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Correspondence: Address correspondence to James T. Fitzgerald, PhD, Department of Medical Education, The University of Michigan Medical School, 1107 Towsley Center, Box 0201, Ann Arbor, MI 48109-0201. E-mail: tfitz{at}umich.edu
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Abstract |
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Key Words: Prior experience • Practice preference
Despite the well-documented demographic imperative and projected health care needs, an increasingly large body of literature suggests that most medical students have little knowledge about aging, mixed attitudes about older adults and their care, and low interest in pursuing geriatric medicine as a career (Coccaro & Miles, 1984; Perrotta, Perkins, Schimpfhauser, & Calkins, 1981). Medical schools and their curricula have to address these issues in the training of physicians; that is, how can curricula be designed to improve the knowledge, attitudes, and skills related to the care of older adults? However, before this question can be answered, a better understanding of the relationships among student knowledge, attitudes, and experience is required. Previous research has shown that providing relevant knowledge alone is not sufficient for changing the attitudes and skills of medical students about older adults and their care. Instead, it is suggested that appropriate socialization—by means of training in multiple sites, varied experiences with well elderly as well as ill elderly adults, mentoring, and other innovative curriculum methods—is the more critical factor underlying improved knowledge, attitudes, and skills, and, in turn, greater interest in geriatric medicine (Adelman, Fields, & Jutagir, 1992; Deary, Smith, Mitchell, & MacLennan, 1993; Gold, Hadda, Taylor, Tideiksaar, & Mulvihill, 1995; Hartley, Bentz, & Ellis, 1995; Intrieri, Kelly, Brown, & Castilla, 1993; Knight, Knight, Gellula, & Holman, 1992; Linn & Zeppa, 1987; McAlpine, Gilhooly, Murray, Lennox, & Caird, 1995; Penn et al., 2001; Reuben, Fullerton, Tschann, & Croughan-Minihane, 1995; Sheffler, 1998; Ten Haken, Woolliscroft, Smith, Wolf, & Calhoun, 1995; Wooliscroft, Calhoun, Maxim, & Wolf, 1984).
Using baseline knowledge and attitudes of University of Michigan Medical School (UMMS) students who enrolled in 2001, this study examined the relationships among students' knowledge about older adults and aging, their attitudes toward older adults, their prior care experience, and their interest in geriatric medicine as a career upon entering medical school. Analyses were driven by two research questions: First, do the aging-related knowledge and attitudes of entering first-year medical students differ by prior care experience with older adults, age group they anticipate preferring to work with as physicians, or interest in geriatric medicine as a career? Second, are greater knowledge, more positive attitudes, and greater prior experience with older adults associated with a greater interest in caring for older adults or in a career in geriatric medicine?
On the basis of previous research on medical students and geriatrics, we expected to find that students would possess minimal knowledge and neutral attitudes about aging and older adults as well as little interest in geriatric medicine. We hypothesized, however, that increased aging-related knowledge and attitudes would be associated with greater prior contact with older adults and interest in geriatric medicine by the students.
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Design and Methods |
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The student respondents (n = 171) were relatively evenly split between men and women (47% women and 53% men). The majority of the students identified themselves as Caucasian (60%), followed by African Americans (10%), Chinese (9%), Indian–Pakistani (8%), Other Asian (5%), Hispanic (4%), Native American (1%), and Missing (4%). The average age of these incoming students was 23 (SD = 3) years old, with a range from 20 to 40 years old.
Survey Instruments
The students completed the Revised Facts on Aging Quiz 1 (FAQ1), a 25-item multiple-choice test of knowledge of aging (Palmore, 1998). For this study, the percentage correct score on the FAQ1 was used as the measure of student knowledge of aging and older adults. The students also responded to the University of California at Los Angeles (UCLA) Geriatric Attitudes Scale, a 14-item questionnaire on attitudes toward older adults and their care (Reuben et al., 1998). For these UMMS students, the scale was a reliable measure of their attitudes (Cronbach's alpha =.69). Finally, the Maxwell–Sullivan Attitudes Scale (MSAS) is a 27-item questionnaire that includes subscales on general attitude, cost-effectiveness, time and energy, therapeutic potential, and educational preparation attitudes toward medical care of older adults (Maxwell & Sullivan, 1980). In this study, the General Attitude subscale was used as a second measure of medical student attitudes. The MSAS subscale had a moderate level of reliability (Cronbach's alpha =.56) in this group of students. For both attitude scales, student attitudes toward aging were measured by using their responses on 5-point Likert-like scales that ranged from most positive to most negative attitudes.
The UCLA Geriatric Attitudes Scale and the MSAS General Attitude subscale were used to measure different dimensions of student attitudes about older adults. The UCLA Geriatric Attitudes Scale is a more global measure of an individual's attitude toward older adults and the care of older adults. The MSAS General Attitude subscale is a measure that focuses on the individual's attitude toward his or her provision of care to older adults.
In addition to completing the three surveys, the students were asked background questions about their relationships with older adults (both family and nonfamily members), experience caring for older adults, the age group they anticipate they will prefer to work with as physicians, and their overall interest in geriatric medicine as a career at this early point in their medical education. These questions were adapted from Wilderom and colleagues (1990).
Statistical Analysis
T tests were used to determine differences in knowledge and attitudes by gender. An analysis of variance (F ratio p <.05) and Tukey's honestly significant difference (global alpha =.05) were used to determine differences in knowledge and attitudes by ethnicity (using only categories with 10 or more students), prior care experience with older adults, patient age group preferred, and interest level in geriatric medicine. Because of the small number of students that indicated a preference to work with older adults, the "older adults" category and the "adults" category were combined for this and subsequent analyses. Similarly, only one student had a "very strong" interest in geriatric medicine; this response was included with the "strong" interest category for this and subsequent analyses. Pearson correlations were used to examine the relationships among the knowledge scores and the two attitude scales.
An ordinal regression analysis examined the relationship of gender, knowledge of older adults and aging, attitudes toward older adults, important past relationships with older adults, and prior care experience with older adults to predict age group preferred as a physician (an ordinal-level dependent variable).
Finally, a least squares regression analysis tested the relationship of gender, knowledge of older adults and aging, attitudes toward older adults, important past relationships with older adults, and prior care experience with older adults to predict level of interest in geriatric medicine as a career. Standardized regression coefficients (or standardized ßs) were calculated to allow direct comparison of the association of the independent variables to the dependent variables.
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Results |
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Career Preferences
Although most entering students indicated an interest in working with adult patients, only 2% preferred patients aged 65 and older, 16% preferred 19-to 24-year-old patients, and 46% preferred 25- to 64-year-olds. Further, only 4% expressed a strong or very strong interest in geriatrics as a career, and 30% indicated a moderate interest in geriatrics. The majority of the students indicated slight (44%) or no (21%) interest in geriatric medicine as a career.
Knowledge About Aging and Older Adults
The scores on the FAQ1 indicated that the students were correct on only 37% (SD = 13.8) of the statements that were presented to them. Correct responses ranged widely across items. For example, few (7%) of the incoming medical students knew that, of people over the age of 65, only 5% reside in long-stay institutions at any point in time. In contrast, 92% were correct that physical strength tends to decline with age. Students selected the item response "don't know" an average of seven times (SD = 6) in the 25-item quiz.
The students' knowledge scores did not differ significantly by gender, ethnicity, prior care experiences with older adults (Table 1), age group preference (Table 2), or interest in geriatric medicine (Table 3).
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The MSAS General Attitude subscale is scaled in reverse; that is, lower scores on the range from 1 to 5 signified more positive attitudes. For this subscale, the average score of 2.0 ± 0.4 indicated a moderately positive general attitude toward the medical care of older adults. As with the findings from the UCLA Geriatric Attitude Scale, students who were moderately interested in geriatrics as a career reported significantly more positive attitudes than did students with little or no interest in geriatrics (Table 3). There were no significant differences by gender, ethnicity, prior care experience with older adults (Table 1), or age group preference (Table 2).
Correlation Between Knowledge and Attitudes
The scores on the FAQ1 were not significantly correlated with the UCLA Geriatric Attitude Scale (r = -.04) or the MSAS General Attitude subscale (r = -.04). The UCLA Geriatric Attitude scale and the MSAS General Attitude subscale were moderately correlated (r = -.60), suggesting that although they measure overlapping attitudinal dimensions they also tap somewhat different concepts, thus justifying our use of both scales to measure attitudes.
Correlates of Age Group Preferred in Physician Practice
As shown in Table 4, only one model variable (gender) was significantly associated with patient age group preference. The ordinal regression results indicate that women are more likely than men to prefer the older age group. However, the model's R2 of.03 (p =.10) indicates that these measures explain little of the variance in student preferences.
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Discussion |
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These findings support the view that the most effective interventions to increase the number of geriatricians and physicians skilled in caring for older adults will focus on positively influencing learners' attitudes before and during medical school through meaningful experiences in caring for older adults. Perhaps one method of increasing the number of physicians who have a more positive attitude toward and a greater interest in the care of older patients is through the admissions process. Schools could proactively seek students with this type of experience or require incoming students to have experience with both community-dwelling elders and nursing home residents. Another approach is to provide such experiences during medical school.
These results supported previous findings that medical students have limited knowledge about aging and older adults. The multiple-choice format of the FAQ1 that was used for this study has been shown to be a more reliable test of knowledge than the prior true–false format used in other studies (Palmore, 1998). Although this more difficult format likely contributed to the low scores of entering UMMS students (37%), their scores were lower than the 55% correct for medical residents reported by Kramer and colleagues (Kramer, Damron-Rodriguez, Lee, & Wong, 2001). Because these are entering medical students, one would not expect them to know much about aging and older adults. Nonetheless, it does not appear that knowledge is associated with interest in geriatrics as a career. In a related manner, the knowledge level of these students was not significantly associated with their attitudes or their preferred patient age.
Both the UCLA and MSAS attitude scales suggest that the UMMS students entered medical school with relatively positive attitudes toward older adults—they were more positive than those reported for other health care providers. For example, the mean score of these students on the UCLA Geriatric Attitude scale was more positive toward aging than those of the first-year internal medicine and family practice residents described by Reuben and colleagues (1998). Similarly, the mean score on the MSAS General Attitude subscale was more positive than the mean score of first-year family practice residents reported by Maxwell and Sullivan (1980).
What is more important, however, is that their interest in geriatric medicine increased as their attitudes (as measured by both scales) became more positive. These baseline data cannot assess whether better attitudes increase interest, greater interest improves attitudes, or other factors influence both attitude and interest; nor can these data assess whether or how attitudes and interest will change over the course of students' medical education. Recent studies that have suggested that positive attitudes toward older adults and interest in geriatrics might actually decrease during medical school offer speculations but no conclusions on why these interests might deteriorate (Alford, Miles, Palmer, & Espino, 2001).
These finding have implications for medical curricula that aim to improve their students' knowledge, attitudes, and skills related to the care of older adults. In 2001 the UMMS implemented a comprehensive program funded by a Donald W. Reynolds Foundation grant that is aimed at expanding and enhancing the medical school's geriatrics education activities. The overall goal is to ensure that every medical student who completes her or his training at UMMS has meaningful educational experiences in geriatrics and has demonstrated competence in providing care for older adults. Although the goal is ambitious, it recognizes the fact that physicians in all specialties (with some exceptions, such as pediatrics) will increasingly care for older patients during the course of their careers. The medical school curriculum is being revised to include greater geriatrics content across all 4 years with required components in both preclinical and clinical phases of medical school education. The results from this study suggest that hands-on clinical experience is an essential element in this program and that additional efforts should focus on increasing students' direct contact with older patients.
Although the study's cross-sectional design and descriptive statistics limit our ability to offer firm conclusions at this early stage, the study's findings combined with the students' limited knowledge about aging but relatively positive attitudes about aging are signs that enhanced training in geriatric medicine is needed. Certainly, the limited strong interest by the majority of students in the care of older adults contrasts sharply with the patient mix that most are likely to see in their future practices. However, the findings that most students (64%) indicate a preference for adult patients of any age and that a large minority (34%) report at least a moderate interest in geriatric medicine are promising. Future evaluations of the ongoing UMMS program will address the effects of the varied curriculum interventions aimed at increasing knowledge, improving attitudes, and enhancing skills of UMMS students in caring for their future older adult patients.
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Footnotes |
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Department of Medical Education, The University of Michigan Medical School, Ann Arbor.
Geriatric Research, Education and Clinical Center, VA Ann Arbor Healthcare System, Ann Arbor, MI.
Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA.
Department of Internal Medicine, The University of Michigan Medical School, Ann Arbor.
Decision Editor: Linda S. Noelker, PhD
Received for publication July 29, 2002. Accepted for publication December 16, 2002.
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