An unfolding case with a linked OSCE: a curriculum in inpatient geriatric medicine

This study sought to design, implement, and evaluate a unique educational curriculum in inpatient geriatrics for internal medicine housestaff.

Traditionally the didactic curriculum on an inpatient geriatrics unit varies according to the attending faculty on service, the types of patients admitted, and preferences of the housestaff and students-in-training. However, a more structured educational curriculum would allow for comprehensive attention to, and a detailed exploration of, the principles of geriatric care necessary to effectively treat all hospitalized older adults. We have developed a unique curriculum using an unfolding case that is followed by an OSCE, which assesses the knowledge and skills gained by the learners. An unfolding case is one that evolves over time and is unpredictable to the learners when they begin participating in the curriculum. It is well suited to postgraduate training and assessment since the learner must develop a differential diagnosis, discuss possible work-ups, and use the work-ups' results to reassess the case as it unfolds. Our scripted case, administered by a geriatrics fellow rotating on the unit, follows an ambulatory geriatric patient from her admission throughout her treatment and until the end of her stay. It culminates in a decision-making session about her functional ability and hence her discharge plans. Moreover, several topics relevant to inpatient geriatrics, including dementia, delirium, falls, urinary incontinence, wound care, and depression, are covered in three one-hour sessions. Written examinations or pre- and post-testing after an intervention are better suited to the early years of medical training but provide poor measures of curriculum mastery and clinical competency. Alternatively, our OSCE approach uses "stations" and "interstations" that provide a structured and timed opportunity to test these skills and assess specific areas of knowledge. We have designed a five-station, five-interstation OSCE that is conducted one week after the unfolding case-based conferences have ended. Learners are evaluated by attending physicians and given immediate feedback after each station and interstation.

This newly developed project has been implemented as a standardized curriculum on our inpatient geriatrics unit since September 2001. Thus far, it has been extremely well received by housestaff because of real-time assessment and review of the materials covered during the month. In addition, this progressive approach has provided an excellent forum for geriatrics fellows to develop teaching skills. Attending physicians have shown their support, finding the content to be appropriate and relevant to inpatient geriatrics. Finally, this didactic approach will be continued on our unit and a modified version is being developed and piloted for other unit staff.