Pulse
Aging Not So Gracefully
Medical students learn what it’s like to be an elderly patient by walking in their uncomfortable shoes.
Thirty University of Minnesota medical students are about to fast-forward in time. The students, most of whom are twentysomethings and in their fourth year of medical school, are gathered in a basement conference room at Hennepin County Medical Center (HCMC) to take part in the Aging Game, an experience that gives them an idea of what it can be like to grow old.
James Pacala, M.D., associate professor of family medicine and community health, has been conducting the exercise as part of the primary care clerkship for more than 10 years. Before the game begins, Pacala talks about aging. He explains that in an ideal world, people would be relatively independent and disease free until they’re 100 or 110. However, most elderly people contract chronic diseases—osteoarthritis, hypertension, diabetes, Alzheimer’s disease—that progress as they age. “The vast majority of patients you see on rotation are somewhere along that progression,” Pacala explains. “This is the most common scenario of aging and the most likely thing that will happen to all of us.”
The students then pick a number between 65 and 85 that represents their age at the start of the game. They’re then asked to describe where they live and their three most prized material possessions. Some students get into it right away, taking on names such as “Grammie Clarke” and “Old Man Fred” and talking about their beach house on the California coast or beloved dog and cat. Others quietly put kernels of popcorn in their shoes to simulate the pain of osteoarthritis in their feet and put on an extra pair of sweat socks to get the idea of what it feels like to have swollen feet and ankles.
Earplugs, Goggles, and Splints
The students pass through three stations during the hour-and-a-half-long game. At each, they “age” another five years. At the first one, they’re given earplugs to impair their hearing and a card describing a life-altering event (losing their pet and being ridiculed by the family for their grief, going to a class reunion and feeling embarrassed about not remembering a classmate’s name), after which they may lose or gain a poker chip from a bag they’re given at the start. Different colored chips represent self-esteem or financial assets. Half the group is further disabled. Some are outfitted with leg splints to make walking difficult; others have their arms placed in slings to emulate a frozen shoulder or their hands bound to give them an idea of what it’s like to have the lost dexterity associated with arthritis. All are given goggles covered with plastic film to suggest what it’s like to have cataracts or macular degeneration.
The students are then turned loose on Easy Street, part of the Knapp Rehabilitation Center, which is divided into stations that replicate real-life situations. The students must board a bus with a high step, read the fine print on a menu through their goggles, punch the buttons on an ATM machine with their bound hands, shop for groceries only to be ignored by a high school student posing as a “clerk,” and wedge themselves into a taxi with their splinted legs and frozen shoulders.
The final stop is the basement conference room, which has been transformed into a nursing home. The students are dressed in hospital gowns, some are confined to wheelchairs, and some have marshmallows placed in their mouths to let them know how difficult communication can be for a person who has had a stroke.
The “staff” treat them rudely, talking at them, rather than to them and ignoring their requests. They’re placed in their “rooms” to take a nap, left on the commode, or shepherded to various stations against their will to play Bingo, color, or participate in “recreational therapy”—batting a balloon back and forth. Students show signs of frustration, and many truly look and act old.
A Lasting Experience
Pacala, who plays both a rude nursing assistant and an insensitive doctor during the course of the morning, is a geriatrician as well as an educator in real life. When he joined the faculty in 1992, he was looking for a way to help students understand why elderly patients behave the way they do. At a national meeting, he and a colleague saw a video on the Aging Game that was being done at Duke Medical School in North Carolina. “We decided we wanted to present a Rolls Royce version of the game,” Pacala says.
The following year, third- and fourth-year students in the primary care clerkship were given the option of participating in the game. The experience was so well-received that it became a requirement.
Altogether, about 190 students from the university take part in the game each year. In addition, Pacala has presented an abbreviated version to the staff of UCare Minnesota. Visitors from a number of organizations and medical schools also have come to observe.
One of those who came to watch was Darryl Chutka, M.D., associate professor of medicine at Mayo Clinic College of Medicine. A Mayo medical student had seen a television report about the game and brought it to Chutka’s attention. “I was convinced that our students wouldn’t take it seriously and that it was something we really didn’t need to include in our curriculum. Fortunately, the student persisted and contacted the University of Minnesota and got us invited up there to observe one of the sessions.” Chutka liked what he saw. “I was so impressed with the reality of the situation and how beneficial it was in terms of the educational experience toward the elderly that I decided we needed to include it in our program as well.” Ten years later, first-year Mayo students are still playing the game.
In satisfaction surveys, students at both schools give the exercise high marks. In an article published in the January 2006 Journal of the American Geriatrics Society, Pacala reported that nearly all of the almost 700 students who completed surveys after participating in the game over a 10-year period said they considered the experience extremely valuable and worthwhile. And more than 90 percent rated it as an excellent or very good way of effectively teaching about growing old.
A survey of 84 Mayo students who took part in the game found a statistically significant improvement in their attitude toward caring for the elderly and in their empathy toward elderly patients following the game. “Quite often students come back five years later and ask if we’re still doing this,” Chutka says. “And they tell us, ‘Don’t ever stop.’”
Get Angry or Shut Down
After the University of Minnesota students remove the goggles and earplugs and strip off the hospital gowns and immobilizers, they gather to talk about what they learned.
The students explain that they were frustrated with “being put in the middle of the room and left there,” “being lied to,” and having the staff and the doctors not introduce themselves. They talk about feeling isolated because they couldn’t hear and frustrated because they were separated from friends when the staff wheeled them around the nursing home. “It got depressing. There wasn’t the attention to you as a person,” one student said.
Fourth-year M.D./Ph.D. student Frederick Langheim says the more he was treated like a child, the more child-like he became. “I didn’t realize how much you could influence a patient’s response by the way you treat them.” Pacala emphasizes that while situations and behaviors are purposefully exaggerated to drive home a point, many of the game’s experiences do reflect those observed in clinical settings. He asks the students to think back on their rotations. “I’ll bet you’ve seen patients in wheelchairs slumped over, shutting out the world. I’ll bet you’ve seen patients become argumentative. They wander, they try to leave, they yell, refuse to eat. All of you have seen such patients, and all of you were doing that.”
He explains that such behaviors are not an inherent part of getting old. Rather, they’re normal human reactions to becoming disabled or the way they were being treated. And he reminds the group to do little things that will make a difference: to introduce themselves, to pay attention to sensory deficits, to get down on their patient’s level and look them in the eye, and to understand that it’s going to take more time to work with a disabled, elderly patient than it would with a younger, able-bodied one.
“These aren’t lessons you need to pay $120,000 to learn in medical school,” he says. “These are things you already know.”—Kim Kiser