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Introduction1 and Framing of the Issues
The Global Forum on Innovation in Health Professional Education2 at the National Academies of Sciences, Engineering, and Medicine held a workshop on Addressing the Needs of an Aging Population through Health Professions Education on December 7–8, 2022. A pre-workshop session took place on November 15, 2022, to introduce the topic through an implementation science lens. Although there was an option to attend the workshop in person in Washington, D.C., participants primarily joined virtually. The workshop and pre-workshop agendas were planned by an expert planning committee (see Appendix D) whose work was guided by a Statement of Task (Box 1-1).
Of note is that these proceedings are organized by subject area, rather than chronologically (see Agenda in Appendix C). Chapter 1 opens with a framing discussion focused on the perspectives and needs of patients. This brief introduction is followed by presentations and discussions about working with older adults, learner reluctance to work with older adults, and speakers’ views on applying the World Health Organization’s intrinsic capacity framework within and across health professions. Chapter 2 presents discussions about educating learners on aging across the life course and
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1 The planning committee’s role was limited to planning the workshop, and this Proceedings of a Workshop was prepared by the rapporteurs as a factual account of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They should not be construed as reflecting any group consensus.
2 See Appendix B for a full list of forum members and staff.
summarizes a presentation on an age-friendly health education tool. Chapter 3 explores the question of whether the current health workforce supply is adequate to meet the needs of an aging population. Chapter 4 explores ways to address the gap between supply and demand, with summaries of presentations on a variety of approaches currently in use. Chapter 5 closes the proceedings with a description of implementation science and how it can help health professions education develop evidence-based approaches for building a workforce that is eager and prepared to work with older adults.
FRAMING THE ISSUES
Key Messages from the Presenters3
- Health professions education programs do not require classes in geriatrics, and it can be difficult to get programs to even offer elective opportunities to gain experience in geriatric care. (Pfeifle)
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3 This list is the rapporteurs’ summary of points made by individual speakers, and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine. They are not intended to reflect a consensus among workshop participants.
- Giving older adults the opportunity to be engaged in the community and to help other people is an essential part of healthy aging. (Newton)
- The “elephant in the room” is the need for a paradigm shift in how students are taught to think about older adults and the ideas that shape our attitudes. (Maxwell)
- At the learner level, it is important to move students into the community and learn from older adults directly. (Talib)
Andrea Pfeifle, the associate vice president for interprofessional practice and education for The Ohio State University and Wexner Medical Center, and Donna Ferguson, the mental health and wellness program manager at the Department of the Army Criminal Investigations Command in the Department of Defense, welcomed participants to the workshop by highlighting the importance of building the health care workforce to be prepared to care for the needs of older adults. An implementation science lens, Pfeifle said, is a useful approach for discussing how to make the necessary changes in health professions education. She noted that most health professions education programs do not require classes in geriatrics and said that it can be difficult to get these health professions education programs to even offer elective opportunities for students to gain experience in geriatric care.
The December 7 workshop session began with a conversation among Pfeifle, Ferguson, and community members Nancy Cruz and Willie Ann Burroughs. Pfeifle said that when exploring ways to inspire learners to pursue training and education in the care of older adults, it is critical to keep the focus on the “captain of the ship”—that is, on the older adults themselves who are in a position to make their own life decisions. Ferguson added that a team-based approach is important in both education and care and that the center of the team is the patient. Ferguson asked Cruz and Burroughs to tell workshop participants about themselves, their lives, and their work.
Cruz lives in Queens, New York. After a career working as a nurse in both a hospital and in a school, she now volunteers at the local senior center. She takes seniors’ blood pressure readings and listens to their problems; she added that some seniors at the center are “so lonely” and that just being there to listen is “such a big deal for them.” Cruz said that at mealtime some of the seniors want to maintain their independence and “eat what they want to eat.” She coaches them to try new things but also understands that every once in a while they need a special treat of something they are not supposed to have, “even if the doctor doesn’t like it.” Cruz said she gets around mostly on foot and is able to walk to the supermarket and many other stores. There are plenty of buses available if she needs to travel farther, such as to the doctor. As a former nurse, Cruz said she is able to
communicate easily with her doctors and understand their lingo, but some of the seniors whom she helps cannot. Cruz encourages the seniors to speak up and ask their doctors for what they need. In offering some observations about the health care system in general, Cruz said that most nurses today do not have the time with patients that she had when she was a young nurse; nurses are overwhelmed with 10 to 15 patients and are likely to miss signs and symptoms that are important. Young nurses need support from older nurses and more time with patients, she said; without this support, the system loses many good nurses.
Burroughs lives in Thomasville, Alabama. She drives herself to doctor appointments in Mobile and to visit her children in Birmingham, Mobile, and other places. She helps to care for two “young ladies”; one is 86 years old, and the other is 101 years old. Burroughs helps them with cooking, cleaning, getting to the doctor, and just getting out of the house. She helps them remember when to take their medications and how to follow their doctors’ instructions. Burroughs said that helping these ladies is “very rewarding.” Their children live in different cities, and Burroughs is often the only person nearby for them to talk to. When Burroughs goes out of town, she asks her relatives to step in and check on the ladies and see what they need. By cooking for the ladies, Burroughs has learned what they like. The 86-year-old, for example, loves bacon and croissants, cherry-cola, and caramel chocolate candy bars, and Burroughs said she has to hide the candy bars because otherwise the 86-year-old will eat them all at once. To take care of her own health, Burroughs goes to the gym three days a week and drinks fruit and vegetable smoothies for breakfast. Burroughs has to drive a considerable distance to see a specialist and said that she wishes there were more specialists available near her small town.
Warren Newton, the president and chief executive officer for the American Board of Family Medicine, observed that both Burroughs and Cruz embody the importance of social engagement and meaningful roles. Giving older adults the opportunity to be engaged in the community and to help other people is an essential part of healthy aging. Another workshop participant, Zohray Talib, the senior associate dean of academic affairs at the California University of Science and Medicine, added that in her work in Uganda and Kenya she has observed older people staying purposeful and engaged in their communities. There is a sense of community and support around older adults, and issues such as dementia are not pathologized but treated as normal behaviors. Talib described how a Kenyan woman spoke about her 90-year-old mother-in-law, who lives in a rural village and is busy with a sense of purpose and surrounded by family and grandchildren. However, Talib said, as people in these countries move to cities and become geographically dispersed, aging with a sense of purpose has become more difficult.
WORKING WITH OLDER ADULTS
Ricardo Custodio is a pediatrician and professor of health sciences based in Hawai’i. Hawai’i is a special place, Custodio said. It is geographically isolated, which has resulted in having an enormously biodiverse ecosystem and one of the most diverse, multiethnic, and multicultural populations in the world. There are a few Hawai’ian values that have been key to surviving and thriving, he said: aloha (love), malama (caring), and ’ohana (family). These values are expressed when you give the gift of flower lei to celebrate special occasions, including birthdays, weddings, graduations, and goodbyes. The elderly, called “kupuna,” are celebrated in Hawai’i, he said. Custodio joked that you are officially elderly in Hawai’i when a cashier calls you “auntie” or “uncle” and automatically gives you the 10 percent discount. According to Custodio, the merging of Asian and Pacific Islander cultures means that “we malama our kupuna,” or care for our elderly, because this is what ’ohana (family) does. He added that homes in Hawai’i are twice as likely to be multigenerational or more crowded than the national U.S. average, underscoring the concept of ’ohana, and “family means no one gets left behind or forgotten.”
The values of aloha, malama, and ’ohana, Custodio said, are reflected in the fact that people living in Hawai’i have the longest life expectancy and are the happiest people in the United States (Arias et al., 2018; Mitchell et al., 2013). “We must be doing something differently and right to live longer and be happier,” he said. The priority is to care for elders at home with the support of family and community, and it is a longstanding expectation that kupuna stay at home with their families. However, he added, not all people in Hawai’i enjoy this support. For example, when Custodio was a medical student in the emergency room, there was an elderly woman who would come in several times a week just to “talk story.” She was the mother of a rich developer, but her son and grandchildren never came to visit; all the money in the world could not prevent her from being lonely, he said.
Custodio said he has spent his career trying to serve those who have been left behind, with a focus on providing health care to underserved children and families. His patients are primarily the poor, Pacific Islanders, and recently arrived non-English-speaking immigrants. For over 40 years Custodio has worked in community health centers that provide comprehensive services beyond primary care, regardless of patients’ ability to pay. These services include homeless outreach, assistance with insurance eligibility, transportation, and translation as well as support from community health workers. More importantly, he said, these centers provide clerkships and training for health professions students to help them understand and experience what it is like to work in a community. The hope is to “brainwash” them into staying and committing to serve, he said. Over the last 12 years, Custodio has helped
start a medical school, a nurse practitioner residency program, a clinical psychology fellowship, and a university division of natural and health sciences; all are focused on poor and underserved communities. These programs are part of his efforts focused on “growing our own, from our community, for our community.” There are a huge number of health professions careers, and many are among the fastest growing occupations in the country. Training young people in these careers is a way to get underserved students into professions that can pay a living wage, he said.
Custodio noted that health professions training is often conducted in siloes and that upon entering practice, professionals are “thrown together” and expected to work like a team from day one. In sports, individuals learn individual skills but also spend dedicated time practicing and playing together as a team. “Why doesn’t that happen in medicine?” he asked. He encouraged stakeholders to create a model of health professions education that consistently reminds students of the values of professionalism, teamwork, and service to the community. Clinical training centers should be created where students are given interprofessional health education directly in underserved communities. As an example of interprofessional training, Custodio spoke of how in the early 1990s a grant-funded project brought together medical, nursing, social work, and public health students for weekly sessions in a community health center. This experience instilled a sense of “community heart” in these students, he said.
Custodio also described a recent experience he had that showed him the power of love, caring, and family. He was hospitalized because he was urinating blood. He was in the hospital for several days receiving treatment, which gave him “a lot of time to think,” he said. One reassuring insight he had concerned the strength of the community around him: the urologist was his former medical school classmate, the hospitalist was his former medical student, and the evening nurse was a former patient. The connections and support that he felt at his hospital gave him a sense that his community was rooting for him. The challenge, he said, is how to teach this to the next generation of health care providers. Where are the role models, and how can patients be guided to teach students about family and community? This is increasingly important to Custodio, he said, as he recently turned 65 and enrolled in Medicare.
Custodio discussed a number of trends relevant to the workshop. There is an increase in the number of older adults needing health care, while at the same time there is a decrease in the overall health care workforce due to retirement, death, and burnout. There is an increase in the amount of health care delivered at home rather than at hospitals and clinics. An interesting recent trend, he said, is that 85 to 90 percent of students going into health care are female, many of whom are immigrants, first-generation Americans, and minorities. This trend is in part due to the not-so-subtle advertising to
caring, compassionate, and impressionable little girls; Custodio shared a picture of the wide variety of girl-oriented doctor toys and dolls that are available. This, he said, is how we make doctors. A more nurturing and caring workforce will change medicine for the better. The challenge for health professions education is to help young people define a purpose beyond the goal of acquiring material possessions and making money and toward social equity and justice, beyond the struggle for subsistence and toward serving others and building a sense of trust and hope for our kupuna.
During the pandemic, Custodio said that he felt this type of purpose and urgency in the younger generation. His clinic received a grant to train community contact tracers, with a focus on serving vulnerable populations; they had over 3,000 applications for 150 slots. Grades and degrees were important in choosing applicants, but the priority was to find candidates who had “community heart.” Custodio described community heart as the “one kid who stays back and helps clean up” after everyone leaves a big family gathering. As health professions educators move forward in addressing the needs of an aging population, he said, there is a need to understand how individuals’ development and their foundation of family and community affect their health and wellness. Providers need to actively encourage and seek out health professions candidates who have community heart, purpose, and desire to serve. The future that Custodio envisions is one in which older adults are healthy and are not alone because family and community are integrated into their care.
LEARNER RELUCTANCE
The global older adult population will double by 2050, said Cathy Maxwell of the Vanderbilt University School of Nursing. In the United States, the proportion of older adults will grow from 16 percent in 2021 to 22 percent in 2050 (ACL, 2021; WHO, 2022). In anticipation of this growth, the Institute of Medicine published a report in 2008 called Retooling for an Aging America: Building a Healthcare Workforce (IOM, 2008). Unfortunately, Maxwell said, the report did not have the desired impact. In fact, there has been a solid decline in geriatricians and nurse practitioners who work with older adults. Despite this report and other national initiatives—including the Eldercare Workforce Alliance, the Geriatric Workforce Enhancement Program, and the Nurses Improving Care for Health System Elders Program—the barriers to working with older adults have not been addressed. Maxwell reviewed a number of recent publications on aging adults and the health care workforce in order to lay a foundation for the rest of the workshop.
In April 2021, Nature Aging published a comment by John Rowe of Columbia University on the state of the U.S. eldercare workforce (Rowe,
2021). The piece included three major recommendations to improve the care of older adults, Maxwell said. First, Rowe urged a dramatic increase in the number of geriatric health care professionals, with a focus on public health professionals. Second, he advocated for population-focused and evidence-based policies and programs to support well-being. Third, Rowe addressed the need to implement recently formulated consensus recommendations regarding the care of community-dwelling older adults with serious illness. These recommendations included incorporating family members, applying technology, advancing cultural competency, and refining payment models.
One of the major barriers to expanding the workforce and improving the care of older adults, Maxwell said, is ageism among health care professionals as well as among older adults themselves. A study published in 2020 reported that not only does ageism exist, but it is well-established, socially accepted, and prevalent throughout the Western world (Chang et al., 2020). The study’s authors advocated for educational interventions among clinicians to increase awareness of ageism, additional education and training to improve knowledge about aging, and research to explore factors related to the phenomenon of ageism among older adults. A 2019 special issue of the Journal of the American Geriatric Society addressed consensus-based recommendations for an adequate workforce, noting the need to use interprofessional teams; connect social, clinical, and home care services; build a culturally competent workforce; and train clinicians with appropriate communication skills (Spetz and Dudley, 2019). The special issue also emphasized the importance of the home care workforce, family caregiving, and palliative care.
A 2020 systematic review examined factors related to the preferences of students for working with older adults, Maxwell said (Hebditch et al., 2020). The review synthesized 62 papers and identified seven categories of factors that influence preferences, including student characteristics, experiences, courses, career, patient characteristics, and work characteristics. Maxwell described several key findings. First, during student training programs the preference for working with older adults actually decreases. The socialization process during these programs is seen as a deterrent and was referred to as a “hidden curriculum.” The review noted there was a lack of educational interventions to address this hidden curriculum. A second key finding was that students had certain perceptions about the work, patients, and careers associated with working with older adults. Negative perceptions included a feeling that the work would be boring or emotionally challenging, the focus on quality of life rather than on curing patients, difficulties communicating with patients, and negative patient dispositions. Finally, the review identified the importance of exposure to healthy adults in order to reduce stereotypical prejudices and to promote working with older adults.
The National Hartford Center for Gerontological Nursing Excellence published core competencies for gerontological nursing educators in 2019 (NHCGNE, 2019). According to these findings, nursing educators should:
- Maintain knowledge and skills in the care of older adults
- Serve as advocates and positive role models for quality care for older adults
- Implement innovative teaching strategies for engaging learners to develop knowledge, attitudes, and skills for supporting healthy aging and the care of older adults
- Facilitate interprofessional learning opportunities related to healthy aging and care of older adults
- Facilitate the integration of concepts of healthy aging and care of older adults in academic and professional development programs
- Collaborate in the evaluation of learning about healthy aging and care of older adults in academic and professional development programs
- Demonstrate scholarship and leadership that advances gerontological nursing education and practice and that fosters others’ professional development.
The “elephant in the room,” Maxwell said, is the need for a paradigm shift in how students are taught to think about older adults and the ideas that shape our attitudes. Traditionally, she said, older adults are portrayed as frail, with fixed ideas of young versus old. There is a need to change learner attitudes about aging, Maxwell stated, before adding, “we don’t have another decade to figure it out.” Compounding the issue, she said, teachers are unlikely to engage in the type of collective change that is needed because of three factors: presentism, conservatism, and individualism. In a 1975 publication, Lortie described presentism as a focus on the short term, conservatism as a focus on small-scale achievements rather than broad change, and individualism as an idea that is reinforced by jobs with uncertain criteria for successful performance and reliance on their own indicators in isolation of a broader agenda (Nash and Ducharme, 1975).
Implementation science, to be discussed later, offers a path forward, Maxwell said. Implementation science is the study of the methods and strategies that facilitate the uptake of evidence-based practice and research into regular use by practitioners and policy makers (see Chapter 5 for more details). Maxwell said that a broader, holistic approach is needed in order to acknowledge the reality that aging is a process that begins early in life. The mechanisms of aging take place over decades, and most people have a long period with clinically healthy status. Once age-related pathologies appear, it is often too late to reverse the mechanisms of biological aging due
to a lack of compensatory mechanisms and physiologic reserve. Maxwell compared the process to an iceberg, in which age-related pathologies are only the tip (Figure 1-1). There is a need, she said, to advance the understanding that aging is a continuum that begins around age 30, with a slow and incremental decline that is largely unnoticeable in younger and middle years. Later discussions at the workshop would focus more closely on how to shift attitudes and perceptions among learners in order to improve the capacity of the health care workforce to care for older adults.
INTRINSIC CAPACITY FRAMEWORK
The World Health Organization (WHO) articulated a vision for aging in 2016 (WHO, 2017). This vision, Maxwell said, represented a shift
SOURCES: Maxwell presentation, December 7, 2022; Franceschi et al. 2018.
away from thinking about health in older age as the presence or absence of disease and toward looking at functional ability. In addition, the vision endorsed the need for countries to cater more effectively to the needs of older people and to provide health services and care in a more integrated way. The intrinsic capacity (IC) framework comprises cognition, mobility, psychological, vitality, and sensory functions (Figure 1-2) (Zhou and Ma, 2022). Maxwell said that while this framework holds promise for mitigating functional decline, chronic conditions, and early mortality, it may not fully address other factors that contribute to harmonious aging. The harmonious aging approach, she explained, is designed to recognize the challenges and opportunities of old age, the tension between activity and disengagement, the integrity of the body and mind, and the interdependent nature of human beings. With this in mind, she, along with others involved in planning the workshop, suggested adding several factors to the intrinsic capacity framework: social, family, community, cultural, and spiritual. A roundtable of health professionals, students, and other stakeholders discussed the expanded IC framework and whether it is the right model to guide health care professionals in the care of older adults.
SOURCES: Presented by Maxwell, December 7, 2022; Cesari et al., 2018.
Integrative Health and Medicine Perspective
The IC model is an excellent one, said Liza Goldblatt, the director of national and global projects at the Academy of Integrative Health and Medicine, but it does focus mostly on the biological factors for aging. There are many other important areas that affect healthy aging, including social, cultural, community, economics, and family factors. Goldblatt said there are two movements that blend the IC model with the core values that Custodio discussed, such as family ties and cultural traditions. The first is the whole health movement, which began at the Department of Veterans Affairs and focuses on the whole person, including asking individuals what matters most to them and what their health priorities are. The second is the integrative health movement, which consists of conventional medicine providers working together with complementary medicine. Professionals in this movement include conventional medicine practitioners as well as acupuncturists, chiropractors, naturopathic physicians, Chinese medicine practitioners, and licensed massage therapists. Each of these disciplines addresses healthy aging and well-being as well as the treatment of diseases and conditions. These two movements, Goldblatt said, address the body, the mind, the emotions, the spirit, and the environment.
In 2014, a study found that over 30 percent of the U.S. population has access to integrated health care and that this percentage is even higher for seniors (Siddiqui et al., 2014). Since 2018 the Joint Commission has required hospitals to discuss non-pharmacological treatment of pain with patients. For example, patients who do not wish to be heavily sedated for pain management may be able to use acupuncture instead. Other options to improve the well-being of seniors include tai chi, chi gong, chiropractic care, mindfulness training, and nutritional strategies. However, conventional medical systems are still largely unaware of these disciplines, their philosophies, and their scopes of practice. This is a significant gap in health professions education and practice in the United States. The current health care system, Goldblatt said, is not set up for optimal health and well-being. It is designed more for the treatment of diseases, which, while being an important part of health care, is limited. Since so many diseases are preventable, she asked, is it not time to also put the country’s economic resources towards supporting the creation of good health? Health professionals are dedicated and motivated, but they simply cannot address the needs of patients in 15-minute visits in a for-profit medical system. As Cruz observed in the first session of the workshop, health professionals are not given the time they need with patients. “We need to change our health care system” if there will be any impact on the health and well-being of the aging population, Goldblatt said.
Nutrition Perspective
Food and nutrition touch all of the five original domains of the IC framework as well as the factors that the planning committee suggested adding, said Kathy Kolasa, a professor emerita at East Carolina University’s Brody School of Medicine. While not everyone can share the beautiful flowers of Hawai’i, she said, people around the globe share food with their families and friends as a way of expressing love and caring. Food is an important component of the IC framework, although it is rarely mentioned in the literature. Kolasa gave three reasons why nutrition should be considered in all domains of the IC framework. First, frailty and malnutrition are established risk factors for loss of function (Cesari et al., 2018). Roughly 22 percent of older adults in the hospital and approximately 30 percent of those in long-term care are malnourished, which has an impact on their recovery and function. Second, activities of daily living (ADLs) are discussed in the IC literature, but there is a need for more emphasis on the instrumental ADLs, such as accessing and preparing food (Zhou and Ma, 2022). Health professionals can screen for food insecurity in clinical settings and can help connect people to the resources they need. Dietitians can counsel patients on how to get a good-quality diet, which is important for retaining function. Third, Kolasa said, many chronic disease conditions have a nutrition component, and about 50 percent of older Americans are obese (Jimenez et al., 2022). The standard advice given to young people for weight loss may not be effective for older adults and could even lead to loss of function. Registered dietitian nutritionists can conduct nutritional assessments and promote the adoption of preventive strategies for aging that address frailty, disability, and other issues that matter most to older adults. Kolasa said that weight loss is sometimes discouraged for older adults because of fears of making function worse, but the things that matter most to older adults often require weight loss. For example, an individual may want to run around with his or her grandchildren or get up off the floor independently. Weight loss can be done safely and appropriately and should not be discouraged for this population, Kolasa said. She added that a focus on function for older adults can be an opportunity to bring together professionals from different specialties; for example, occupational therapy students and dietetic students could work together to help patients use adaptive tools to cook and eat healthy meals.
Medical Perspective
The model of care in both the United States and around the world is disease-centered, said Senthil Rajasekaran, the associate dean and chief academic officer at Khalifa University College of Medicine and Health
Sciences. However, for the geriatric population in particular, the ideal model of care is function-centered, with an emphasis on issues that matter to the individual. Functional ability is determined primarily by the intrinsic capacity—that is, the composite of all of the physical and mental capacities of the individual—along with the environment. The five domains of the IC framework are pivotal for capturing an individual’s intrinsic capacity, he said. Unfortunately, he added, the health professions education system does not adequately address these topics or focus on function-based care. The growth in the population of older adults is not being matched by a growth in relevant areas of health education. It is critical, he said, that the health professions education system “takes a huge stride” in including a significant amount of educational material that will help learners be prepared to take care of the elderly population when they enter clinical practice. There are a variety of methods to introduce this content, he said, including simulations, gamification, and opportunities for students to “roll up their sleeves” and work in the community with older adults. The current generation is motivated to make an impact in their community, Rajasekaran said, so there need to be opportunities for them to do so.
Learner Perspective
A doctoral student in nursing practice within adult geriatrics at Vanderbilt University, Brooke Hazen commented that there is not much emphasis on the duty within the health care system to serve others. Specifically, she said, patients are seen as separate from providers, and providers do not see taking care of patients as a way of making their own lives better. Hazen said that while there have been many efforts to improve the health care system—for example, to make it more cost-effective or more evidence-based—there is a need for a mindset shift toward a value-based system. Health professionals need to be given the time and training to act as patient advocates, and they need to think of themselves as advocates. The “whole country” needs to push back on our current system, she said, and demand a change. As a student, Hazen said, she has had the opportunity to meet with patients for long periods of time, to listen to their issues, and to identify multiple ways that their health and care could be improved. No one else in the system is catching these things, she said, because they simply do not have the time to see the big picture. There is a need for a major shift within health professions education and practice in order to provide patient-centered care that addresses the whole person.
Hazen also spoke of the importance of interprofessional training and practice. Part of her nurse practitioner training included a 2-year clinical program in which nursing students worked on teams that included medical, pharmacy, social work, divinity, and counseling students. The teams
worked in clinics and also visited older adults in their homes. Hazen emphasized the value of this interprofessional training, saying it was the highlight moment for her in terms of how she provides care and how she sees health care.
Community Perspective
Zohray Talib of the California University of Science and Medicine agreed with other speakers about the need for a cultural shift within the health care system. The question, she said, is what will this mean for health professions educators and what actions need to be taken? Talib described three levels at which changes need to be made. First, at the macro level there is a need for new policies and an evolution of accreditation and regulatory requirements. These changes cannot wait, she said, because the demographic shift is already happening. At the institutional level, institutions need to be responsive to the needs of an aging population and should incorporate the perspective of older individuals in leadership and governance. Furthermore, many educators themselves are older adults, so institutions need to be thinking about issues such as retirement and burnout. At the learner level, students need to move into the community and learn from older adults directly. Talib said that the discussions at the workshop have made her feel inspired, but she also feels a sense of urgency to act. There is a need to start visualizing what success looks like and what steps can be taken to get there, she concluded.
Psychology Perspective
Health professions education often focuses on disease, said Catherine Grus, the chief education officer at the American Psychological Association, but there is a need to shift the perspective toward health promotion. Training health professionals to think about how to promote health and well-being in older adults can make a big impact, she said. For example, several speakers mentioned the issue of loneliness in older adults. Loneliness can progress to depression, and there are high rates of suicide in older adults (Crestani et al., 2019). Taking a health promotion perspective can lead one to intervene early and mitigate against the progression of the depression. However, the current health care workforce does not have the capacity to take this approach, she said, and educators are “not going to get there overnight.” Another critical piece of caring for older adults, Grus added, is using an interdisciplinary approach and working closely with professionals across the spectrum. For example, if an individual presents with symptoms of depression, it is imperative to work with other professionals to discern whether the depression is related to a medical condition or perhaps is an
early stage of cognitive decline. In psychology in particular, she said, there is a lack of emphasis on health promotion and the role of communities in promoting and supporting well-being.
Social Work Perspective
The IC framework fits nicely with the social work perspective, said Nancy Kusmaul of the University of Maryland School of Social Work. For generations, social work has taught the person and environment model, which looks at the interaction between the environment and the individual’s strengths and challenges, including physical, mental, cognitive, emotional, and spiritual issues. The problem, however, is getting social work students interested in working with older adults. Offering separate classes on older adults is not particularly effective, she said, because the only students who enroll are those who are already interested in working with this population. Kusmaul added that while students may say they want to work with families and children, they do not generally think about the fact that older adults are part of families. Connecting students with older adults through the classroom or practical experiences, she said, is one approach to get students interested. She commented on hearing from multiple practitioners that “accidental experience” with older adults is what got them interested in the field. Kusmaul urged health professions educators to think of ways to expose students to older adults in order to spark interest and improve care for this population.
