Home-visit programs are effective ways to help provide geropsychiatric services to community populations (1). These programs provide access to mental health care for seniors who are unable or unwilling to use traditional healthcare resources. Evidence suggests that outreach may prevent psychiatric hospitalization and institutionalization (1).

Medical students may hold negative attitudes about elderly patients even in their first year of study (2). The Maxwell- Sullivan Attitude Scale (MSAS) (3) assesses physician views about various aspects of geriatric practice. The MSAS has been used to rate medical students (2, 4), and scale items have been demonstrated to change in response to geriatric training (4). Programs succeeding at improving student attitudes toward seniors have utilized contact with well-elderly patients (5), group-discussion sessions (6), and placement in a geriatric practice (4).

We have previously described Beth Israel Medical Center’s home visit program for mentally ill seniors (7). In this program, attending physicians and fellows from our Division of Geriatric Psychiatry work with local agency social workers to evaluate and treat elderly patients in the community. In this study, we hypothesized that medical students who experienced a visit would show more positive attitudes about working with geriatric patients. We also expected that students would find that the home-visit experience had educational value.

Over a period of 3 years, during their required 6-week psychiatry clerkship, third-year students at Albert Einstein College of Medicine (Einstein) were assigned to a home-visit group (N=43) or a control group (N=81). Because we did not know how many home visits would be scheduled during each rotation, we could not strictly randomize students into the two groups. Instead, each student, before the clerkship, was given a number by chance (generally, 1–4, as most students rotate four-at-a-time on psychiatry at both participating hospitals). Student #1 attended the first available home visit; student #2, the second, etc. Because home-visit opportunities were limited, most students were never assigned a visit and, thus, became members of the control group. Surveys, returned on a voluntary basis, were coded to protect the confidentiality of the students. The Office of Educational Affairs at Einstein approved the project. The protocol received an exemption from review by the Institutional Review Board of Beth Israel Medical Center. Training sites included Montefiore Medical Center and Beth Israel Medical Center.

Control participants completed their clerkships as usual in adult inpatient psychiatry. Experience with geropsychiatry patients was generally limited, and the clerkship included one lecture on geriatric psychiatry. Einstein students receive a 2-week geriatric-medicine rotation, generally taken in their fourth year. Students in the home-visit group completed the pre- and post-clerkship geriatric attitude survey, participated in a home visit, and completed a home-visit questionnaire at the end of the rotation. For the home visit, the student accompanied a geropsychiatry attending physician and/or fellow on one scheduled geriatric home assessment. The student conducted the interview and, with consent, contacted the patient’s physician and social worker. The student’s psychiatric report was reviewed by the attending physician.

The Maxwell- Sullivan Attitude Scale (4) was administered to all students before and after their rotation. The MSAS is a 28-item, 5-point, Likert-type survey that measures attitudes toward elderly patients. Responses range from 1: Strongly Agree to 5: Strongly Disagree. Some items are reverse-scored; for example, “Elderly patients need too much attention and sympathy.” The MSAS includes five subscales: General Attitudes, Cost-Effectiveness, Time and Energy, Therapeutic Potential, and Educational Preparation. Most items equate positive attitudes with a willingness to treat seniors.

The 10-item, home-visit questionnaire included 5 usefulness ratings, 1 rating of time commitment, 3 subjective questions regarding the home-visit experience, and 1 section for comments. Ratings of usefulness included 1: Not at all useful; 2: Somewhat useful; 3: Very useful; and 4: Extremely useful.

The Education Preparation subscale of the MSAS had inadequate scoring instructions. Therefore, analysis was done on the four other subscales, and no total score was tallied. A t-test was used to measure differences between the home-visit and control groups at baseline. A paired t-test was used to detect change within groups between baseline and follow-up. An analysis of covariance (ANCOVA) was used to detect group differences at follow-up, controlling for baseline values. To assess baseline attitudes about geriatric patients among the medical students, the significance of the differences in the observed mean from the theoretical mean of 3 (a neutral response), in each MSAS subscale was calculated with a test of location using PROC UNIVARIATE from SAS. For the five closed-ended “usefulness” items on the home-visit questionnaire, mean scores were determined.

Baseline student attitudes toward caring for elderly patients were significantly better than neutral in all subscales of the MSAS. With “3” being neutral on the 1–5 Likert scale, baseline mean scores ranged from 2.01 (General Attitudes) to 2.48 (Cost-Effectiveness) in the control group and from 2.03 (General Attitudes) to 2.48 (Cost-Effectiveness) in the home-visit group. For all comparisons between mean scores and the neutral score, the difference was highly significant, with p<0.0001. The one group differences at baseline was for Time and Energy, where attitudes in the Home Visit group were more positive than in the Control Group (p=0.03). Although both groups trended toward more positive responses, at follow-up, on all subscales, the only significant change from baseline was Time and Energy in the control group (p=0.03). There were no significant group differences in attitudinal changes after controlling for baseline scores.

The responses to our home-visit questionnaire show that students valued this educational activity; mean ratings on most items ranged between Very Useful and Extremely Useful. The highest mean rating was given to the overall home-visit experience: 3.5 out of 4.0. This was followed by Seeing the Home Environment (3.4), Conducting the Psychiatric Evaluation in the Home (3.1), and Contacting/Consulting With Others Involved in the Patient’s Treatment (3.0). The least useful aspect for students was the written report (2.8). Most students (84%) reported that the amount of time involved for the home visit was just right; 9% wanted more time, and 7% reported the visit took too long. All students responded favorably to a question about the experience of seeing an older patient in his or her home. The most common responses focused on two aspects of the visit; 72% mentioned that the experience helped them learn about the daily functioning of the patient, and 35% noted that the patient felt more comfortable in his/her own home.

According to the questionnaire, the home visits did not greatly affect students’ attitudes about working with older adults; 19% reported having equally positive feelings toward seniors before and after the home visit; 23% reported no change in feelings; 9% reported more-positive feelings; and 46% gave no clear response. One student voiced mixed feelings, stating, “I’m more receptive because it was a pleasant experience. On the other hand, it was also depressing, as geriatric patients have to deal with so many age-related problems and death.”

In the Comments section, 27 of the 29 respondents gave positive assessments or made suggestions for program improvements. Suggestions included following up with home-visit patients; increasing the length of the home visit; clarifying the goals of the home visit; and continuing the home-visit program in the future. Two students stated that the visit took too much time.

Our study found no difference between the home-visit group and the control group with respect to attitudinal change about geriatric patients during the psychiatry clerkship. In fact, both groups of students, based on the MSAS subscale scores, held highly positive attitudes about geriatric patients at baseline, in contrast to a study from 1995 (2). As Einstein students have limited formal exposure to geriatric patients before the clerkship, this finding may indicate better acceptance for geriatric work in the last decade. Thus, the MSAS baseline scores left little room to demonstrate significant attitude improvement in either group. Nonetheless, we were unable to demonstrate that a single home-visit experience produced a significant attitude effect. This intervention may simply be insufficient to generate change.

The responses to our home-visit questionnaire show the aspects of the visit that students identified as most educational. Students rated Seeing the Home Environment most useful and Writing the Clinical Report least useful. This finding was reinforced by the students’ comments indicating that, for most participants, the value of the visit resulted from information that students could obtain about the patient’s living situation. Students also recognized that the patient’s comfort level can be enhanced in the home. Although home visits are commonly criticized for being time-intensive, few students raised that concern.

However, the effects produced by this early geriatric exposure remain unclear. Although the majority of our students praised their home-visit experience, only 9% indicated that their overall feeling about geriatric work was more positive after the visit. This may reflect the fact that the home visit was a one-time experience and that most students began with a positive stance. In fact, student comments reflected a desire for more geriatric home visits, more geriatric lectures, and more contact with geriatric medicine providers.

One limitation of our study was the use of the MSAS, which, subsequent to the initiation of this project, has been shown to lack reliability and validity (8) in spite of its sensitivity to attitudinal change. The inadequacy of this scale raises the question: What is the best way to assess our educational efforts in geriatric psychiatry? Better methods might entail measuring specific educational outcomes (8), such as the ability of students to understand and implement geriatric-care plans.

In conclusion, introducing medical students to senior patients in the home environment can enrich geriatric education. In the future, we must refine our assessment of geriatric learning opportunities to truly improve the access of seniors to quality healthcare.

This study was supported by the Grant for Excellence in Medical Education, Albert Einstein College of Medicine.