The under-representation of elderly patients in a problem-based medical school curriculum

Dear Sir,

A second-year Dalhousie medical student voiced her concern that the problem-based cases were not representative of the older patients she expected to care for in her future practice. This prompted a review of the first and second year cases (2004/5) for age and issues relevant to geriatric medicine, specifically function, cognition and atypical disease presentation.

There were 69 cases. The average age was 33. Over 20 percent were pediatric patients, and half were below 30. Only 5 (7%) were 65 or older, and none were over 70. The patient with congestive heart failure was 18. The hip fracture case was a 52 year old who sustained her injury skiing.

Function and cognition were described in the dementia case. The only other mention of function was a patient who became uremic, and whose nurse reported he was suddenly ‘able to do nothing for himself’. There was no further documentation of function or cognition.

Although medical students will care for increasing numbers of elderly persons, such patients are barely represented in the curriculum. Under-representation of elderly persons is at odds with the concept of social accountability. Exclusion of elderly patients gives students an unrealistic understanding of the medicine that they will practice. Attitudes may develop early about what is ‘real’ medicine. This likely contributes to delirium and falls being mistakenly seen as ‘social problems’ rather than as presentations of acute medical illness.

This problem is not unique to Dalhousie. In Australia, only 4% of case patients were over 70 (Finucane et al. 2002) and in Malaysia (Majumder et al. 2004), there was only one.

Multiple factors likely contribute. Authors mistakenly believe that including frail elderly patients would make cases too complex to meet learning objectives. They are frequently unaware of the cases in the other modules, and no structure exists to monitor the content of the PBL curriculum.

Frail elderly patients are the present and future reality of health care. Medical schools have a responsibility to their students, and to society, to provide education that is relevant for the population to be served.