U med students live among and learn from
By Susan Maas
When a bunch of 20-somethings move into an apartment for senior citizens, someone is inevitably going to worry about disruption and noise.
That’s why 95-year-old Augustana Apartments resident Miriam Manfred is careful about when she plays her piano. “I’m very sensitive that my piano playing won’t disturb the students,” says Manfred, referring to her neighbors in the apartment below hers. “But they say they enjoy it; they’re very affirming. It’s no fun playing the piano if you can’t increase the volume.”
Augustana Apartments in downtown Minneapolis is home not just to hundreds of senior citizens, but also to a growing number of medical students — as well as social work, pharmacy, physical therapy, seminary, and other students — thanks to a novel course developed by Edward Ratner, M.D., associate professor of medicine at the University of Minnesota.
Four years ago, Ratner, an internist specializing in geriatrics, created a yearlong learning opportunity in which University medical students (and starting recently, graduate students in other disciplines) live, study, and socialize among residents of the senior-housing complex.
“The students have longer-term relationships that help them understand the lives of seniors over time, in ways that you don’t get in clinical coursework or episodic [interactions],” Ratner says.
Simply ‘being there’
It’s service learning broadly defined. “Often, we think of service as, ‘I’m going to take blood pressure, or I’m going to give flu shots. Or, I’m learning to be a doctor, I’m gonna volunteer in a free clinic,’” Ratner says. “In this context, we define service as simply being there. I’ve used the term ‘milieu therapy.’ It’s the idea of doing your homework in the lounge, going to game night, going to church services in the building. Asking, ‘Can I pick something up for you at the store?’ Being part of the community, being a neighbor.”
For more than 13 years, Ratner brought groups of students to Augustana on day visits, essentially to conduct comprehensive geriatric assessments. But eventually it became clear to Ratner that the kind of relationships developed in that program — which he calls Seniors as Teachers — could be expanded and deepened, to everyone’s benefit.
“Over the years, the stories got more and more concerning about levels of isolation and frailty,” Ratner recalls. “And I heard that they had a bunch of empty apartments in the building. And students have to live somewhere. So I came up with this idea.
“We wrote a grant, and that first one got rejected — but writing the grant got everybody excited,” Ratner says. Still, the process of creating such an unusual course was a challenge (not least because, like many institutions, the University had shut down its geriatrics division — in 2000).
“Everything else in the Medical School is in two- or four- or six-week blocks. But [in geriatrics] you need to see people over time,” Ratner explains. “So I got the University to agree to a yearlong course — although the expectation is that [the students are] only going to do 80 hours of coursework over the whole year, so it’s only a couple hours a week rather than 40 hours a week.
“Then I had to find students who wanted to do it. And I started to understand why this is not a common model: It’s hard,” Ratner says. Implementing such an unconventional approach to learning, one based on genuine human relationships unfolding in real time, is challenging enough that few — if any — other institutions nationwide are attempting projects like it.
Miriam Manfred’s friend Erin Morcomb, a fourth-year medical student and aspiring family physician, is one of many course participants who’s grateful that Ratner’s course got off the ground. She’s living at Augustana for the third time since January 2011 (she left once to study for boards at home in Rushford, Minn., and once to do a rural hospital rotation in Winona) and has enjoyed her time there immensely.
Dispelling fears and stereotypes
Morcomb and Manfred met through Manfred’s role on the apartment’s welcoming committee, and they bonded over a shared interest in music.
Although she worked in nursing homes and Alzheimer’s care facilities for years before starting medical school, Morcomb says living in a senior apartment complex has been a uniquely fulfilling experience.
“I worked a lot of hours in long-term care, probably 3,000 hours, but I never lived 24/7 with older people,” she says. “And before, it was direct medical services, tasks. Now it’s more companionship. I get to learn more now about [neighbors’] everyday lives and concerns.”
Morcomb sees in some of her young peers an aversion to dealing with elderly patients’ complex medical problems. She’s been asked why she’d want to go into primary care, which would necessitate treating seniors. “Why would you want to be around so much chronic disease and people complaining all the time?” some classmates have wondered.
But Morcomb has always found her interactions with elders rewarding. “People have a lot of fears and stereotypes about this population group,” says Morcomb, but her experiences don’t bear them out. “Seniors are easier to talk to. They talk about more meaningful things,” she says.
Living at Augustana prompted Morcomb to start a volunteer program she calls No One Dies Alone, in which undergraduates and first- and second-year medical students visit with Augustana nursing home residents and hospice patients. She enlisted an Augustana resident, a retired artist with whom she regularly plays Scrabble, to design fliers for it, and she just earned a grant from the University to boost the project.
Ratner’s course, which is supported in part by external foundation grants and by the School of Public Health’s Center on Aging, the U’s Office of Public Engagement, and the Minnesota Area Geriatrics Education Center, has inspired similar projects locally. Three years ago, some Luther Seminary chaplains-in-training began living at Augustana; this fall the apartments are home to three medical students and six students from other disciplines and universities.
There’s no concrete, objective goal for student-residents to accomplish, Augustana social worker Tammy Ferderer says. “It’s, ‘Let’s go play bingo,’ or, ‘Let’s go watch the Twins game down in the TV room.’ Some of the best interactions I’ve seen have been in the laundry room. It’s [about] slowing down and being with seniors,” she says.
The concept of simply spending time with seniors without a checklist of tasks to perform can be tricky for some Westerners to grasp, Ratner believes. He’s noticed that many of his course’s most eager participants are foreign-born students. “Americans don’t always get this; for many students [from other countries], this kind of relationship is not as strange.”
He says that one observation frequently emerges: Our culture, unlike most others the world over, segregates its elders. “The United States is relatively unique even among developed countries in having policies — and government subsidies — that segregate seniors,” says Ratner. “We really don’t allow segregation of any other groups. That segregation of just frail elderly increasingly institutionalizes care; you need more and more staff to support the residents.” One of his hopes is that his students will question that phenomenon and, in the long run, work to change it.
Reflection is key
Ratner emphasizes the importance of reflection and asks each student participant to keep a journal about his or her experiences. One past student, Hanaa al-Khansa Nik Rushdi, wrote touchingly about the joy with which one neighbor received a simple gift of cookies:
“I never expected this surprise. An old man like me getting a surprise.”
Arthur* came to thank me 1 week after we gave away cookies. He is such a sweet old man. I felt a pang of sadness for him that he didn’t think he could get a nice thing this season. Or at anytime for that matter. Why wouldn’t he? I think I will write to him starting the new year.
In another part of her journal, she shared her newfound understanding that, like any other group, the elderly can’t be defined by generalizations.
From the Halvorsons and the Kleckers, who are active and social, to Mrs. Jenkins and Mrs. Felbeck, who need a little more help, it will be important to keep the spectrum in mind when I see patients years from now. I can never go back to thinking of the elderly in one lump group. Not after living here.
If there’s a downside to Ratner’s course, Ferderer says she hasn’t seen it yet. “It’s been a win-win since its inception and it just keeps getting better.” The medical students who lived at Augustana previously and have moved on to residencies around the country still keep in touch with their former neighbors in the apartments, she says.
And Ratner points to another marker of success: “A number of the students have stayed for several years,” he says. “It’s a month-to-month lease — so if [students like Morcomb] stay through their last two years of medical school, it must be working.”
Miriam Manfred couldn’t agree more. “I think it’s wonderful to have intergenerational [living],” she says. “Why not? I’d be all for having babies live here, too. I think this business of having only old people live together ” Manfred trails off, shaking her head. “Why can’t we mix it up?”
Susan Maas is a freelance writer and editor who lives in Minneapolis.
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