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Title: Medical Education Immersion Learning: Student Lives the Life of an Elder Nursing Home Resident 
Authors: 
David Drozda, BA, MS IV & Marilyn R. Gugliucci, MA, PhD (Corresponding Author)
Division of Geriatric Medicine
University of New England College of Osteopathic Medicine
11 Hills Beach Road, Biddeford, ME 04005
(P) 207-602-2453; (F) 207-602-5943
 HYPERLINK "mailto:mgugliucci@une.edu" mgugliucci@une.edu

Neither author has any conflict of interest
No grant funding was applied to this research, however in-kind services were provided by the nursing home without any cost to the student or the medical school.


Introduction: 

The objective of the University of New England College of Osteopathic Medicine (UNECOM) Learning by Living project (heretofore referred to as Learning by Living) is to immerse student doctors into the role of an older adult nursing home resident, complete with diagnoses and standard procedures of care for an extended period of time to answer the question, �What is it like for me to live the life of an older adult nursing home resident?� [1]. This article provides one medical student�s lived experience as an older adult nursing home resident and how this life altering medical education research affected his views on holistic and empathic care for older adults.

The Institute of Medicine (IOM) defines patient-centered care as: "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions"[2].  As a student in medical school and after living in a nursing home for extended period of time as a recipient of care, the stated definition of patient-centered care above offered only part of the equation. Even though I appreciated being respected it was only when I felt the bond with my care providers that I felt valued. For many medical students, the choice to become a doctor has been guided by the desire to develop meaningful connections with the people they care for. However, the nature of this bond is as complex as the two people it connects. The osteopathic profession recognizes this, and teaches that each person is a multifaceted unit of mind, body, and spirit [3]; making them more than patients. Aiding a person to attain a sense of well-being, especially when ill or physically compromised, is essential and begs the question, what role should the physician play in nurturing the mind, body and spirit of those s/he cares for? This is the question I pondered as I lived in a nursing home for 10 days with diagnoses that made me unable to transfer on my own, unable to walk, and needing to be bathed, toileted, and eat pureed food. The situation I was in highlighted how little I understood the unique challenges of caring for an older adult nursing home resident; how the definition of patient-centered care was merely a string of words with little meaning; and how important bonds with all care providers and fellow residents contributes to one�s sense of self.   

The early years of medical school provide ample opportunity to learn about the body; through text, lecture, and in simulated patient encounters. At UNECOM there are programs in place specifically to give students an introduction to working with older adults. Actually, UNECOM dedicates 28 hours to geriatrics education and older adult encounters, far more than most medical schools. Still, young student doctors are challenged to engage with and understand the mind and spirit components of the older adults they work with. These components are dynamic, developed over time and shaped by an individual�s unique experiences, as well as by the personal beliefs which are formed and tempered by these experiences. Younger practitioners raised in a different generation may have difficulty understanding the daily challenges faced by older adults and their families. Because of this, patient-centered care may not be the best term. Living the life of an older nursing home resident for an extended period of time highlighted these challenges and how understanding and connecting with the person (not the patient) is essential for the delivery of holistic and empathetic care. As osteopathic physicians, we need to consider person-centered rather than patient-centered care. Labeling anyone as a �patient� is demeaning, implying a less than whole person; this holds especially true for the residents who reside in nursing homes.

Methods:

The UNECOM Learning by Living Project was designed implemented by Marilyn R. Gugliucci, MA, PhD, Project Principal Investigator, Professor, and Director of Geriatrics Education and Research in 2006. She has since admitted 33 students into 14 different nursing homes in 4 states. Nursing homes volunteer to participate in the project providing a bed, standard care by staff, and meals for no cost.  A qualitative ethnographic/auto-biographic research design was utilized. A 23-year-old male osteopathic medical student volunteered to be �admitted� into a New Hampshire nursing home during July 2014 for 10 days. He was diagnosed with right-side paralysis secondary to stroke and aspiration pneumonia and lived in the nursing home 24 hours a day sharing a room with an 85 y/o male resident with dementia. The student was immersed in his role and was cared for by staff as a typical resident of the home.  Due to his �stroke� diagnosis, he was wheelchair reliant which required him to be toileted, bathed, transferred with assists; and due to his �aspiration pneumonia,� he experienced a pureed (honey thickness) diet for 36 hours. Only non-dominant hand usage was allowed. Physical therapy and occupational therapy were observed in a buddy situation with a 75 year old resident who had the same diagnoses.  Data was collected in the form of journal notes for pre-fieldwork, fieldwork, and post fieldwork and included subjective and objective reporting of observations, experiences, and resident encounters, amounting to 75 single-spaced pages. The journal was reviewed each evening by the project principal investigator to ensure sound qualitative accounts of life lived as a nursing home resident and to determine the student�s demeanor.  Analyses of the data included journal review, thematic categorization, and qualitative coding through content analysis [3].

Results: 

The extended immersion into the nursing home environment provided the medical student with experiences and challenges to those expressed by the nursing home residents he lived with.   Thematic coding of journal data generated a number of varied themes, however three key themes for the medical student included: (1) Adaptation; (2) Communication; and (3) Loss. 

Adaptation: 

It was a frightening moment to be sitting in the [wheel] chair for the first time. Several things hit me all at once. The first is that I suddenly have to look up at everyone in order to make eye contact, and they have to look down at me�I was conscious of the feeling that staff were �talking over my head� literally. I was physically lower down, and staff would do this thing where they would say something to the person pushing me around, which meant that they were speaking in a direction that was both above and behind me. It made me feel vulnerable to have someone consistently direct their attention to a source that was both above and behind me. And I realized� I am totally dependent on their care.  

As I was being wheeled around I was doing my best to take in my surroundings, but I only had as much time as the person who was pushing me allowed. Had I been walking independently, I would have stopped to read a sign or look down a hallway or paused at a painting.  Adapting to this environment was complex; a mix of new surroundings, new modes of transporting myself, dependence on others, strangers all around me. As I enter new environments now in my role as student doctor, I am reminded of these past feelings and remain conscious to the fact that all the people I encounter and provide care for are also adapting, which is far more challenging than I would have ever thought had I not lived in a nursing home. The word �pride� is more prevalent in my lexicon � the importance of being allowed to struggle through things on your own, without initial assistance. And I wonder to this day what happens to people when they can no longer experience a sense of accomplishment; how do they adapt?

Communication: 

The conversation with Jane [pseudonym] (a resident with cognitive impairment) was important�At first, she spoke in cycles. She�repeats over and over �aloha�aloha�aloha� [but] the third time I communicated with her she greeted me with �HIYA David, how ya doin?��What struck me about Jane was that when she sits alone I can hear her just repeating �aloha, aloha, aloha�. It is interesting what a different person she becomes when people are talking with her. She really comes to life. 

The heterogeneity of older adults is well known in the field of geriatrics, but experiencing it while living in the nursing home was new to me. As I lived there and made friends I began to understand how people varied in their communication. I was acutely aware of body language and voice tone, especially if non-verbal. These cues spoke volumes about how the residents were feeling, and what they wanted to communicate.  I coined a term �present silence� which involves validating a person and the importance of the thoughts and feelings they share by allowing silence in the conversation. Prior to this experience I might have avoided Jane and certainly didn�t understand the power of silence to build connections. Now, I am aware of various forms of communication; for example, when I interject to speak it is no longer the person�s story, it is my story. I understand that my body language, voice tone, and words can either open pathways to communication with people or close them down.  

Loss:

Leaving the nursing home presented the challenge of saying goodbye to people whom I had come to care very much about. One of these people was Helen (pseudonym), a stroke patient who became my teacher and my friend. We talked about what the most difficult changes have been since her stroke. She said she really struggled with the loss of dignity and freedom, That her biggest struggle was the loss of control... Helen put this in perspective for me when she stated: �you measure progress not in days and months, but in little steps. Measure in inches�� It reminded me of a line from a Rudyard Kipling poem I really like �Turn the unforgiving minute into 60 seconds worth of distance run.� 

Within minutes of entering the home I experienced loss. Even with kind and professional staff I felt my dignity slip when being toileted or bathed; my freedom was confined by losing my independence; I required the aid of others to fulfill my most basic human needs. Dealing with loss presents significant challenges to many older adults; its manifestations are varied as are the methods of coping. The concept of �measuring in inches,� a variation on the idea of celebrating small victories, was a concrete approach that has been added to my doctoring tools; a concept that applies to all people regardless of their age. 

Discussion:

By spending time immersed in nursing home life as a fellow resident, the medical student experienced and identified challenges and adaptations necessary to maneuver within a culture that was foreign. He gained insights through discussions with older adults especially when experiences appeared to be parallel. 

When medical students enter a nursing home for the UNECOM geriatrics practicum they talk of illness, dependence, loss, and death; they fail to see the humanity, the essence of each resident, the small joys that makes them whole even in the face of physical frailty and the community that is alive and well in the nursing home environment. As future doctors, the potential harms of making assumptions or taking a situation at face value without considering the full context are not new concepts in limiting patient care. For example, it could also be posited that regardless of whom the patient was before her stroke, she is a stroke patient now and her treatment will be based on the realities of her present situation. However, the Learning by Living experience affirmed the significance of getting to know the person one cares for as a physician and the importance of treating the person not the disease.   

Conclusion: 

For older adults in a nursing home, loss represents a common bond: loss of health, loss of freedom, loss of friends, loss of comfort, and loss of dignity. And yet, in the face of these losses, many older adults are able to adapt and grow in their new environment. Learning by Living has allowed this student an intimate look into the lives of older adults who are much more than their challenges. This experience imparted knowledge and challenged the student doctor�s attitudes about aging, loss, and the critical role of making meaningful connections in order to adapt to challenging circumstances. These insights provided an understanding of osteopathic care gained through immersion learning that is person-centered, comprehensive, and empathic.

As stated by the student doctor: This experience is something I want to talk about; it is not done with just because my 10 days are up. It is a part of me now, and I think it will take a lifetime to sort it out in full (D. Drozda, 2014).
References

[1] Gugliucci M, & Weiner A. Learning by Living: Life-Altering Medical Education Through Nursing Home-Based Experiential Learning. Gerontology & Geriatrics Education. 2013;34(1):60-77. doi:10.1080/02701960.2013.749254.

[2] Institute on Medicine.  HYPERLINK "http://iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx" "Crossing the Quality Chasm: A New Health System for the 21st Century". National Academy Press  HYPERLINK "http://www.nap.edu/books/0309072808/html/" http://www.nap.edu/books/0309072808/html/ (Accessed January 20, 2016).

[3] American Osteopathic Association. Tenets of Osteopathic Medicine,  http://www.osteopathic.org/inside-aoa/about/leadership/Pages/tenets-of-osteopathic-medicine.aspx (Accessed January 20, 2016)










Running Head: Medical Student Lives in a Nursing Home                Corresponding Author: Marilyn R. Gugliucci, PhD


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