3rd Place WINNER: Product of the Year at the 2009 Reynolds Grantees Meeting in Las Vegas, NV

“Lions and tigers and bears! Oh, my!” exclaimed a young Dorothy in the 1939 film “The Wizard of Oz”. A much older Dorothy would have exclaimed “Pills, pills and more pills!” if she had the average number of chronic illnesses that older adults have along with the illnesses' concomitant treatment with pharmaceutical agents. This problem of polypharmacy is the issue addressed in “Pills, Pills and More Pills: A Pill Box Exercise to Reduce Polypharmacy” by an interactive, “hands-on” experience paired with group reflection by Diane Brown, Kathryn Denson and Jessica Kuester from The Medical College of Wisconsin. This POGOe product was voted 3rd Place WINNER as Product of the Year at the 2009 Reynolds Grantees Meeting in Las Vegas, NV.

Targeting learners at various levels – medical students, residents and fellows - the goal of this exercise is to improve the learner’s awareness of the barriers to medication adherence and to increase medication discontinuance/dosing changes. Learners are each given a pillbox and a medication list. They must fill the box with the dosages from a list of “prescriptions” that are given to them as a fictitious patient, “Mr. K”. The prescriptions consist of candies of varying colors and shapes, which are used to represent real medications. Learners must take the “medications” for one week and take note of any problems that they might encounter (e.g. forgetting to take a dose). This is then followed by a faculty-facilitated discussion about barriers and solutions (both physician and patient/family initiated) that could be used to aid adherence.

This product provides detailed instructions on how to implement the program, including a sample list of 15 medications for “Mr. K” and a 5-item pre/post survey to assess the effectiveness of this educational intervention. The educator who may want to implement this exercise must prepare the educational materials in advance. The materials include a seven-day pillbox with AM-Noon-PM-Bedtime per day compartments for each student. The assignment also requires 15 labeled prescription bottles handed out in a large bag for every 2-3 students. All of these items can be reused, making this a one-time purchase. The educator will also need to purchase different types of candies in bulk for all of the students to fill their fake prescriptions. With the variety of candy shapes and colors available, this is an effective way to simulate taking various medications.

By putting the students in a patient’s shoes, this exercise shows them first hand how complicated medication adherence can be. Learners will experience the challenges of medication adherence to a long list of prescriptions. Hopefully, the learners, especially those in the postgraduate levels, will be more aware of their patients’ medication lists and the issue of polypharmacy and aid in reducing medication non-adherence among their patients.

Try this interactive exercise now! It is available for FREE right here at POGOe.org. Besides, eating candy for a homework assignment is not a bad deal and would certainly make this a memorable and fun experience for all!

WINNER: Product of the Year at the 2009 Reynolds Grantees Meeting in Las Vegas, NV

Among the domains in the AAMC Geriatric Competencies for Medical Students, Medication Management is challenging to teach given the expansive nature of the topic as well as the danger of subjecting learners to endless rote memorization of drugs, their side effect profiles as well as their use or avoidance in the care of the older adult patient. Fortunately, the recipients of the Donald W. Reynolds Foundation’s grant to Strengthen Physicians’ Training in Geriatrics have developed educational products addressing this issue to make learning medication management interactive, fun and engaging.

One of these high-quality educational products is Principles of Rational Prescribing from Wake Forest University School of Medicine, which was the Winner of the 2009 Product of the Year at the recent Annual Reynolds Grantees Meeting in Las Vegas, NV. Developed by Kaycee M. Sink, MD, MAS and Hal H. Atkinson, MD, it is one of five lessons in the SmartPrescribe curriculum developed to teach learners about the need for evidence-based prescribing and the influence that drug company marketing has on medical practice. Intended users of the product include medical students during their clinical years, housestaff as well as practicing health care providers.

Utilizing Adobe’s Captivate as an authoring tool, this multimedia product includes PowerPoint slides, audio, and interactive features including focus questions within three sample cases that address polypharmacy, adverse drug events, and off-label prescribing. Included in this product as well is a highly interactive Drug Interaction Game that requires the learner to associate drugs with their side effect profile as well as drug-drug and drug-disease interactions. Printable resources available for download include two Beers List tables (one by drug type and severity rating and one by disease/condition and severity rating), and a sample medication grid for patient use.

Through a very straightforward graphical user interface, the learner can easily navigate through the slides as well as through the sections of the product. The learning materials are separated into brief sections with the use of navigation icons and textual elements found on the left-hand side of the screen, which help in improving learner comprehension and retention. One suggestion to enhance user interactivity would be developing a tutorial structure, especially within the cases, that progress through material in a path that depends on the learner's response to questions.

Overall, this is a high-quality interactive e-learning product that addresses the following 2 medical student competencies in the Medication Management domain:

1. Explain impact of age-related changes on drug selection and dose based on knowledge of age-related changes in renal and hepatic function, body composition, and Central Nervous System sensitivity.

2. Identify medications, including anticholinergic, psychoactive, anticoagulant, analgesic, hypoglycemic, and cardiovascular drugs that should be avoided or used with caution in older adults and explain the potential problems associated with each.

Check out this product NOW! It is available for free from the Wake Forest website and also right here in POGOe!

The development of minimum competencies in geriatrics for medical students presents an enormous challenge to medical educators. Today’s clinician-educators are being stretched thin with increasing teaching demands while also facing increasing institutional demands to be more clinically productive. Thus, traditional instructor-centered teaching is yielding to a learner-centered model that puts learners in control of their own education. E-learning is increasingly being used by medical educators today to improve the efficiency and effectiveness of educational interventions in the face of these pedagogical challenges.

Drs. Heather Anderson and Mary McDonald from the University of Kansas Medical Center have developed an interactive web module that focuses on easing up an instructor-driven curriculum by shifting to one that is web-based and learner-driven. Faced with only 2 weeks of neurology clerkship, KU employed the use of a web module as a vehicle to deliver geriatric neurology education to their 3rd year medical students. The module covers 10 geriatric neurology topics: Parkinson's disease, stroke, dementia, delirium, peripheral neuropathy, neck/back pain, sleep disorders, temporal arteritis, cranial nerve disorders, and localization of a lesion.

The web module design will be familiar to anyone who has spent time browsing the internet. Information is displayed on a single page, and students are encouraged to click links to view pop-up windows with diagrams and photographs relevant to the topic. To solidify learners’ comprehension of the material, the outlined content of each topic is followed by sample cases with interactive multiple-choice or open-ended questions. Once learners have decided on the answer, they can follow a link to a brief explanation of the correct answer. Accompanying videos and images help to enhance the learning process.

Highlights of the module include a video of a man with Parkinson’s Disease walking across the room demonstrating abnormal gait, several images throughout the module including a comparison of an MRI and CT scan of a brain prior to a stroke, as well as the aforementioned interactive quizzes to ascertain the learner’s grasp of the information.

One of the limitations of the module appears to be its linear nature. Students have to learn from "top to bottom" and can only jump to the beginning of one of the ten topics. The font size chosen for the web page is quite small, but can be enlarged by the more savvy computer user by holding Ctrl and either scrolling the mouse wheel or pressing + or -. An accompanying resources list would also be beneficial to direct the student for more in-depth discussion of the topic. Although the self-assessment questions are helpful, there are no directions noting that some require more than one answer; this may not  be intuitive to the learner.

Overall, this educational product appears to be a very appropriate method for delivery of geriatric content to achieve outcome-based competencies in geriatrics – a rational compromise between geriatric educators, who are handicapped by their inadequate number and burdened by increased teaching demands, and today’s medical students, who function with a world of communication and information at their fingertips. KU's small study of the module's usage shows it to be as effective as didactic lectures to improve one's geriatric neurology knowledge on the 10 topics as assessed by multiple choice questions. This is the only web based module to address geriatric neurology to date, and it can be accessed right now - for free - at POGOe.org!

The subtle differences between the presentations of delirium and dementia create much confusion for physicians who have not been trained to distinguish between the two cognitive dysfunctions.  Serena Chao, M.D. of the Boston University School of Medicine has developed an interactive, multimedia online curriculum to help medical students in their clinical years recognize signs and symptoms of delirium.  Dr. Chao’s product, Delirium in Older Patients: An Online Case-Based Curriculum, takes advantage of the advances in e-learning formats to present a detailed summary of the vital aspects of delirium in older patients. 

Designed specifically for medical students completing a required Geriatrics rotation or during a Medicine clerkship, this multi-faceted approach serves well as a supplement to clinical encounters.  The Delirium in Older Patients: An Online Case-Based Curriculum product consists of two modules, each with separate videos and PowerPoint presentations that cover the broad topics of diagnosis, evaluation, and management of delirium. This product uses videos to simulate patient visits, mock patient charts to supplement the video component, and PowerPoint presentations providing didactic teaching methods and informal quizzes. 

Dr. Chao’s modules depict many of the characteristics of delirium including risk factors and drugs that may induce delirium, forms of delirium, and prevention of delirium.  Additionally, these modules introduce methods to distinguish between delirium and dementia, evaluation methods for delirious elders (such as the CAM method), management of patients, restraint use, and the incidence rates of delirium.  As America’s older adult population grows over the next several decades, it is of vital importance that delirium, an extremely common condition, be understood.  The lessons taught in Dr. Chao’s product should help students appreciate the severity of the problem, better recognize the presentation, and understand its urgency and how to treat it. 

For the doctors of tomorrow, the issues of older patients will be omnipresent.  Yet, while they will be caring for more and more patients from generations far removed from their own, the way in which they expect to be taught is sure to be cutting edge.  This multimedia online curriculum is an excellent example of a new delivery method for critical information, and certainly this product will prove to be useful to any medical student in their clinical years. 

Starting in 2000, the Assessing Care of Vulnerable Elders (ACOVE) project endeavored to develop a comprehensive set of quality-indicators to improve the care of "vulnerable elders," community-living persons 65 years of age and older who are at high risk for death or functional decline. This group uses a disproportionate share of health care resources and is most susceptible to the effects of poor quality care. Until ACOVE, objective measures to evaluate their care were lacking. The ACOVE project developed quality-of-care process indicators to evaluate the care provided to vulnerable elders.

ACOVE-3, the third phase of this project completed in 2007, includes 392 quality indicators covering 26 different conditions in all four domains of care: screening and prevention, diagnosis, treatment, and follow-up and continuity. Three of these conditions involve the most basic functions of the human body - cognition, ambulation/mobility, and elimination - which are hugely important to consider when assessing the decline of a patient's health due to aging. Educating the physicians of tomorrow on cognitive impairment, falls and mobility disorders, and urinary incontinence should feature prominently in the education of physicians.

To help ease this process, Dr. David Reuben, in collaboration with AGS, RAND Health, and Pfizer, have developed ACOVE - an interactive video-lecture CD containing three distinct modules which efficiently and entertainingly delineates the unique challenges presenting to those entrusted with the care of the vulnerable elderly with these conditions. An interesting and attractively designed program, ACOVE guides the physician through crucial facets of these three conditions, while simultaneously integrating relevant patient interaction. ACOVE's primary target audience include residents as well as practicing physicians, but the patient is not left out of the equation. A variety of handouts are available for download that are designed for patients (as well as a multitude of handouts specific to physicians). The bulk of the content is organized into three modules, one for cognitive impairment, one for falls and mobility disorders, and the last for urinary incontinence. Dr. Reuben's lectures are accompanied by a virtual image of him, often juxtaposed to helpful text, images, graphs, or other video relevant to the topics that are being presented. ACOVE was developed with the intention of educating physicians on how to assess and care for older patients with these conditions by appealing to both visual and auditory learners. The CD is interactive, as the user can select not only modules, but also individual topics within each module. Learners can navigate through the module content with ease using easy-to-use navigation buttons on the screen. Additionally, Dr. Reuben gives frequent tips and words of advice to accompany the topic content.

However, while ACOVE is interactive, and was quite advanced at the publish date (February 2006), users technically savvy with current e-learning products may find the program's platform a bit dated. The overall user experience may benefit from enhancements such as an interface that allows interaction within the content of the modules, the ability to see your progress through the modules, and self-assessment opportunities. While the technology used in the production of the video and the platform to host the content may not be the latest and the content is largely summarative, the information is presented in a clear, concise, and effective manner. The marked expertise of Dr. Reuben permeates throughout the programs' presentations, and ACOVE performs well in educating physicians on the unique needs of their vulnerable older patients. With three separate modules and a total running time of just eighty minutes, ACOVE succeeds in its effort of helping to improve the quality of care for vulnerable older adults. This CD's production has already been discontinued; however, ACOVE is readily available for download - right now and for free - only at POGOe.org!

POGOe EDITORS CHOICE: GERIATRIC RHEUMATOLOGY

Despite the frequent manifestation of rheumatologic disorders in elderly patients, the diagnosis and especially the management of related symptoms remain problematic due to various complicating factors. The "Geriatric Rheumatology" module from the Donald W. Reynolds Department of Geriatric Medicine of the University of Oklahoma Health Sciences Center, addresses these issues with a comprehensive yet straight forward, web-based tutorial. Created by Dr. Yuri Nakasato and Dr. Shari M. Ling with developmental collaboration from Dr. Thomas A. Teasdale, this educational product educates learners about variant presentations, diagnostic caveats, and management issues associated with such disorders.

The product primarily consists of 3 modules: Overview (including epidemiology), Common Disorders in the Elderly, and Medications. Other modules include an archive of printable documents for patients; a picture index (12 images), cases (3 cases with discussion prompts) and self-assessment multiple-choice questions. The most comprehensive module, Common Disorders in the Elderly, provides lessons on osteoarthritis, rheumatoid arthritis, crystal-induced arthritis, polymyalgia rheumatica, and spinal stenosis. Within each disorder, this module defines and explains vital aspects of each as they specifically relate to older adults, such as differential diagnosis, etiology, epidemiology, and unique presentations. Combining these programmed lessons with radiological imagery and medication guidelines, this module helps clarify some of the uncertainty in management of rheumatologic disorders. Furthermore, the three case studies and the MCQ self-test are provided to test the learners understanding and demonstrate how knowledge of rheumatologic disorders translates into proper management.

The interface is clean and user friendly, and the product appears to work best with Internet Explorer as web browser. The developers also were clearly aware of the voluminous amount of information that this product contains. What you will notice immediately when you navigate through the site is the attention given in ensuring that navigation tools assist the users in finding specific content topics through every step of the navigation process. Users can navigate via the menu listing arranged as books on the left hand side, search words through a comprehensive word search function on the top, utilize the index listing, and also use the footprint on the upper right hand corner in case they need to backtrack.

At the completion of the modules in "Geriatric Rheumatology," the learner should be able to "recognize atypical presentations of common rheumatologic disorders in the elderly, understand the physiologic changes associated with aging that predispose patients to adverse effects of pharmacologic therapy, and evaluate risk and benefits of such therapies, and formulate an adequate therapeutic plan for elderly patients with rheumatologic conditions including non-pharmacologic modalities focusing in maintaining or improving patients level of function and quality of life." We highly suggest "Geriatric Rheumatology" and it is appropriate for all levels of learners from clinical medical students to practicing physicians. It can be found right here on POGOe!

Rarely does a singular approach to teaching a concept reach every student in the classroom. Therefore, multiple teaching approaches are useful and crucial to ensure comprehension of what is being taught.  To attend to the tactile and visual learners out there, Dr. Daniel Pound and colleagues from UCSF have developed "Incontinence Bingo" a game that brings together the learning of chronic urinary incontinence and the fun interactive game of chance, Bingo!

While Bingo may already have a somewhat stereotypical 'geriatric' connection, the game developed by Dr. Pound puts a new spin on this traditional game.  Designed to be utilized as a way to reinforce key principles after a didactic session in urinary incontinence, "Incontinence Bingo" allows students the opportunity to explain incontinence concepts in their own words. Asking students to recall and restate concepts in their own words is a key effective teaching technique and helps students assess their understanding so they can improve their reasoning skills. The game's bingo matrix cross categorizes bladder and sphincter pathophysiology in chronic/persistent incontinence with their management.  Students place 8 chips on the bingo board and must justify the placement of each chip to the instructor. The use of bladder/sphincter figures on the bingo cards and chips are also helpful in reinforcing key incontinence concepts visually.

While there may be no "jackpot," per se (though the implementation of the game is up to the instructor and we suppose a theoretical winner could technically hit the jackpot), the end result will be even more rewarding - a solid understanding of chronic urinary incontinence.  The "bladder bingo" game can be used individually or as a group exercise, and all the guidelines and materials are available on POGOe.

The Educational Resources on Aging (ERA) from the Reynolds Team of the Warren Alpert Medical School at Brown University is a collection of educational learning objects which provides POGOe users with an array of topics in clinical geriatrics and skills development. Due to its depth of geriatrics and aging topics, this collection is an invaluable addition to the POGOe digital library. Most of the learning objects are modifiable PowerPoint slides and include some pdfs of handouts and articles. The main page is arranged by user (students or residents) and includes a “General Resources” section. Topic areas include basic science courses (e.g. anatomy, pathophysiology, pharmacology); doctoring courses in the pre-clinical years (e.g. medical interviewing and the physical exam of the older adult); and clinical clerkship topics in geriatrics.

Educators familiar with the Web-CT learning system platform will find navigating through the website quite easy. Those not familiar with Web-CT may want to proceed to the Index section which provides users with a listing of all learning products; better yet is the "search" tab in the top section, which provides word matches for search terms. Try to spend time browsing through the site and the topics before you click on a title of a learning object (clicking a topic header automatically downloads the file into your system and opens it up, which may or may not be what you would want to do).

The ERA also provides useful web links, including the AGS “Geriatrics at Your Fingertips”, as well as the “Fast Facts” collection of palliative care topics from AAHPM.

Please use the following to access the ERA website directly at mycourses.brown.edu:

Username: reynolds.guest

Password: aging

Image citation: Fournier, Frank (Artist). (2004). Foofie Harlan [Photograph]. Contact Press Images.

CHAMP (Care of the Hospitalized Aging Medical Patient) is a phenomenal set of educational products from the Section of Geriatrics of The University of Chicago. Collectively designed primarily for clinical educators, the material is easily adaptable for practicing physicians, housestaff, advanced practice nurses and others who care for hospitalized older adults.

The 15 topics in the care of hospitalized older adult patients in CHAMP are organized around four themes: frailty, hazards of hospitalization, transitions of care, palliative care and end of life issues. Central to this curriculum is the training of educators who would teach these topics. This faculty development program merges the educational needs of faculty teachers, residents, and medical students around the goal of improving the care of hospitalized older adults.

Access to the curriculum is through a user friendly web interface and navigation is convenient through quick links in the site. The busy educator will find it convenient that each topic is set up as a module complete with a slide presentation, bedside teaching trigger, pocket teaching card, updated references; weblinks as well as a session evaluation form. These modular components are all modifiable to support the educational goals of the user. Embedded in the CHAMP Faculty Development Program is Teaching on Today's Wards, a 5-session mini-course aimed to strengthen inpatient teaching skills for clinicians as well as an Observed Structured Teaching Exercise (OSTE), a performance-based teaching assessment using standardized learners.