DOI: 10.1111/j.1741-6612.2012.00620.
Research
Evaluation of a blended learning model in geriatric medicine:
A successful learning experience for medical students
Gustavo Duque
Medical Education Centre, Division of Geriatric Medicine, Discipline
of Medicine, Sydney Medical School Nepean, The University of
Sydney; and Department of Geriatric Medicine, Nepean Hospital,
Sydney, NSW, Australia
Oddom Demontiero
Division of Geriatric Medicine, Discipline of Medicine, Sydney
Medical School Nepean, The University of Sydney; and Department
of Geriatric Medicine, Nepean Hospital, Sydney, NSW, Australia
Sarah Whereat
Medical Education Centre, Sydney Medical School Nepean, The
University of Sydney, Sydney, NSW, Australia
Piumali Gunawardene, Oliver Leung, Peter Webster, Luis Sardinha,
Derek Boersma and Anita Sharma
Department of Geriatric Medicine, Nepean Hospital, Sydney, NSW,
Australia
Background: Despite the increasingly ageing population,
teaching geriatric medicine at medical schools is a challenge
due to the particularities of this subspecialty and the lack of
student interest in this subject.
Methods: We assessed a blended system that combines
e-learning and person-to-person interaction. Our program
offered the students a hands-on learning experience based
on self-reflection, access to technology, interactive learning,
frequent interaction with the multidisciplinary team, more
exposure to patients, and regular feedback.
Results: Our results indicate that the students appreciate
this system as a rich and effective learning experience
demonstrated by their positive feedback and by their
significant improvement in knowledge assessed at the end
of their rotation.
Conclusion: Implementing an interactive blended system is
a beneficial approach to teaching geriatric medicine in
medical schools and to motivating medical students’ interest
in this important medical subspecialty.
Key words: blended, geriatric medicine, medical student,
video game, web-based.
Introduction
The proportion of older people requiring increased medical
care has experienced a dramatic growth worldwide. Unfortu-
nately, this increase in demand for medical care has not been
Correspondence to: Professor Gustavo Duque, Department of
Geriatric Medicine, Nepean Hospital. Email:
gustavo.duque@sydney.edu.au
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© 2012 The Authors
Australasian Journal on Ageing © 2012 ACOTA
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followed by a rise in the number of medical schools imple-
menting teaching programs in geriatric medicine [1]. As a
result, medical students worldwide are graduating without
appropriate exposure to the principles of geriatric medicine
and with only a very limited understanding of the particulari-
ties of geriatric patients, which include challenging character-
istics such as significant functional limitations, multiple acute
and chronic medical diagnoses and a need for a complex
combination of medical and social support services across
hospital, community, rehabilitation and long-term care set-
tings [2].
Given the problem of limited access of medical students to
geriatric medicine, several medical schools have implemented
and evaluated a variety of models designed to facilitate stu-
dents’ learning of geriatric medicine and to increase the
visibility of this subspecialty among medical students and
advanced trainees. These approaches have varied from mul-
tilevel programs for learners in clinical settings [3,4] to clerk-
ships that address medical students’ negative attitudes
towards geriatric medicine [5]. In addition, some programs
have integrated technology as an important teaching and
learning tool [6,7]. In general, these experiences were suc-
cessful in improving students’ knowledge and attitudes,
although remained unsuccessful in increasing students’ inter-
est in pursuing a future career as geriatricians [5,7]. A limi-
tation of these designs in geriatric medicine is that they have
been restricted to either a person-to-person or a fully web-
based model. A structured and effective model combining
web-based and structured face-to-face learning, defined as
‘blended learning’, remained to be explored.
The term ‘blended learning’ is being used with increased
frequency in both academic and corporate circles. In 2003,
the American Society for Training and Development identi-
fied blended learning as one of the top 10 trends to emerge in
the knowledge delivery industry [8]. Blended learning is
defined as the combination of different learning environ-
ments in order to facilitate the acquisition of knowledge and
skills [9]. In medicine, the typical example of blended learn-
ing could be the mixture of e-learning with student–patient–
tutor experience [6] thereby combining two archetypal
learning environments in medicine with expected higher effi-
cacy in terms of students’ learning and fulfilment.
Since 2008, the Division of Geriatric Medicine at Sydney
Medical School Nepean in collaboration with the Depart-
ment of Geriatric Medicine at Nepean Hospital in Penrith,
NSW (Australia) has implemented a blended system during
3rd and 4th year students’ integrated clinical attachment
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 D u q u e G , D e m o n t i e r o
Table 1: A blended model of teaching geriatric medicine to
3rd and 4th year medical students
Blended Model
e-learning Face-to-face learning
Web-based modules Ward rounds
Falls Case conferences
Frailty Meetings with the team: physiotherapy,
Osteoporosis occupational therapy, social worker
Dementia
Delirium Community practice:
Urinary incontinence Nursing home
Pharmacology Home visit
Home visit Paper-based portfolio
Interactive video game
http://www.riskdom.com
(ICA) (equivalent to a clerkship) in geriatric medicine. This
blended system (Table 1) combines a series of web-based
modules, a video game and an intensive exposure to patients
followed by self-reflection and feedback using a paper-based
learning portfolio. The theoretical models used in this unit
included a blended approach complemented with andragogy.
The term ‘andragogy’ refers to the theory that postulates ‘the
attainment of adulthood is marked by adults coming to view
themselves as self-directed individuals’ [10]. This theory is
now widely used as one of the bases of adult learning [11].
Therefore, our system focused upon the principles of stimu-
lation of internal motivation and self-directed learning,
bringing life experiences and knowledge into learning expe-
riences, establishing clear goals and learning objectives,
regular exposure to real practice and respecting the students
as adult learners.
To design this rotation, the authors used and adapted a
learning model previously implemented at another Univer-
sity, which proposed a novel blended approach to teaching
geriatric medicine; however, its effectiveness has never been
assessed [12]. This article reports a comprehensive assess-
ment of this novel learning experience by surveying the stu-
dents’ opinion about the system and assessing students’
learning using a pre- and post-test design.
Methods
Program description
In 2008 the Division of Geriatric Medicine at Sydney Medical
School Nepean (The University of Sydney) in collaboration
with the Division of Geriatric Medicine at Nepean Hospital
implemented a blended model of learning to 3rd and 4th year
medical students during the completion of their four-week
rotation in Geriatric Medicine at Nepean Hospital. This
compulsory blended program was based on the principles
and methodology previously proposed by Duque et al. [12]
and included the following elements (summarised in Table 1):
• Eight web-based interactive modules, covering all the
major geriatric syndromes as well as other important
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Table 2: The 10 basic skills in geriatric medicine (adapted
from Duque et al. [12])
Ten basic skills in geriatric medicine
1. Functional assessment: ADLs and IADLs
2. Diagnosis of cognitive impairment (cognitive assessment)
3. Gait assessment: Timed up and go, gait velocity
4. Identification of mood disorders in older adults
5. Alternative housing decision
6. Nutritional status assessment
7. Medication review with recommendations
8. Pressure ulcer risk assessment with preventive & treatment
recommendations
9. Care plan design with a multidisciplinary team
10. Urinary incontinence assessment with management recommendations
ADL, activities of daily living; IADL, instrumental activities of daily living.
elements for the practice of geriatric medicine. The stu-
dents could complete the required components of each
module in any order, although the sequence of modules
was fixed. The structure and content of the modules was
developed using WebCT (Blackboard, Washington DC,
USA) and included a pre-test, an interactive online
lecture (no longer than 20 minutes) and a post-test.
Additionally, each module included links to more
detailed information so that students could pursue
deeper learning in areas of interest. These hyperlinks
included access to videos on how to perform the most
common elements of the multidimensional geriatric
assessment as well as access to a repository of online
learning resources in geriatric medicine (http://www.
pogoe.com).
• Video game (http://www.riskdom.com): This video
game has been previously validated as an effective edu-
cation tool to teaching medical students about the char-
acteristics of an efficient geriatrics home visit [13]. As
part of the exposure to this video game, and to deter-
mine the level of learning acquired by the students in this
particular unit, the unit included also a pre- and post-test
based on a geriatrics home visit.
• Community practice: In this weekly session, the stu-
dents joined a geriatrician during either a nursing
home or a home visit. The learning objectives of this
session, detailed in their rotation handbook, were to
expose the students to a real-life home visit after inter-
action with a simulated one in the form of a web-
based video game.
• A paper-based portfolio following the principles of a
previously tested electronic portfolio [14]. Students were
required to demonstrate appropriate performance in at
least five of 10 major skills in geriatric medicine
(Table 2). The portfolio report included a section on
comments and action plan that were expected to stimu-
late students’ self-reflection while also demonstrating
a good understanding of the role and value of each one
of those skills within the multidimensional geriatric
assessment.
• Regular bedside teaching rounds and tutor-guided
feedback sessions as well as attendance at outpatients’
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clinics including a falls and fractures clinic, a memory
clinic and a general geriatrics clinic.
• Meetings with the multidisciplinary team: Students
attended a weekly case conference where they interacted
with the multidisciplinary team on a case-by-case basis.
The multidisciplinary team was composed of physicians
and advanced medical trainees, nurses, physiotherapists,
occupational therapists, social workers, nutritionists and
case managers. The role of the members of the multidis-
ciplinary team was explained to the students at their
introductory session. In addition, students had case-
based small group interactive sessions with the physi-
otherapist, occupational therapist and social worker.
Program evaluation
This blended model was evaluated through feedback from
students on their learning experience, specific aspects of the
components of their rotation, the effect of this rotation on
their perceptions about geriatric medicine and the applicabil-
ity of this rotation to the students’ future clinical work.
Students were asked to compare their learning experience in
this rotation with any other rotations they have completed
during their medical program. Feedback surveys addressed
three areas: (i) appropriateness of the components of the
online format; (ii) evaluation of the other components of the
person-to-person format; and (iii) the effect of this rotation
on the students’ perceptions of geriatric medicine. All sec-
tions contained Likert scale responses. Student responses
were tabulated and percentages calculated.
Student evaluation
A pre-to-post evaluation design [15] was used to assess the
effectiveness of each module on students’ learning. As part of
a non-evaluating exercise, students were asked to complete a
pre- and post-knowledge assessment instrument. Students
were also asked to complete pre- and post-tests immediately
prior to and after completion of every web-based module.
The pre-knowledge assessment comprised five one-best
answer (A-type) multiple choice question (MCQ) items (one
key and four distractors), for a maximum score of 5. The
post-knowledge assessment comprised 10 one-best answer
MCQ items, five identical to the pre-test and five new addi-
tional questions closely associated with the learning objec-
tives of the module, for a maximum score of 10. The
knowledge assessment was intended to measure students’
change in knowledge of the subject matter covered in the
modules. The pre- and post-assessment instruments were
available online using the quiz tool function of the learning
management system (Blackboard).
Ethics
In agreement with the National Statement on Ethical
Conduct in Human Research (2007) and following the rec-
ommendations of the University of Sydney Human Research
Ethics Committee (HREC), this study was considered as
‘negligible risk’; thus no HREC application was required.
Nevertheless, students were aware that the data were going
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l e a r n i n g i n g e r i a t r i c m e d i c i n e
to be submitted for publication. Students’ responses were
anonymised using the appropriate function in WebCT.
Statistical analysis
Conventional statistical analysis was made using spss for
Windows 20.0. The P-value represents the comparison
between the two groups after consolidation of the complete
range of results for each one of the categories. Results are
expressed in percentages with a P considered significant if
<0.05.
Results
One hundred and thirty-seven medical students completed
their rotation in geriatric medicine between January 2009
and September 2011. All students (100%) completed their
feedback surveys and their pre- and post-tests.
Students’ self-perception on the appropriateness of the
components of the online format
After completion of their ICA in geriatric medicine, 88% of
the students agreed that WebCT was a useful tool for this
rotation (Figure 1). When the students were asked about
their perceptions of the use of a paper-based portfolio, 68%
agreed that they felt comfortable using it whereas 16% some-
what disagreed with this statement (Figure 1).
Students’ self-perception on the person-to-person
components of the program
Ninety-six per cent of the students agreed that they had
‘sufficient contact with the multidisciplinary team’. Further-
more, 64% agreed that they had ‘sufficient contact with the
community’ whereas 32% disagreed with this statement
(Figure 1).
Change in students’ attitude towards geriatric medicine
Eighty per cent of students agreed that this rotation positively
changed their view of geriatric medicine as a subspecialty
(Figure 2). In addition, and although this was not one of the
objectives of this rotation, we surveyed the students on the
possibility of considering geriatric medicine as a future
career. Twenty-eight per cent agreed that, after completing
their rotation in geriatric medicine, they were considering it
as a future career whereas 32% disagreed with this statement
(Figure 2).
Pre- and post-knowledge assessment scores
Figure 3 summarises the overall mean pre- and post-
knowledge assessment scores for each one of the learning
modules. Paired samples t-test analyses indicated a significant
pre- to post-knowledge increase (P = 0.001) after interaction
with each of the learning modules at the P < 0.05 probability
level.
Discussion
Using a blended model that combines web-based modules,
person-to-person interaction and patient-based learning
activities, we demonstrated that this novel method for
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 D u q u e G , D e m o n t i e r o O , W h e r e a t S e t a l .

Figure 1: Students' self-perception on the online and person-to-person components of the program.

Figure 2: Effectiveness of a blended learning model on changing students' attitude towards geriatric medicine.

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Figure 3: Pre- and post-knowledge assessment scores.
*P < 0.001 indicates a significant pre- vs post-knowledge increase after interaction with the learning module. U. Incontinence, urinary incontinence.
learning and teaching geriatric medicine resulted in a signifi-
cant improvement in students’ knowledge about the major
geriatric syndromes. Equally important, our interactive
method was enhanced students’ learning experience and
changed their perception about geriatric medicine.
The majority of the learning methods utilised in this rotation
have been previously validated. The program includes the
content and structure of an integrated 4-week rotation in
geriatric medicine [12,16], an evaluation portfolio [14] and a
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l e a r n i n g i n g e r i a t r i c m e d i c i n e
web-based interactive video game [13]. This time we have
assessed whether the combination of all these validated
methods is effective as a teaching system that could be easily
implemented at other medical schools.
Clinical rotations in geriatric medicine demand a more
complex infrastructure than other specialties in medicine as
they demand more human resources, several sites of prac-
tice and community resources [15,17,18]. Health profes-
sionals other than physicians play an important role in the
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 D u q u e G ,
care of older people (e.g. nurses, physiotherapists, pharma-
cists, occupational therapists, social workers, speech thera-
pists) and should be involved in teaching students in
geriatric medicine. Students’ interaction with these health
professionals should be a major component of any rotation
in geriatric medicine and demands specific training and atti-
tudes from the latter in order to offer a real learning expe-
rience to the students.
Furthermore, community resources should include visits to
nursing homes and well-implemented programs of home
care. These settings offer students the opportunity to under-
stand first, the range of services available to promote resto-
ration of an independent lifestyle, and second the indications
and benefits of the home visit in the assessment and manage-
ment of older adults. The Riskdom video game has demon-
strated the ability to facilitate both elements of this learning
component [14].
An essential element in curriculum development is the selec-
tion of appropriate teaching methods based on the learning
objectives. In the case of geriatric medicine, teaching methods
have been assessed from a vertical integrated model [19] to a
case-based e-learning experience [7]. In both models, the
content and methodology were defined by the particular
learning objectives and the resources available at each site.
Although these methods have been demonstrated to improve
students’ knowledge acquisition, they have been unsuccessful
in either changing the students’ attitudes towards geriatric
medicine or improving important elements of the standard
geriatric medicine rotation including contact with the multi-
disciplinary team of community practice.
We have combined the most positive aspects of several previ-
ously tested methods in order to develop our novel and
integrated blended system of teaching and learning geriatric
medicine. We combined a set of web-based learning modules
together with ward- and community-based learning as well
as regular interaction with the multidisciplinary team. We
eliminated the use of face-to-face lectures as a teaching
method due to their well-known disadvantages for improving
students learning process. During lectures, students are often
passive because there is no mechanism to ensure that they are
intellectually engaged with the material, their attention
wanes quickly after 15 to 25 minutes, and the information
tends to be forgotten quickly [9,10]. As an alternative, we
designed a whole interactive system in WebCT that included
eight interactive modules combined with a face-to-face expe-
rience during their bedside rounds.
The learning theory used for the design of the students’
exposure to the eight modules was the ‘progressive building
of knowledge’ or scaffolding, regular feedback, self-
evaluation and easy access to additional information, when
required. Based on the students’ feedback and their change in
knowledge, this method provided the students with an
opportunity to interact with the content in a more effective
manner followed by a structured system of in- and out-
hospital learning experiences.
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D e m o n t i e r o O , W h e r e a t S e t a l .
A significant strength of our model is that we facilitated
regular interactions between students, patients, tutors and
members of the multi-disciplinary team. In fact, as the stu-
dents were not required to attend small lectures during their
working time, they had a significant amount of time available
to attend the ward and emergency rounds, which they valued
as real ‘teaching sites’ in their feedback reports. In addition,
some elements of the system were perceived by students as
particularly successful, such as the use of WebCT and inter-
action with the members of the multidisciplinary team. Inter-
estingly, these two methods made this rotation unique and
easy to differentiate from other clinical rotations where these
resources are not available. At the same time, this feedback
confirms our notion that this type of system reinforces the
students’ acceptance of novel learning experiences while
highlighting the particularities of geriatric medicine as an
attractive medical subspecialty.
Conclusions
In conclusion, we used a combination of ‘real life’ practice
exposing the students to the major levels of care in geriatric
medicine while offering them a novel and interactive expo-
sure to curriculum including the theoretical basis of the major
geriatrics syndromes. Future directions include the imple-
mentation of new interactive techniques to facilitate the stu-
dents’ community experience such as electronic portfolios
and logbooks, which could be accessed via mobile phones.
We expect that, as in their in-hospital experience, students
will be able to enhance their learning experience using a
similar blended system in community settings in aged care.
With the worldwide decline in the number of students pursu-
ing geriatric medicine as a subspecialty, interactive learning
techniques are highly recommended to teach and prepare not
only our future physicians but also other members of the
multidisciplinary team who will care for the increasing older
adult population.
Acknowledgements
This study was funded by a Small Teaching Improvement
and Equipment Grants (TIES) medical education grant from
the University of Sydney and a grant from the Nepean
Medical Research Foundation.
Key Points
• Blended systems of learning are effective methods
in medical education.
• Medical students’ learning of geriatric medicine is
facilitated by a combination of technology and
person-to-person interaction.
• Students’ interest in geriatric medicine could be
stimulated by the use of innovative teaching
methods.
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