geriatric population was not covered in their curriculum versus 34.8% of postgraduate residents, the difference being statistically significant (P = 0.003). Similar results were obtained for physiological changes (72% vs. 30.4%), pathological changes (76% vs. 34.8%), pharmacodynamics/pharmacokinetics (72% vs. 45.7%), and treatment regimens (76% vs. 47.8%) in elderly, the difference being significant in each case.
|Figure 3: Average scores on the knowledge questionnaire, comparing undergraduate interns with postgraduate students|
Click here to view
Nearly 67.4% interns reported that they were not taught the management of a geriatric patient versus 43.4% of postgraduates and this difference was found to be statistically significant (P = 0.019). On the question, “As compared to adults, are additional investigations required in the elderly?”, only 52.4% of interns answered with a yes versus 90.2% of postgraduates answering positively, this difference was found to be statistically significant (P < 0.001). About 60% of interns reported that geriatric patients are similar to adult patients with regard to clinical aspects, whereas none of the postgraduates thought so with the difference being statistically significant (P < 0.001).
About 66.7% of interns and 75.5% of postgraduates reported that they did not have a separate teaching module for geriatrics/geriatric medicine. Nearly 58.3% of the entire sample reported that they had not received training for the clinical assessment of geriatric patients. No significant difference between interns and postgraduates was found with respect to these two questions.
About 46.8% of all the participants did not feel competent in treating geriatric patients and 57% did not feel competent in prescribing medications to the elderly. This percentage was similar for interns as well as postgraduates.
An average of 74% interns reported of not having been introduced to history taking, physiological changes, pathological changes, pharmacodynamics and pharmacokinetics, and treatment regimens for the elderly patients.
The results of the comparison between undergraduate interns and postgraduate medical students for all three questionnaires have been summarized in [Figure 4].
|Figure 4: A comparison of the average scores on the perception, attitude, and knowledge questionnaires, comparing undergraduate interns with postgraduate students|
Click here to view
On comparison of the different postgraduate branches, it was seen that general medicine and ENT had the highest scores on the perception questionnaires as seen in the scatter chart [Figure 5]. General medicine and psychiatry had the best scores on the attitude questionnaire [Figure 6]. Radiology and obstetrics and gynecology had the highest scores on the knowledge questionnaire [Figure 7].
|Figure 5: Comparison of average scores of the different branches of postgraduation and undergraduate interns on the perception questionnaire|
Click here to view
|Figure 6: Comparison of average scores of the different branches of postgraduation and undergraduate interns on the attitude questionnaire|
Click here to view
|Figure 7: Comparison of average scores of the different branches of postgraduation and undergraduate interns on the knowledge questionnaire|
Click here to view
| Discussion|| |
The study was conducted with the aim of comparing the knowledge, attitude, and perception toward elderly and aging in medical interns and postgraduate residents in an Indian tertiary care hospital. The medical students were hesitant to participate in the study and many of them did not return the questionnaires citing lack of time and having examinations coming up.
The study shows that the perceptions of needs of the elderly are similar in the undergraduate and postgraduate medical students, indicating a general realization of the challenges of old age. Both the groups had an adequate perception of these needs. Moreover, they also reported a lack of adequate facilities in India to meet these needs.
On comparison of the different postgraduate branches, for perception toward the elderly, it was seen that general medicine and ENT had the highest scores indicating that they were better sensitized to the needs of the elderly as compared to the other branches. General medicine has a separate geriatric clinic which may have led them to be better sensitized to the needs of the elderly. This could also be due to higher number of elderly patients attending these outpatient departments.
The result on the attitude questionnaire shows that the interns showed a more negative attitude toward aging compared to the postgraduate students toward the elderly. The result also indicated that the old people are assigned negative stereotypes, and there is an ageism bias that is common to both groups.
Ageism involves applying false stereotypes to the elderly or changing the way one treats older people “in regard to their competence and value in society.” It may be a fundamental determinant of health and access to adequate resources, depending on the cultural values and social traditions that shape social inequality and health disparities.,
Overall, it has been seen that compared to the average population, medical students display an increased negative attitude toward older people. Such attitudes, as well as a lack of interest in older people, have been described in several international and national investigations.,,,, For this reason, it is of particular importance that some necessary features are taught during medical education related to the diagnosis and treatment of older people.
The analysis between the different postgraduate branches revealed highest scores for general medicine and psychiatry on attitude questionnaire indicating that they have been sensitized to the different facets of aging. These branches also offer courses in geriatric medicine and have separate geriatric OPDs in our hospital which might have led to the higher scores. This could be due to higher number of elderly patients attending these outpatient departments.
On the knowledge questionnaire, it shows that geriatric medicine is not introduced even in theory at the undergraduate level in most cases. Even at postgraduate level, about 20%–50% of students are not introduced to geriatric medicine as a subject. A significant difference was seen between the teaching and training in undergraduate interns and postgraduate students. Only 56% of the interns reported of having been taught about the geriatric population in their medical curriculum. An average of 74% interns reported of not having been introduced to history taking, physiological changes, pathological changes, pharmacodynamics and pharmacokinetics, and treatment regimens for the elderly patients. Both groups reported not having been taught clinical assessment of elderly patients. Both groups reported feeling incompetent in treating and prescribing medications to the elderly.
These results show that undergraduate interns are not given practical knowledge in the management of elderly patients in most cases which translates to inadequate knowledge about the additional investigations required in the older patients and their clinical evaluation. The findings also suggest that the lack of practical knowledge being imparted during the training of undergraduates and postgraduates translates into a feeling of incompetency among them. A similar study concluded that because of the multifactorial nature of many illness states in the elderly and barriers to communication there is frustration in caring for elderly patients.
Another consideration is that although an integrated approach to teaching medical subjects has been well accepted to be an effective educational strategy and recommended to be introduced, it has not yet become popular in medical colleges in India.,,
Following the MCI guidelines, a pattern of 1 year of basic sciences, 1 1/2 years of paraclinical sciences, and 2 years devoted entirely to clinical subjects has been adopted in medical colleges in India. The subjects are taught in isolation of each other with little or no attempt to integrate the basic sciences with the clinical disciplines.
A review study also demonstrated that in general, the current curricula do not devote enough time to the teaching of pharmacology. A move toward an integrated curriculum is likely to reduce the fragmentation of the medical course, and lead to better learning.
Thus, an integrated approach to the medical curriculum may lead to better utilization of important opportunities to rule out comorbidities and screen for diseases commonly seen in old age at the point of contact with a general practitioner.
On comparing the different postgraduate branches, it was seen that the scatter on the knowledge acquisition was not significantly different [Figure 7]. The analysis between the different postgraduate branches on the attitude questionnaire revealed that the branches of general medicine (score = 33 out of 45) and psychiatry (score = 27.4 out of 45) had the best scores indicating that they have been sensitized to the different facets of aging [Figure 6]. There was no correlation between the attitude score and knowledge score on the questionnaires indicating that knowledge alone is not enough for bringing about a holistic change in the attitude toward the elderly. This is consistent with previous research which has not shown a consistent relationship between knowledge acquisition and attitudinal change.,,,,,,,,,
Interestingly, another study found that exposure of students to clinical material in the 1st year of the course greatly improved the levels of interest and understanding generated in the students.,,
Studies done in urban health centers have found that the number of geriatric patients attending outpatient department ranges between 9.9% and 13.7%. The current share of the geriatric population in India is about 8.6% according to the “Elderly in India” report of 2016 published by the Ministry Of Statistics And Programme Implementation. As the number of elderly is expected to rise, the number of geriatric patients is also likely to rise and so will the challenges faced by health-care staff.
Thus, an early introduction to geriatric medicine, utilizing a combination of a didactic approach, introduction to practical aspects of clinical assessment, soft skills training, and management of elderly would be more favorable and go a long way in improving health care for the elderly.
There were some important limitations to this study.
- It was a pilot study, so a small sample size was used
- Biased sample from a single medical college
- Self-constructed questionnaires which require validation on a larger sample.
However, this was a pilot study, and after validating the questions, we intend to further our study by possibly doing an internet survey method including participants from all over India.
| Conclusions|| |
The study shows that the perceptions of needs of the elderly are similar in the undergraduate and postgraduate medical students, indicating a general realization of the challenges of old age. However, ageism was seen to pervade both the groups and all the aspects of life with some common negative attitudes in both the groups. This seems to stem from the inadequate knowledge being imparted during the medical curriculum at the undergraduate level and postgraduate medical students. With the growing number of geriatric patients seen today in the outpatient departments and clinics, there is a need for introducing geriatric medicine in the undergraduate course to improve attitude toward the elderly and making them more competent and confident in managing the elderly patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
United Nations, Department of Economic and Social Affairs, Population Division World Population Prospects: The 2015 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP. 241; 2015.
Voogt SJ, Mickus M, Santiago O, Herman SE. Attitudes, experiences, and interest in geriatrics of first-year allopathic and osteopathic medical students. J Am Geriatr Soc 2008;56:339-44.
Fitzgerald JT, Wray LA, Halter JB, Williams BC, Supiano MA. Relating medical students' knowledge, attitudes, and experience to an interest in geriatric medicine. Gerontologist 2003;43:849-55.
Lee M, Reuben DB, Ferrell BA. Multidimensional attitudes of medical residents and geriatrics fellows toward older people. J Am Geriatr Soc 2005;53:489-94.
Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: A five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group. J Am Geriatr Soc 1995;43:1430-6.
Green SK, Keith KJ, Pawlson LG. Medical students' attitudes toward the elderly. J Am Geriatr Soc 1983;31:305-9.
Goldenhar LM, Kues JR. Effectiveness of a geriatric medical student scholars program: A qualitative assessment. J Am Geriatr Soc 2006;54:527-34.
Palmore E. The ageism survey:First findings. Gerontologist 2001;41:572-5.
Butler RN. Age-ism: Another form of bigotry. Gerontologist 1969;9:243-6.
Nelson TD. Ageism: Stereotyping and Prejudice Against Older Persons. Cambridge, MA (USA): MIT Press; 2002.
Klaghofer R, Buddeberg C, Schleuniger M, Herta KD. Attitudes toward older people at the beginning and end of medical students' education. Z Gerontol Geriatr 2009;42:365-71.
Bagri AS, Tiberius R. Medical student perspectives on geriatrics and geriatric education. J Am Geriatr Soc 2010;58:1994-9.
Brooks TR. Attitudes of medical students and family practice residents toward geriatric patients. J Natl Med Assoc 1993;85:61-4.
Le Couteur DG, Bansal AS, Price DA. Attitudes of medical students toward careers in geriatric medicine. Australas J Ageing 1997;16:225-8.
Paris BE, Gold G, Taylor B. First year medical students' attitudes toward the elderly: A comparison of years 1986, 1991 and 1994. Gerontol Geriatr Educ 1997;18:13-22.
Drickamer MA. Perceived needs for geriatric education by medical students, Internal medicine residents and faculty. J Gen Intern Med 2006;21:1230-34.
Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues. Acad Med 1998;73:S24-31.
Harden RM. The integration ladder: A tool for curriculum planning and evaluation. Med Educ 2000;34:551-7.
Dunaway GA, Faingold CL. Development and implementation of a multidisciplinary sophomore medical curriculum: Integration of pharmacology with basic and clinical sciences. Pharmacologist 2001;43:83-90.
Medical Council of India. Regulation on Graduate Medical Education. New Delhi: Medical Council of India; 1997.
Medical Council of India. Recommendations of the Workshop on Need-Based Curriculum for Undergraduate Medical Education. New Delhi: Medical Council of India; 1992. p. 28-30.
Keijsers CJ, van Hensbergen L, Jacobs L, Brouwers JR, de Wildt DJ, ten Cate OT, et al.
Geriatric pharmacology and pharmacotherapy education for health professionals and students: A systematic review. Br J Clin Pharmacol 2012;74:762-73.
Barry PP. Geriatric clinical training in medical schools. Am J Med 1994;97:8S-9S.
Shahidi S, Devlen J. Medical students' attitudes to and knowledge of the aged. Med Educ 1993;27:286-8.
Intrieri RC, Kelly JA, Brown MM, Castilla C. Improving medical students' attitudes toward and skills with the elderly. Gerontologist 1993;33:373-8.
Murden RA, Meier DE, Bloom PA, Tideiksaar R. Responses of fourth-year medical students to a required clerkship in geriatrics. J Med Educ 1986;61:569-78.
Fields SD, Jutagir R, Adelman RD, Tideiksarr R, Olson E. Geriatric education. Part I: Efficacy of a mandatory clinical rotation for fourth year medical students. J Am Geriatr Soc 1992;40:964-9.
Smith MR, Marcy ML, Mast TA, Ham RJ. Implementation and evaluation of a model geriatrics curriculum. J Med Educ 1984;59:416-24.
Powers CS, Savidge MA, Allen RM, Cooper-Witt CM. Implementing a mandatory geriatrics clerkship. J Am Geriatr Soc 2002;50:369-73.
Hall NK, Riesenberg LA, Stein LK, Biddle WB. Longitudinal effectiveness of a medical school geriatrics clerkship. Acad Med 1997;72:S28-30.
Lindberg MC, Sullivan GM. Effects of an inpatient geriatrics rotation on internal medicine residents' knowledge and attitudes. J Gen Intern Med 1996;11:397-400.
Holtzman JM, Beck JD, Coggan PG. Geriatrics program for medical students. II. Impact of two educational experiences on student attitudes. J Am Geriatr Soc 1978;26:355-9.
Vyas R, Jacob M, Faith M, Isaac B, Rabi S, Sathishkumar S, et al.
An effective integrated learning programme in the first year of the medical course. Natl Med J India 2008;21:21-6.
Abramovitch H, Shenkman L, Schlank E, Shoham S, Borkan J. A tale of two exposures: A comparison of two approaches to early clinical exposure. Educ Health (Abingdon) 2002;15:386-90.
McLean M. Sometimes we do get it right! Early clinical contact is a rewarding experience. Educ Health (Abingdon) 2004;17:42-52.
Arun A, Gupta P, Srivastava JP, Prakash D. A study of the morbidity pattern amongst patients attending the OPD at urban health training centre, Era's Lucknow medical college and hospital, Lucknow. Int J Adv Res 2013;1:906-13.
Yadav V, Manjunath SR, Mukherji S, Ramakrishnan TS. Morbidity profile of OPD patients of an urban health and training center: A tool for the health planners. Natl J Community Med 2015;6:46-50.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]