Abstract
Background:
Graduating US medical students must build strong skills in caring for older adults, necessitated by shifting population demographics. Little is known, however, about current medical student exposure to geriatrics on a national scale. This systematic website review characterizes geriatrics opportunities at US medical schools, seen through the lens of publicly available information online.
Methods:
Reviewers searched for 18 online Geriatrics Elements, in the domains of Information Prevalence, Geriatrics Environment, and Geriatrics Education, for all 191 US medical schools accredited as of January 2020. Latent Class Analysis was used to classify schools according to their publicly visible geriatrics opportunities.
Results:
Schools had a median of 7 Geriatrics Elements identified online [IQR 4–10]. Optional geriatrics clinical activity was the most prevalent (76%), while fewer than half of all schools had online evidence of required geriatrics clinical activity (45%). A profile of the three groups of schools identified by Latent Class Analysis, termed Geriatrics Online-Visibility groups (High n = 39, 20%; Medium n = 90, 47%; Low n = 62, 32%), is presented. Online evidence of geriatrics-specific funding was the greatest distinguishing factor among the groups.
Conclusions:
Examining US medical school websites collectively and comparatively across Geriatrics Online-Visibility groups can ground discussions of geriatrics education in current national data. Though many school websites present optional geriatrics activities, far fewer specify geriatrics requirements. High Geriatrics Online-Visibility schools present an array of both optional and required geriatrics opportunities on their websites, but this cohort comprises only 20% of schools. Recommended next steps are proposed to guide schools inspired to enhance their Geriatrics Online-Visibility.
Keywords: education, geriatrics, medical student, national, online
INTRODUCTION
How visible is geriatrics at medical schools across the US? Despite the demographic imperative for widespread geriatrics education, prior studies indicate that geriatrics exposure for US medical students has been highly variable – plentiful at some institutions while sparse at others – and, as a whole, insufficient to meet the needs of our aging population.1,2,3 To our knowledge, medical student exposure to geriatrics has not been characterized on a national scale in the past decade.
In this systematic website review, we examine publicly available information online for all 191 allopathic and osteopathic US medical schools accredited as of January 2020. We introduce the novel construct of “Geriatrics Online-Visibility,” and present a profile of High, Medium, and Low Geriatrics Online-Visibility schools. We now turn to consider how this review can contribute to a nationwide needs assessment of medical student geriatrics education.
WHAT PERSPECTIVE CAN BE GAINED FROM SYSTEMATIC REVIEW OF PUBLICLY AVAILABLE INFORMATION ONLINE?
Data triangulation
Systematic website review holds great potential for data source triangulation. Sole reliance on the self-report of institutions volunteering to participate in an education study introduces expected biases. From self-selection to social desirability biases, a rather “rosier” version of reality can emerge when less robust programs go underreported. By using an observational design, school website review can fill in gaps left by response-rate-dependent methodologies and can side-step certain self-reporting and Hawthorne effect biases.4 Additionally, systematic website review can serve as an important antecedent to future studies by chronicling a wide array of education offerings and illuminating how different institutions conceptualize and promote their education programs.
Institution Priorities
Medical school websites serve as an essential portal for prospective students and other information seekers, a role accentuated in 2020 when in-person communication was limited by the COVID-19 pandemic.5,6 School websites reflect the priorities of their academic institutions, showcasing self-identified strengths and areas of emphasis.7,8 Information missing from school websites may thus offer insights into the relative value the institution places on these omitted areas.9 Schools with abundant geriatrics education for medical students may be more likely to highlight geriatrics offerings on their websites, while, for schools with fewer offerings, geriatrics education may be left underrepresented or invisible.
METHODS
Identification of Geriatrics Elements
Our team obtained a list of all 191 US medical schools accredited as of January 2020 by the Liaison Committee on Medical Education (LCME) and the Commission on Osteopathic College Accreditation (COCA). We conducted a preliminary review of a subset of schools (10%, n = 19) to trial search strategies. We identified focus areas for initial review based on the authors’ own training experiences, a librarian-assisted literature search, and the author team’s expertise in geriatrics education and education research. We selected eighteen final Geriatrics Elements for website review, grouped into three domains: Information Prevalence, Geriatrics Environment, and Geriatrics Education. Table S1 provides additional description of each Geriatrics Element reviewed.
For Domain 1, “Information Prevalence,” geriatrics-related keywords were searched in the following two ways: (1) on each school’s academic website as well as (2) on an independent website search engine (Google ©) to account for variability in academic website search engines and in accordance with prior studies.10,11,12 We tracked relevant links identified in keyword searches using a binary system (threshold ≥3 links).
Domain 2, “Geriatrics Environment,” captured five features of the surrounding geriatrics ecosystem: an affiliated geriatrics fellowship program, a center for aging, geriatrics-specific funding, available geriatrics faculty mentors, and any mention of geriatrics or aging in the school’s mission statement. For “geriatrics-specific funding,” reviewers searched for online evidence of funding sources for projects in geriatrics education or implementation of geriatrics care in settings that hosted medical students (examples of funding sources include GACA, GWEP, the John A. Hartford Foundation, and the Donald W. Reynolds Foundation).
Domain 3, “Geriatrics Education,” mapped the following eleven opportunities for students:
Required geriatrics clinical activity
Optional geriatrics clinical activity
Required geriatrics education in a course (non-clinical setting)
Optional geriatrics education in a non-clinical setting
Early integration of geriatrics topics (medical school year 1 or 2)
Interprofessional geriatrics education experiences
Student assessment on geriatrics topics, required of all students
Geriatrics-related site visit (such as to a skilled nursing facility)
Pairing with an older adult (termed “senior mentors” in prior literature)3
Geriatrics student interest group
Scholarly concentration13
Categorization of learning opportunities was not mutually exclusive. For example, a series of required site visits could be counted toward required geriatrics clinical activity as well as geriatrics-related site visits.
GERI Team systematic website review process
In June 2020, 12 pre-medical and pre-dental undergraduate students were recruited to form the GERI Team (Geriatrics Education Review Investigator Team), with selection based on a written application. As prospective health-professions students, the GERI Team reviewers were intentionally representative of a primary target audience for medical school websites.
Team collaboration occurred virtually, spanning 10 states across the country (CA, CO, CT, FL, IL, LA, MA, NY, TX, WI). Prior to formal data collection, the GERI Team conducted practice website reviews as a group, individually, and in pairs, and our team modified data collection tools based on reviewer feedback. GERI Team reviewers additionally received education on topics in geriatrics and medical student education in weekly team meetings over a three-month period.
During the formal data collection phase from July to August 2020, two independent reviewers documented the presence or absence of each Geriatrics Element for their assigned schools, and two Student Leads tracked website review progress. Lists of schools for individual review were created using a free randomizer (random.org © 1998–2021). Reviewers also recorded website links, screenshots, and short descriptions on a companion Profile Page for each school to support their binary designations. At the conclusion of individual website reviews, reviewer pairs initiated a consensus review to address areas of discrepancy, with author CMPD available for adjudication during the consensus procedures.
After data collection, three reviewers with a shared data language (R ©) prepared the data for analysis by spot-checking 10% of each spreadsheet column and running initial descriptive analyses. These reviewers also collected publicly available information about school characteristics, including degree offered (allopathic/osteopathic), school funding source (public/private), total enrollment (for academic year 2019–2020), the age of the school (by year of entering inaugural class), and location (state/territory and US census region).
Data analysis
In consultation with a data analyst at the Harvard T.H. Chan School of Public Health, we performed data analysis using JMP® statistical software (Version 15.0.0. SAS Institute Inc., Cary, NC, 1989–2021). We used Latent Class Analysis,14 a data reduction technique that identifies subgroups within a population, to categorize schools according to their constellation of Geriatrics Elements. We then employed Partition Analysis,15 a method by which a decision tree model tests for the most influential factors leading to a given classification, to evaluate associations among school characteristics and the distinct groups of schools identified by Latent Class Analysis.
Our study protocol was submitted to the Harvard Longwood Institutional Review Board and was deemed exempt from full committee review. A Research Determination Form was also submitted to the VA Boston Associate Chief of Staff of Education, with a resulting designation of not human subjects research.
RESULTS
All 191 medical schools had online academic websites available for review during the study period. Out of the 18 possible Geriatrics Elements searched, schools had a median of 7 Geriatrics Elements identified, with an interquartile range of 4–10 and a total range from 0–16 (as shown in Figure S1). The mean number of Geriatrics Elements per school was 7.1 (SD ± 3.9). Because the online information was not static over the course of the review period, traditional measures of interrater reliability, such as a kappa statistic, were not used. The overall percentage of interrater agreement across all schools was 73%, with 2511 agreements out of 3438 total Geriatrics Elements evaluated, and all reviewer pairs reached consensus for identified discrepancies.
Figure 1 depicts the online prevalence of each of the 18 Geriatrics Elements, grouped by Domain. Optional geriatrics clinical activity was the most prevalent (n = 146, 76% of all schools), and, by comparison, required geriatrics clinical activity was reported less frequently (n = 85, 45% of all schools).
FIGURE 1.
We depict the percentage of US medical schools (N = 191) meeting the criteria for each of the 18 Geriatrics Elements searched in our systematic review of medical school websites. The 18 Geriatrics Elements are categorized into 3 domains, Information Prevalence, Geriatrics Environment, and Geriatrics Education, and results are displayed in order of descending prevalence for each domain. Further description of the 18 Geriatrics Elements can be found in Table S1.
For our Latent Class Analysis model, all 18 Geriatrics Elements were included as indicator variables (given that more relevant indicator variables typically enable better data characterization).16 Our maximum possible number of latent classes was 3 to ensure positive degrees of freedom for the model.17 Our 3-class model had better fit than our 2-class model for negative log-likelihood and Akaike’s Information Criterion (AIC) (respectively, 1743 vs. 1789; 3598 vs. 3651). The Bayesian Information Criterion (BIC) was higher for the 3-class model than the 2-class model (3780 vs. 3771), in the setting of having a higher number of parameters (56 vs. 37).18 The 3-class model was selected based on this constellation of fit estimates and on our ability to contextualize the resulting 3 classes, as described next.19
When plotting the sum of Geriatrics Elements per school for the 3 classes in our model, we found the groups had distinct medians and interquartile ranges (Group 1: median = 3, IQR 2–4; Group 2: median = 8, IQR 6–9; Group 3: median = 13, IQR 12–14), as shown in the violin plot in Figure S2. We observed that schools in Group 1 trended toward lower scores in all domains whereas schools in Group 3 trended toward higher scores in all domains (as shown in Figures S3 & S4). Our team labeled these 3 latent classes the Low, Medium, and High Geriatrics Online-Visibility groups.
We define “Geriatrics Online-Visibility” as a novel classification system indicating how prominent geriatrics opportunities are at US medical schools, as seen through the lens of their online presence. High Geriatrics Online-Visibility schools made up the smallest group (n = 39, 20% of all schools), Medium Geriatrics Online-Visibility schools formed the largest group (n = 90, 47% of all schools), and Low Geriatrics Online-Visibility schools comprised a mid-size group (n = 62, 32% of all schools).
The heat map in Figure 2 shows the percentage of High, Medium, and Low Geriatrics Online-Visibility schools that meet the criteria for each Geriatrics Element reviewed online. The 18 Geriatrics Elements are listed on the left, in descending order of prevalence across all schools (reported in Figure 1). The percentages provided can be compared within each Online-Visibility Group by reading vertically down the columns or compared across different Online-Visibility groups by reading horizontally across the rows. For example, looking at the column of Medium Geriatrics Online-Visibility, we see that online information about geriatrics-related site visits for students was present for 61% of Medium Geriatrics Online-Visibility schools, while online information about early curricular integration of geriatrics topics was less prevalent for schools in this group, at 40%. For geriatrics-specific funding, moving horizontally across the row reveals a steep drop from the High (87%) and Medium (77%) Geriatrics Online-Visibility groups to the Low Geriatrics Online-Visibility group (5%).
FIGURE 2.
In this heat map, US medical schools are separated into High (n = 39), Medium (n = 90), and Low (n = 62) Geriatrics Online-Visibility groups. The percentages listed represent the number of schools meeting the criteria for a given Geriatrics Element in either the High, Medium, or Low Geriatrics Online-Visibility group, divided by the total number of schools in that Geriatrics Online-Visibility group. An example interpretation across a row of this heat map would be: interprofessional geriatrics education experiences were identified online at 87% of schools in the High Geriatrics Online-Visibility group, 53% of schools in the Medium Geriatrics Online-Visibility group, and 8% of schools in the Low Geriatrics Online-Visibility group. Further description of the 18 Geriatrics Elements can be found in Table S1.
The ability of each of the 18 Geriatrics Elements to distinguish among different Geriatrics Online-Visibility groups can be calculated using the Likelihood Ratio (LR) Logworth statistic (see Table S2), and an LR Logworth above 2 correlates with a significance level (α) of 0.01. Inclusion of geriatrics in the school mission statement was the only Geriatrics Element with an LR Logworth below 2. All 17 other Geriatrics Elements had an LR Logworth >2, indicating statistical significance. The most influential factor in distinguishing among latent classes was online evidence of geriatrics-specific funding.
None of the school characteristics tested in Partition Analysis (degree offered, school funding source, total enrollment, the age of the school, and location) were significantly predictive of Geriatrics Online-Visibility. We further analyzed geographic patterns by comparing the percentage of each state’s population age 65 and above with the Geriatrics Online-Visibility of the schools in each state; these relationships were also not statistically significant.
DISCUSSION
This systematic website review characterizes geriatrics opportunities for US medical students through examining publicly available information online. Optional clinical activity was the most prevalent opportunity in geriatrics for medical students, identified on 76% of school websites. Previous studies indicate, however, that a minority of students choose to participate in optional geriatrics education.22,13 Medical student discomfort with uncertainty and medical complexity, as well as preconceptions about complicated family dynamics and ethical dilemmas inherent in geriatrics care, contribute to student hesitancy to explore the field.23 Relying on medical students to opt into geriatrics opportunities is unlikely to generate enough physicians with strong skills in delivering Age Friendly care24 to meet the needs of the increasing number of Americans reaching elderhood.25
Required geriatrics clinical activity, which could be as robust as a geriatrics clerkship or as limited as a single clinical skills session, was reported on fewer than half of medical school websites (45%). How might this compare to other specialties? A systematic website review of accredited US medical schools in 2015 (n = 136; only allopathic schools were included) found that, in addition to all schools (100%) requiring clerkships in Internal Medicine, Obstetrics/Gynecology, Pediatrics, Psychiatry, and Surgery, a majority of schools also reported required clinical rotations in Family Medicine (96%), Neurology (81%) and Emergency Medicine (55%).26 By contrast, Geriatrics was combined into an “Other” required clinical rotation category, defined as “Geriatrics/Ambulatory care,” and required rotations in this mixed group were identified on only 40% of school websites.26 The numbers suggest that graduating US medical students are much more likely to have dedicated time to learning about neurology from expert neurologists than dedicated time to learning about geriatrics from expert geriatricians.
Currently, the Liaison Committee on Medical Education asks medical schools to teach concepts relevant to “each phase of the human life cycle”20 and an American Geriatrics Society Working Group has recently updated the recommended Minimum Competencies in Geriatrics for Medical Students.27 Yet, US medical school accrediting bodies have not historically included geriatrics in expected core clinical experiences, and they do not currently mandate the inclusion of geriatrics in medical school curricula.20,21 Because medical schools may offer geriatrics activities as either optional or required, the percentage of graduating US medical students receiving geriatrics-specific training remains unknown.
Evidence has shown that medical students with required, geriatrics-specific clinical experiences are more committed to the care of older adults and may be more likely to see their experiences working with older adults as rewarding.28 Geriatrics fellows have named early geriatrics exposure as influential in their career choice, advocating for increased geriatrics exposure in medical school.29 Our findings suggest that a number of medical schools, particularly those in the High Geriatrics Online-Visibility group, do showcase multiple opportunities for geriatrics exposure, including through required activities. But High Geriatrics Online-Visibility schools comprise a relatively small group among the total schools reviewed (20%, n = 39), and the majority of Medium and Low Geriatrics Online-Visibility schools do not report required curricular activities in geriatrics on their academic websites.
For any school, curricular shifts can take considerable resources. And, indeed, the most influential factor in distinguishing among Geriatrics Online-Visibility groups was geriatrics-specific funding. Gaining perspectives from medical education leaders will be critical in further understanding currently available geriatrics education, whether curricular changes are desired, and the magnitude of any anticipated efforts for geriatrics curricular development.
An important limitation of this study is that some existing geriatrics opportunities at US medical schools may not be represented online. Caution should be exercised in interpreting the absence of information from academic websites. An inability to locate a queried topic may have multiple possible contributors, from a web-based platform that is difficult to navigate to an overall paucity of website information. There may be mismatches with selected search terms, a dearth of posted information about existing programs, or a true lack of educational offerings in the queried area.10 Insufficient funds or technical support for website development can also be contributors to the inaccessibility of information online. And yet, because academic websites typically reflect the priorities of the school and act as a primary information access point, particularly during the COVID-era, Geriatrics Online-Visibility is a promising marker of how geriatrics is presented and regarded at a given institution. School self-report will be a valuable complementary data source in future studies.
Additionally, despite our librarian-assisted literature review, our team’s expertise in geriatrics and medical education, and our preliminary website review pilot, some Geriatrics Elements may be missing or excluded from our study. Future studies should explore additional online indicators for geriatrics at medical schools across the US. Other study limitations include potential inconsistencies in reviewers’ website interpretation and the reality that, unlike published literature or printed admissions viewbooks, academic websites change over time. We proactively addressed these sources of variability through (1) employing group, individual, and paired website reviews prior to formal data collection, (2) conducting team meetings 1–2 times weekly to support a shared understanding of the review criteria, (3) establishing a reviewer Profile Page for each institution to track decision making, and (4) utilizing reverse order lists of schools for each reviewer pair to account for website changes over the course of the review period and to counterbalance the increasing experience of reviewers over time. Collectively, these measures enabled our team to produce a rigorous depiction of Geriatrics Online-Visibility for US medical schools, the first study of its kind. Though our initial focus is on geriatrics education for medical students, important future directions include examining geriatrics education at various levels of training across the spectrum of health care professions.
We now invite readers to try an online search for geriatrics at your own academic institution. Are you able to identify geriatrics opportunities for students? What “hidden curriculum”30 messages might the website convey to students about the importance of geriatrics?
Figure 3 offers recommendations for enhancing Geriatrics Online-Visibility on your school’s publicly facing academic website. We acknowledge that these recommendations are not directly emergent from our results; rather, these suggestions, which are informed by our work, are proposed as a guide for those seeking actionable next steps. Ensuring any currently existing opportunities in geriatrics are visible is key. After all, how can students be what they cannot see?
FIGURE 3.
We offer these recommendations for enhancing Geriatrics Online-Visibility on the publicly facing school website at your affiliated academic institution.
If we value preparing medical students to adeptly address the health care priorities and the health care realities of older adults, we must ensure that evidence-based best practices in older adult care are a visible part of their education.
Supplementary Material
Table S1. This table contains additional description for each Geriatrics Element in our systematic review of online information for US medical schools. The “term used in subsequent figures” portion signals the abbreviated terminolgy for each Geriatrics Element in Figures and Tables for this article.
Table S2. All 18 Geriatrics Elements were included as indicator variables for our latent class analysis. Because a likelihood ratio logworth above 2 correlates with a significance level (α) of 0.01, all Geriatrics Elements were significant factors in distinguishing among the 3 classes except for the mention of geriatrics or aging in the school mission statement. Because only one school mentioned geriatrics or aging in its mission statement, this geriatric element’s inability to distinguish among classes is not surprising.
Figure S1. This figure presents a histogram showing the distribution of the number of Geriatrics Elements identified for each school out of a possible range from 0 to 18.
Figure S2. This figure depicts the distributions of Geriatrics Elements broken down by latent class.
Figure S3. This figure provides distributions of Geriatrics Elements in the Geriatrics Education and Geriatrics Environment Domains as additional context for our 3-class model of Geriatrics Online-Visibility.
Figure S4. This figure provides a granular depiction of Geriatrics Elements sums broken down by Geriatrics Online-Visibility group for readers interested in specific characteristics of each latent class.
Key points
To characterize geriatrics opportunities for US medical students nationwide, we systematically reviewed publicly available online information for all 191 medical schools accredited in the US.
In this study, we find that optional geriatrics clinical activity was reported on 76% of medical school websites, whereas only 45% of medical school websites indicated having geriatrics clinical activity required for all students (Figure 1).
We introduce a novel classification system, termed Geriatrics Online-Visibility, to facilitate the comparison of geriatrics opportunities reported on school websites across High, Medium, and Low Geriatrics Online-Visibility groups (Figure 2).
Why does this paper matter?
By examining US medical school websites collectively as well as comparatively across Geriatrics Online-Visibility groups, we equip the geriatrics community with updated national geriatrics education data, and we provide recommended next steps for schools inspired to enhance their own Geriatrics Online-Visibility.
ACKNOWLEDGMENTS
We proudly highlight the members of the GERI Team Research Group: Jacob I. Abraham,1,2,* Ermias Araia,1,2 Bazif A. Bala,2 Roopa Duvvi,2 Fayez H. Fayad,2 Anthony L. Harwell III,2,ǂ Victoria G. Koenigsberger,1,2,*,ǂ Elizabeth M. Leon,3 Anwen Lin, Nadine Najah,2 Elizabeth Song,2 and Keyana Zahiri.2,ǂ
GERI Team: Geriatrics Education Review Investigator Team.
1The Warren Alpert Medical School of Brown University, 2Program in Liberal Medical Education, Brown University, 3Department of Oral Science and Translational Research, Nova Southeastern University, College of Dental Medicine.
*Student Leads, ǂReviewers selected for phase 2 data management.
We are deeply grateful for the statistical expertise and generous guidance of Amy Cohen, an Instructor in the Department of Healthcare Policy and Management at the Harvard T. H. Chan School of Public Health. We would also like to acknowledge Jason Smith, VA Boston Healthcare System Library Service Chief, for his valuable assistance with searching and selecting relevant literature, and Dr. Julianne Ip, former Associate Dean for the Brown University Program in Liberal Medical Education, for her kind collaboration in assembling our team. We are truly appreciative of the insights and feedback from our broader lab group, comprised of Drs. Ariela Orkaby, Shivani Jindal, Ahmed Nahas, and Ben Seligman.
FUNDING INFORMATION
We acknowledge the funding support of the Harvard Medical School Dean’s Innovation Award in providing protected time for medical education scholarly work for senior author AWS. This material is the result of work supported with resources and the use of facilities at the VA Bedford and VA Boston Medical Centers and the New England Geriatrics Research Education and Clinical Center (NE GRECC). The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.
Footnotes
Individual names of GERI Team Research Group members and their ICJME authorship contributions are provided in the Acknowledgements.
Our preliminary findings were introduced in an abstract and virtual poster at the AGS Virtual 2021 meeting.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
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Associated Data
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Supplementary Materials
Table S1. This table contains additional description for each Geriatrics Element in our systematic review of online information for US medical schools. The “term used in subsequent figures” portion signals the abbreviated terminolgy for each Geriatrics Element in Figures and Tables for this article.
Table S2. All 18 Geriatrics Elements were included as indicator variables for our latent class analysis. Because a likelihood ratio logworth above 2 correlates with a significance level (α) of 0.01, all Geriatrics Elements were significant factors in distinguishing among the 3 classes except for the mention of geriatrics or aging in the school mission statement. Because only one school mentioned geriatrics or aging in its mission statement, this geriatric element’s inability to distinguish among classes is not surprising.
Figure S1. This figure presents a histogram showing the distribution of the number of Geriatrics Elements identified for each school out of a possible range from 0 to 18.
Figure S2. This figure depicts the distributions of Geriatrics Elements broken down by latent class.
Figure S3. This figure provides distributions of Geriatrics Elements in the Geriatrics Education and Geriatrics Environment Domains as additional context for our 3-class model of Geriatrics Online-Visibility.
Figure S4. This figure provides a granular depiction of Geriatrics Elements sums broken down by Geriatrics Online-Visibility group for readers interested in specific characteristics of each latent class.