Background
The medical profession has been challenged to engage more effectively with older adults [
1,
2]. Echoing global trends, the proportion of Australia’s population aged 65 and older is predicted to increase from 13 % in 2007 to 23 % in 2061 [
3]. This cohort makes up the highest proportion of those seeking medical services – comprising 28 % of general practice visits in 2010 [
4,
5]. The challenge for the medical profession is to inculcate undergraduate interest in aged care in the context of an increasing prevalence of older people suffering chronic illness and multiple comorbidities.
While medical professionals from most specialities will encounter older patients, shortcomings have been noted in undergraduate curricula worldwide with regard to content about older-adult health [
2]. Evidence suggests that management of acute illness associated with hospitalisation dominate medical curricula [
6,
7]. For example, a United Kingdom survey identified a lack of teaching time in medical undergraduate curricula related to ageing, where less than two weeks of a five-year degree addressed health care for older people [
8]. Across Australia, only 0.5 % of medical students’ clinical placement hours are undertaken in residential aged care facilities (RACFs – also referred to as nursing homes), compared to 78 % of clinical placement time in hospitals [
9]. RACFs in Australia provide a mix of high and low care as well as community outreach services for older people with cognitive and physical impairments (often multiple comorbidities) who require specialised care. These facilities are administered by private and not-for-profit organisations, with government funding support, to meet the needs of individuals who have been assessed as requiring institutional care. Limited medical student engagement with chronically unwell older adults may be exacerbated by a lack of interface between acute care and RACFs [
10] and the absence of an established medical presence in these settings [
11].
Concerns have also been raised about the adequacy of dementia-related content in undergraduate medical curricula [
12]. In the context of an increasing prevalence of dementia associated with population ageing [
13], educationalists from Australia and the United Kingdom have recommended expanding opportunities for experiential learning and skill development regarding dementia [
12,
14]. Current curricular deficiencies are likely to have a negative impact on students’ knowledge of and attitudes towards geriatric medicine [
15,
16] and their capacity to effectively engage with cognitively impaired older adults [
17].
Compounding curricular shortcomings are the mixed attitudes held by medical students towards care of older people [
18‐
22], including what Higashi et al. [
19] describe as persistent and implicitly negative attitudes. Persistent negative student attitudes towards aged care and older adults may be due to an educational culture that reinforces negative stereotypes about older adults [
18], communication challenges that limit reciprocal and effective patient-centred relations [
23], social distance between learners and RACF residents that reduces empathy [
24], low levels of health literacy and compliance [
24], or stark differences from the hospital training environment [
25].
Despite prevailing negative sentiment, evidence suggests that RACFs provide an ideal setting for medical training and exposure to frail older people with complex health problems, including dementia [
26,
27]. In Australia, for example, 52 % of permanent RACF residents had a recorded diagnosis of dementia in 2011 [
28], coexisting with an average of six long-term comorbidities [
29]. As the majority of aged care is provided in the community rather than hospitals [
30], RACFs are a particularly appropriate setting for facilitating medical student engagement with aged care and frail older adults, many of whom have dementia.
There are a small number of published reports of undergraduate medical student RACF clinical placements in Australia and the United States [
31‐
33]. Clinical placements refer to one-off and embedded learning experiences for undergraduate students within particular healthcare settings for the purposes of increasing understanding about and exposure to a specialised sector (i.e. aged care, primary care, ambulance). Two Australian studies have previously reported on programs that include medical students in inter-professional clinical placements at RACFs in Western Australia and Tasmania [
32,
33], while a North American study evaluated mandatory geriatrics clerkships for third-year medical students [
31]. These studies were limited, however, by small samples and a lack of explanatory qualitative data derived from medical students. The current study explores first-hand medical student experiences of clinical aged care placements in Australia to understand how undergraduates engage with the available learning opportunities in a fast-growing, though largely unfamiliar, sector of health.
Discussion
This paper investigated medical student experiences during a five-day clinical placement at two regional Australian RACFs. Survey data collected at the beginning of the placement indicated that most medical students had limited previous engagement with the aged care sector and commenced with an expectation that they would not enjoy the experience. The data show that less than 20 % of students were satisfied with the prospect of an aged care placement, and one in three expected to enjoy working with older adults. These findings are consistent with critiques of medical education that report a lack of interface between aged and acute care [
10] and negative attitudes among medical students towards the care of older people and geriatric specialisations [
18,
31,
44,
45]. Such evidence suggests that negative sentiment is widespread among medical undergraduates and not unique to the cohort of students involved in this study.
Although negative student attitudes are well documented [
18,
31,
44,
45], few researchers have offered evidence to explain why such attitudes persist among medical undergraduates. Survey data from the current study concerning negative pre-placement sentiments were supported by focus-group results. Two themes emerged that provided explanation for students’ negative attitudes.
Firstly, some students struggled to engage with residents with a significant cognitive impairment, such as dementia. These students were challenged by problems with communication, lack of a clearly defined acute presentation, and the complex issues of multiple comorbidity and chronicity. These difficulties may be, in part, explained by student expectations for traditional patient-centred medicine that is challenged when a resident cannot communicate effectively or enter into a reciprocal physician-patient relationship [
46]. In such circumstances, medical students may not have been adequately prepared, with appropriate clinical skills or situational awareness, to make sense of the undifferentiated comorbidities and communication challenges that characterise most frail older people resident in RACFs. The response to this situation among students who lack such skills may be, as reported in the results, to conclude that either assessment is futile in the face of seemingly irresolvable communication challenges or to infer that the resident is clinically stable thereby apparently contradicting the appropriateness of conducting an assessment. Researchers have previously reported that medical students are not adequately prepared by their curricula for communication challenges encountered with cognitively impaired patients [
17‐
47] and that they hold perceptions of older people’s health problems as frustrating and of little clinical interest [
18,
19]. Despite these sentiments, there is evidence to suggest that residents of aged care facilities do not always receive optimal health care [
48‐
50] and can benefit from additional assessment and more targeted management, even when this is provided by students [
33].
A second theme that explains negative attitudes among medical students towards aged care and older adults suggests that students conceptualised the clinical placement as an opportunity cost that reduced training time in preferred hospital settings. Some students had difficulty conceptualising the aged care environment as an appropriate setting for medical students due to the lack of an established medical hierarchy and differences from the hospital environment where they spend the majority of their placement time [
9]. The study findings indicate that medical student learning is oriented around acute care environments. Such settings work to develop more than just a particular set of clinical and professional skills. They also engender particular cultural values that take root in early medical education, a process that is often referred to as the hidden curriculum [
18]. The hidden curriculum describes the learning that occurs through informal interactions with students, faculty members, and medical professionals, which shapes values, attitudes, and professional identity [
25]. Prominent themes that have been reported in the hidden curriculum include patient dehumanisation, disease-focussed medicine, ritualised professional identity, and emotional neutralisation [
25,
51]. In some ways, the aged care placements may have exposed elements of the hidden curriculum. This is reflected in students devaluing the aged care context as a site for productive and important learning and their struggle to engage with patients who do not fit the profile of an acute presentation amenable to treatment or cure. The RACF placement was intentionally challenging. Students encountered older-adult volunteers who exhibited a range of complex cognitive and physical symptoms that moved students beyond their comfort zone and previous experiences of diagnosing and treating a single clinical problem (such as a fracture or infection). While some students struggled to engage with this level of complexity, many students indicated that they valued this experience and that it had extended their competence and increased their understanding of older-adult health issues and the aged care sector. Clinical placements in aged care settings set up the conditions to differentiate between those students who are ready to engage with the complexity of aged health care and those who remain wedded to hospital training environments with expectations for acute presentation, omnipresent medical supervision, and high status settings.
There was a clear continuum of experience among medical students, with some capable of understanding and engaging with the challenge of aged care and others who viewed the experience as confrontational and beyond their developmental needs as trainee medical professionals. Post-placement survey data indicated that positive knowledge and attitudinal changes occurred among medical students who participated in the five-day aged care placement – indicating positive placement engagement outcomes across the cohort irrespective of some negative sentiment. Medical students scored highly on the DKAT 2, indicating good knowledge of dementia before the placement, and displayed a significant increase in knowledge at the end of the placement. Changes in dementia knowledge were supported by self-reported improvements in understanding of the aged care environment among the majority of students who responded to the post-placement survey. Similarly, the survey data indicated that attitudes towards working with older adults improved significantly over the course of the clinical placement. The results of this study reinforce mixed international evidence for variable medical student attitudes towards older adults, aged care, and geriatric medicine [
18‐
22,
45,
52]. International research shows that although students may hold negative, neutral or positive attitudes towards older adults prior to clinical engagement, exposure to this cohort as part of medical training can significantly improve attitudes [
21,
45,
53]. Importantly, it has also been shown that an enduring or improved positive attitude towards older adults increases the likelihood that medical students will consider a career in geriatric medicine [
22,
45]. Considering the ageing demographic profile of western societies, this highlights the imperative to provide students with positive placement experiences that overcome the perceived lack of clinical interest associated with older adults in an aged care setting.
Qualitative themes emerging from this study also highlight positive student learning experiences and meaningful encounters with vulnerable residents. Student reports indicated that the aged care placement stimulated problem solving and critical reflection about the complex health challenges in high care settings and provided opportunities for students to contribute to resident health and quality of life.
The third research theme indicates that, through student engagement in the assessment of older adults, there were powerful cues for learning that facilitated their appreciation of the complex health challenges in high-care environments. While some students were confronted and confused by non-communicative residents, an absence of an acute illness or exacerbation, and the insidious effects of chronicity, multiple comorbidities, and polypharmacy, others used the experience as an opportunity to extend their skills in accessing critical information through collateral history taking. The capacity to take a collateral history has been identified as a particularly important skill for physicians in the diagnosis and management of dementia [
54]. This is because people with dementia (and other cognitive impairments) often have difficulty clearly articulating their needs (for example, thirst or pain management) and may use behaviours, bodily movements, or incoherent vocalisation in an effort to communicate [
55]. Although comparatively limited research has been undertaken that has explored learning outcomes for medical students on clinical placements that include older adults, researchers have noted that attitudes towards and perceptions about this cohort improve with interpersonal contact [
20]. Further, it has been hypothesised that socialisation and empathy building tasks with older adults helps to reduce the stigma of providing healthcare to this cohort and challenge perceptions of the futility of treatment [
20,
56]. Researchers and medical educators who have investigated student engagement with older adults continue to recommend clinical engagement with the aged care sector as a means of improving competencies in the area of geriatric medicine [
53,
57]. These findings highlight the importance of medical students having in-depth engagements with aged care residents in order to develop an informed understanding of the complexity of health care management needs beyond the hospital walls. Such skills will be critical in responding to the expansion of the older-adult population and growing prevalence of conditions such as dementia.
The fourth research theme indicated that students value the opportunity to use their training and emerging clinical decision-making skills to address the complex problems of older residents. As part of the placement, students not only performed a collaborative and comprehensive medical assessment, but also made recommendations for improving the health and quality of life of volunteer residents. These recommendations were presented to RACF staff at the end of the placement and recorded in the residents’ medical notes. This is among the most innovative aspects of the program and an approach to experiential learning that is gaining popularity in Australia. In a small-scale Western Australian study of undergraduate placements in aged care, Seaman et al. [
32] reported that undergraduate medical students and their tutors valued opportunities to make contributions to the health of residents through exchanging knowledge and new techniques with RACF staff and interacting directly with vulnerable older adults. In another Australian study, Elliott et al. [
33] reported that medical students (in collaboration with nursing and paramedic students) “enhance quality of care” for aged care residents by improving facility vibrancy, increasing meaningful social contact, providing opportunities for residents to engage in teaching activities, and increasing capacity for, and confidence of, care. Although embedded placement experiences in aged care settings or interactions with people with dementia remain relatively uncommon within undergraduate medical education [
9,
12], community based experiential learning is considered to offer advantages over classroom and simulation-based activities. Following a systematic review of studies of experiential medical education, Doran and colleagues [
58] reported that community based clinical placements support workforce acclimatisation, appropriate professional socialisation, improved patient-physician relations, and critical self-reflection concerning both biomedical and psychosocial competencies. Doran et al. [
58] identified that community based placements help to vivify clinical practice and increase student understanding of how the health system functions in the real world. Exposing medical students to complex, and often difficult to discern, health issues in aged care provides them with an avenue for detailed investigation and opportunities to meaningfully improve the health-related quality of life of residents. In this way, they are able to practise and refine their clinical decision-making skills in ways that can be carried over into diverse clinical settings, such as the treatment of a person with dementia in hospital and discharge into community care. Further work is required, however, to embed aged care placements as part of ongoing medical curricula adaptations to 21
st century population and health system changes.
Successful learning outcomes achieved in the aged care placement were underpinned by support from RACF mentors, clinical oversight from a GP tutor, and a highly structured yet iterative placement program. Medical educators have recommended that successful pre-vocational clinical placements in RACFs rely on strong administration, internal and university support, and careful integration of staff, students, and residents within the program [
32]. They also suggest that continual improvement and adaptability are important to address student expectations and emerging challenges in the learning environment [
31]. The data from the current study suggests that improvements in knowledge and attitudes may be achieved among some medical students following five days of embedded clinical training. Although positive outcomes have been achieved in this placement, the persistence of negative attitudes and encounters among some students suggests that more work is required to refine the placement structure in the future and, more importantly, to address a pervasive culture in medical education that devalues aged care and older adults as irrelevant or unworthy of the attention of medical students. When medical student placements have been embedded as part of curricula in the United States, for example, educators noted a political backlash citing negative perceptions among senior faculty staff (viewed as taking time away from important internal medicine placements) and the transmission of negative attitudes within learner cohorts [
31]. Such embedded attitudes among teaching staff and students may also relate to limited resources for teaching and assessing geriatric medicine competencies where curricula focus predominantly on biomedical knowledge and hospital-based medicine [
53]. Powers et al. [
31] indicate that strong leadership and support from within medical schools may ultimately be the critical factor in ensuring the success of aged care clinical placements.
Limitations and future research opportunities
There are few measures of dementia knowledge that can reliably gauge understanding of the syndrome among cohorts with a high level of education. Potential ceiling effects in the DKAT 2 may limit the extent to which pre- and post-placement knowledge differences can be reliably ascertained. Limitations in the measure used in this study potentially underestimate knowledge change due to a lack of sensitivity. Further work is required to develop a measure of dementia knowledge that is sensitive enough to measure knowledge change among highly educated individuals in the health sector. A recently published dementia knowledge scale developed by members of the research team (MA and AR) will address this gap in future studies [
59].
This study was also preliminary in nature and the scale of investigation was limited to two RACFs that hosted medical students from a southern Tasmanian Clinical School during 2013 and 2014. Future national expansion of the TACF program would be desirable to attain a nationally representative sample. As all students were from the same Clinical School, it is not yet possible to determine the extent to which different undergraduate medical curricula and cultures influence student engagement.
In this research, students were embedded in RACFs for five days and well supported by an onsite University medical tutor and senior mentors (experienced nurses and care staff) from the participating facilities. The long-standing nature of the clinical placement program (which began in 2011) and high level of faculty and RACF support and supervision arguably provided an optimal learning experience. However, it is possible that replication of these placements in the context of a less supportive environment, where staff members may exhibit negative attitudes towards students or medical tutors could not routinely attend the placements, may be a threat to effectiveness of such learning opportunities. In RACFs, there is currently limited engagement of GPs with residents and few permanent appointments in this sector [
60,
61], which could undermine student perceptions about the relevance of the placement. This situation, however, does not reflect a lack of need or complexity in aged care, but rather the traditional role of the GP in the community (where they are often based in clinics or practices). In this respect, it was necessary to have a GP tutor onsite each day to supervise and direct student activities as well as helping them to understand the relevance of the placement at a time when GP roles are altering with demographic changes (including population ageing). The GP tutor was not present at all times, allowing students to develop their independent clinical decision making, but they were available at the end of each day to support and contextualise the placement experience. Researchers in other institutions should take care to ensure that placement programs are well designed with sufficient engagement from the aged care sector and educational institution support to achieve an optimal mix of independent learning and supervision.
The placement of students in RACFs also has the opportunity to elicit impacts beyond student learning and influence care quality for residents and changes in the clinical behaviour of staff. While a small number of studies have reported the positive impacts of health student placements on resident quality of life [
32,
33], few have investigated how students potentially change the clinical practice of RACF staff. It is possible that embedding fifth-year medical students (who have a high level of training in such topics as pharmaceuticals, pain management, and diagnosis) may bring a greater level of awareness to the aged care sector about the need to provide best-evidence care – even towards the very end of life. This is an area of potential future investigation.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
MA acted as a project officer for the clinical placement program (TACFP), collected research data, conducted the quantitative and qualitative data analysis, and prepared the manuscript. EL assisted with research design and data analysis, participated in data collection, and was involved in drafting the manuscript. AL acted as the medical student tutor and course coordinator and assisted in drafting the manuscript. LT conducted literature searches and assisted in drafting and editing the manuscript. AR developed the placement program, conceived of the study, secured funding for administration and evaluation, and assisted with manuscript preparation. All authors read and approved the final manuscript.
MA has a PhD in gerontology from the University of Otago and works with the Wicking Dementia Research and Education Centre leading programs to develop and evaluate educational initiatives that aim to improve knowledge of dementia and health outcomes for care recipients.
EL has a PhD in public health from the University of Adelaide and is a Research Fellow in the Wicking Dementia Research and Education Centre. She was project manager of the Wicking Teaching Aged Care Facilities Program.
AL is a General Practitioner and Senior Lecturer in Primary Health who has previously worked as the aged care clinical placement tutor and course coordinator with the University of Tasmania.
LT has a Bachelor of Health (Hons) from Macquarie University and works with the Wicking Dementia Research and Education Centre on programs to develop and evaluate educational initiatives that aim to improve knowledge of dementia and health outcomes for care recipients.
AR is the co-director of the Wicking Dementia Research and Education Centre and Professor of Aged Care at the University of Tasmania. AR conceived of and implemented the TACFP program in Tasmania and in other sites across Australia.