Approach to Geriatric Emergency Medicine: A Flipped Classroom Group Learning Exercise for Undergraduate Medical Trainees
Correspondence should be addressed to Tiahna Warkentin, BS at tiahna.warkentin@mail.utoronto.ca
DOI: https://doi.org/10.21980/J8GH03
ABSTRACT:
Audience:
This module is designed for undergraduate medical students during the clinical stage of their emergency medicine training (eg, clerkship). With some modifications to make the objectives and content level appropriate, it may also be shared with postgraduate learners (eg, interns and residents).
Introduction:
Adults aged 65 and older account for 25% of visits to emergency departments (EDs) in the United States (US), and 22% of ED visits in Ontario, Canada.1,2 This share will undoubtedly increase in proportion to the growing number of seniors, who are expected to make up over 20% of the Canadian population by 2023, and 25% by 2047.3
As compared with younger ED patients, older adults are more vulnerable in that they:4,5,6
- Experience high rates of post-visit morbidity, mortality, and functional decline.
- Are more likely to be admitted to hospital.
- Are prone to health care-related harm in the ED.
- Are predisposed to conditions such as delirium and dementia, which can complicate their clinical course and discharge planning.
Factors that account for these differences include:
- Normal age-related decrements in homeostatic response to physiologic stressors like infection and hypovolemia.7
- Tendency to present with nonspecific symptoms such as fatigue, weakness, dizziness, confusion, or “feeling unwell,” with causes that require time and careful inquiry to uncover.8
- Higher prevalence of cognitive impairment, which makes it difficult for patients to describe symptoms and convey past medical history.
Clinician-scientists in geriatric emergency medicine (GEM) have produced primary research and evidence-based guidance to inform safe care of older adults and clear recommendations regarding core GEM competencies for postgraduate medical education (PGME), which have relevance in the undergraduate medical education (UGME) as well.9 Notably, the Academy of Geriatric Emergency Medicine recently published a comprehensive review of the state of GEM education, including a range of practical suggestions to improve how GEM competencies are taught.10
Yet GEM remains poorly represented in both PGME and UGME emergency medicine (EM) curricula.11 The reasons for this deficiency are numerous, and likely include the way that EM has historically defined expertise, and a persistent sense that care of older adults is beyond EM physicians’ scope of responsibility in the busy ED setting.10
Our project is addressed not to these larger challenges, but to the needs of the clinician educator who already includes care of older ED patients in their UGME EM curriculum and needs practical guidance in developing teaching materials. The overall goals are to introduce undergraduate medical students to several practical applicable GEM principles, and improve undergraduate medical students’ comfort with the medical and psychosocial complexity of older ED patients. This module is a self-contained, interactive, learner-driven small group exercise intended to introduce learners to some key principles of safe care of older ED patients.
Objectives:
At the end of the module, learners should be able to: 1) recognize that many benign-seeming presentations, including restricting fatigue and cognitive decline, can have serious and life-threatening causes, 2) describe the importance of screening for delirium in older ED patients, 3) identify situations in which vital signs can be misleading in older adults and know strategies to further investigate such data, and 4) recognize that older adults can rapidly develop delirium in the ED and be able to apply strategies to reduce risk of delirium.
Methods:
This exercise consists of a small group session that uses a “flipped classroom” design. The facilitator should distribute the learner responsible content one week in advance. The learner responsible content consists of: 1) a PDF file titled A Primer on GEM, and 2) a student handout presenting two GEM cases.
Learners are instructed to review the primer and the cases in order to lead an in-class discussion. Questions are included to guide their critical engagement with the cases and to structure the subsequent small group session. Students are encouraged to access supplemental resources, including free open access medical education (FOAM) materials such as podcasts and blog posts, journal articles, textbooks, videos, and interactive media.
The one-hour small group session is a structured learner-led critical discussion of the two cases, guided by the facilitator, using a discussion guide to surface key learning points. At the beginning of the session, the facilitator splits the class into two groups, each with responsibility for one case. Learners have twenty minutes to discuss the cases, share their insights, and prepare the discussion, including a short outline or list of bullet points. Students are encouraged to address the questions in the handout. The facilitator uses the GEM Cases: Facilitator Guide, organized around the handout questions, to stimulate discussion and answer questions.
Topics:
Geriatric emergency medicine, cognitive impairment, delirium, dementia, atypical presentation of disease, falls, orthostatic vitals, gait assessment, elder abuse, flipped classroom, group learning.
