Vanderbilt University Medical Center Geriatric Medicine Fellowship Program

Transcription

1 VUMC, Geriatric Medicine Fellowship program, page 1 Vanderbilt University Medical Center Geriatric Medicine Fellowship Program The purpose of the Geriatric Medicine Fellowship Program at Vanderbilt University Medical Center and School of Medicine is to produce physicians who provide the best possible care to their patients and make important contributions to field of geriatrics, to healthcare, and to the communities in which they work. Overall Program Goals The Geriatric Medicine Fellowship Program at Vanderbilt University Medical Center and School of Medicine has been designed to enable fellows upon completion of the program to be able to: 1. provide patient care that is compassionate, appropriate, and effective for the promotion of health and the management of health problems related to aging; 2. apply established and evolving knowledge in the biomedical, clinical, and epidemiological sciences as well as related knowledge in the social-behavioral sciences to their care of patients; 3. improve the patient care that they provide by continuously assessing their performance and pursuing learning related to improvement opportunities; 4. effectively exchange information and collaborate with patients, their families, and other health professionals that contributes to effective patient care; 5. conduct their professional life in accordance with the expectations of the profession of medicine and society; 6. function effectively with the system of health care beyond the clinical encounter to call effectively on additional resources to provide optimal health care; 7. pursue an academic career focused on research or teaching, or as a scholarly practitioner. Guided supervision in patient care Because the goal of the Geriatric Medicine Fellowship Program is a physician capable of independent geriatrics practice, each fellow upon completion of the program must have demonstrated the ability to care for geriatrics patients and provide consultation on geriatric matters to colleagues without the need for oversight and modification of their work by faculty. Thus, faculty encourage assumption of independence as expeditiously as

2 VUMC, Geriatric Medicine Fellowship program, page 2 the resident's increasing knowledge and experience and professional maturity permit in keeping with both safe patient care and sound educational principles. The responsibility of the attending physician for the patient is never relinquished but the amount of freedom to make decisions and implement them and the amount and timing of faculty supervision will change depending on an individual fellow's demonstrated performance as judged by on-going faculty review of performance as the fellow progresses through the program. Attendings serve as a resource for fellows and are available (by phone, paging device or in person) to fellows for guidance or assumption of care as is needed. Teaching rounds occur daily, Monday to Friday, for patients on the Inpatient Geriatrics/Consult services. On weekends, all inpatients on the Geriatrics Services are seen daily. Consults are seen as indicated. Physician members of the typical interdisciplinary geriatrics care team consist of a supervising attending, a geriatrics fellow, and often medical resident(s), and medical student(s). In this team, there is a hierarchy of increasing authority and responsibility as experience is gained. For example, the fellow has more authority and responsibility than general medicine residents. Judgments on delegation of responsibility are made by the attending; based on his or her direct observation and knowledge of each fellow s skills and ability. The degree of supervision may vary with the clinical circumstances and the developmental stage of the fellow. Approximately 1 to 3 new consultations/admissions are performed daily and follow-up rounds are made on active patients previously evaluated. Fellows on the service are given a primary role in the performance of new consultations/admissions. Recognizing the educational mission of this fellowship, fellows will not be unduly burdened with a large volume of new consultations and will be provided with sufficient time to evaluate their patients fully and read about the problems posed by the patients they evaluate as well as those seen primarily by others on the service. New consultations/admissions, as well as follow-ups, are presented on daily attending rounds, providing a format for indepth discussion of clinical presentation, pathophysiology, and management. All major clinical decisions are discussed and all plans are reviewed with an attending. Fellows would be expected to develop independent practice in three stages: Stage 1 1. Fellow functions as an integral member of the care team. 2. Fellow sees patient initially. a. Performs complete history and physical examinations on all new in-patients and/or outpatients for whom they have primary responsibility. b. Examines all data related to the management of patients they have evaluated. c. Synthesizes all available information to generate differential diagnoses and subsequent diagnostic and therapeutic plans.

3 VUMC, Geriatric Medicine Fellowship program, page 3 d. Communicates the synthesis of the above information in both an oral and written format to their supervising faculty member. e. Follows-up on all tests and procedures ordered for patients under their care. 3. After all new patients are presented in detail to one of the clinic faculty, he or she then examines the patient, followed by extensive discussion of differential diagnosis proposed approaches, etc. 4. All patients seen in follow-up are also discussed in detail with the faculty member and examined by the faculty member, including review of laboratory findings, x-rays (brought to the clinic as indicated). 5. All records in a particular clinic session are reviewed and a faculty note is written by the attending assigned to supervise the clinical setting. Stage 2 1. Fellow functions as an integral member of the care team. 2. Fellow sees patient initially. a. Performs complete history and physical examinations on all new in-patients and outpatients for whom they have primary responsibility. b. Examines all data related to the management of patients they have evaluated. c. Synthesizes all available information to generate differential diagnoses and subsequent diagnostic and therapeutic plans. d. Communicates the synthesis of the above information in both an oral and written format to their supervising faculty member. e. Provides direct care of patients including all order writing, test ordering, and documentation f. Follows-up on all tests and procedures ordered for patients under their care. 3. After a synthesis of data for each new and follow-up patient is presented to one of the clinic faculty and patients are examined by the clinic faculty, extensive discussion of each patient ensues. 4. All records in a particular clinic session are reviewed and a faculty note is written by the attending assigned to supervise the clinical setting. Stage 3 1. Fellow functions as an integral member of the care team. 2. Fellow sees patient initially. a. Performs complete history and physical examinations on all new in-patients and outpatients for whom they have primary responsibility. b. Examines all data related to the management of patients they have evaluated. c. Synthesizes all available information to generate differential diagnoses and subsequent diagnostic and therapeutic plans. d. Communicates the synthesis of the above information in written format in the medical record. e. Provides directs care of patients including all order writing, test ordering, relevant procedures and documentation. f. Follows-up on all tests and procedures ordered for patients under their care.

4 VUMC, Geriatric Medicine Fellowship program, page 4 3. After the essential information for each new and follow-up patients is presented to one of the clinic faculty and the patient is examined by the clinic faculty, discussion of each patient ensues. 4. All records in a particular clinic session are reviewed and a faculty note is written by the attending assigned to supervise the clinical setting. Geriatric Medicine Clinical Fellowship Clinical Competency Committee This committee is charged to evaluate the fellow s clinical competency in his composed of the program director in 2 faculty. This committee meets quarterly to evaluate each fellow and training and recommendations are made to the fellow as part of the program directors quarterly summative evaluation of the fellow. Geriatric Medicine Clinical Fellowship Program Evaluation Committee This committee is charged to evaluate the training program at least yearly. Is it is composed of all current Fellows, the program director and 2 faculty. Recommendations from this committee are made to the annual program review attended by all faculty. The Geriatric Medicine Clinical Fellowship program at Vanderbilt consists of one year duration. Vanderbilt University Medical Center is committed to education, research and clinical care in geriatrics. It has a long history of aging research, education and a multidisciplinary approach to the care of the elderly. A multi-campus clinical program with a primary care and referral base population confirm the community s confidence in geriatric care at Vanderbilt. The University s development of an Institute in Geriatrics complements the clinical program offering fellows a unique environment reflecting quality of instruction and examples of excellent and compassionate care. CLINICAL TRAINING: A combination of longitudinal, block and elective opportunities provide a broad educational perspective. 1. Longitudinal experience: The Senior Care Service at both Vanderbilt and the Nashville Veteran s Hospital provide continuity outpatient experiences in primary and referral geriatric care. Fellows may also follow long-term care patients longitudinally as part of the training experience, and participate in an ongoing scholarly project. 2. Block Rotations: The Vanderbilt ACE inpatient unit and the VA skilled inpatient GEM unit provide experiences in inpatient geriatric care as a member of interdisciplinary geriatric teams. Vanderbilt Stallworth Rehabilitation Hospital provides a concentrated experience in rehabilitation medicine. Three long term care sites including the Murfreesboro VA Long Term Care Unit, Trevecca Health Care Center, and Bethany Health Care Center, offer a wealth of long term care experiences. The geropsychiatry rotation includes exposure to inpatient geriatric units, outpatient care, and state hospital patients. Community resources include the Vanderbilt Home Care Agency, Senior Citizens Inc., the Middle Tennessee Alzheimer s Association, the Nashville Council on Aging, Centennial Adult Day Care, and Memory Works day program. Special educational experiences are

5 VUMC, Geriatric Medicine Fellowship program, page 5 available in neurology, rheumatology, nutrition, urology, and other selective experiences. 3. Research: A block educational program in research methodology, statistics and data management is offered in conjunction with the Department of Preventive Medicine and Division of General Medicine. Over twenty active investigators in biomedical, clinical, epidemiology, and public health fields serve as mentors to fellows. In addition to longitudinal experiences fellows spend approximately ten weeks in each acute care setting, one month in geriatric psychiatry, and the remainder in rotations in long term care, community based and research electives. ACADEMIC PROGRAM: Formal didactic experiences include departmental grand rounds and research seminars and conferences, journal club, mini courses (2-5 sessions with fellow and faculty participation), monthly meetings with the program director, programmatic and faculty evaluations, and additional academic activities specific to individual rotations. PHILOSOPHY: Vanderbilt Geriatric Fellowship Program trains leaders in geriatric care with special emphasis on teaching, program development, and team function. The collaborative multi-disciplinary, multi-campus program coordinated through a cooperative arrangement with Vanderbilt University, Meharry Medical College, and the Veterans Administration provide a rich and fulfilling geriatric educational environment. Rotations/assignments A. Geriatrics Acute Care Inpatient Service The Senior Care Service at Vanderbilt Acute Care for the Elderly (ACE) and Nashville VA Hospitals Geriatric Evaluation and Management (GEM) are active services providing acute and restorative care including evaluation and management of hospitalized inpatients as well as consultation services. Many of the patients are followed by the respective Senior Care Services in the outpatient department on discharge. An interdisciplinary team model guides the rotation and clinical care.

6 VUMC, Geriatric Medicine Fellowship program, page 6 Learning objectives: 1 1. To demonstrate his or her ability to apply medical knowledge about frail elderly inpatients with multiple comorbidities during the clinical encounter, a fellow would be expected to describe and discuss application to practice of: a. The signs and symptoms of geriatric illness and syndromes (MK) b. The distinguishing features of the various presentations of illness in frail elderly inpatients with multiple comorbidities (MK) c. The indications for inpatient versus outpatient evaluation and treatment (MK) d. The basic principles of geriatric pharmacotherapy, as well as common side effects and drug-drug interactions (MK) e. Pathogenesis, symptoms, signs, typical clinical course, and management of geriatric syndromes with a recognition of which are most common. f. Imaging and interventional techniques used in evaluating frail elderly inpatients with multiple comorbidities (MK) g. The bioethical, social, and legal issues concerning patient confidentiality and vulnerability in frail elderly inpatients with multiple comorbidities (MK) 2. To demonstrate his or her ability to diagnose frail elderly inpatients with multiple comorbidities during the clinical encounter, a fellow would be expected to: a. Obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease (PC, MK, CS) b. Perform a physical exam to establish the diagnosis and severity of disease (PC, MK) c. Generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology in frail elderly inpatients with multiple comorbidities (PC, MK) d. Access and use appropriate information systems and resources to help delineate issues related to care of frail elderly (PC, MK) e. Define indications for, order, and interpret results of diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis, justify ordering them, including consideration of test cost and performance characteristics as well as patient preferences (PC, MK) f. Perform basic procedural skills (PC) g. Identify the patient s problem(s) from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients (PC, MK) h. Communicate the diagnosis to frail elderly inpatients with multiple comorbidities and their caregivers in a caring and compassionate way, recognizing the impact that the diagnosis has on a patient s duration and quality of life, well-being, functional ability, and family (CS, P, MK) 1 Each learning objective is categorized as one or more of the ACGME core competencies in parentheses after the objective statement. Abbreviations for each of the core competencies are as follows: PC = Patient Care, P = Professionalism, MK = Medical Knowlede, PBLI = Practice-Based Learning and Improvement, CS = Communication Skills, SBP = Systems-Based Practice

7 VUMC, Geriatric Medicine Fellowship program, page 7 3. To demonstrate his or her ability to manage frail elderly inpatients with multiple comorbidities based on the patient s identified problem, a fellow would be expected to: a. Develop an appropriate treatment plan for frail elderly inpatients with multiple comorbidities 1) Following parameters of disease progression/activity. (PC, MK) 2) Monitor for the development of side effects from treatment including testing and drug-drug interactions (PC, MK) 3) Incorporate patient preferences in clinical decision making (PC,P, CS) 4) Use risk-benefit, cost-benefit, and evidence-based considerations in the selection of diagnostic and therapeutic interventions for frail elderly inpatients with multiple comorbidities (PLI, P, SBP) 5) Respond in a caring and compassionate way to elderly patients and caregivers (CS, P) b. Draw on the expertise of other health care professions in the treatment of frail elderly inpatients with multiple comorbidities and function effectively as the physician member of the interdisciplinary team (P, SBP) c. Consider use of consultants when necessary and referral to specialists, including psychological support, if indicated (PC, SBP) d. Access and use appropriate information systems to ascertain information about health system and community resources (SBP) e. Record, present, research, critique, and manage information about the patient and clinical decision-making (PC) f. Communicate with the patient and his or her family in a caring and compassionate manner that facilitates understanding of the diagnosis, treatment plan, subsequent follow-up plan, rehabilitation measures and prognosis (PC, CS) g. Review performance, identify opportunities for improvement, and pursue learning activities focused on improvement that include, but are not limited to reading, conversations with attending and peers, and participation in formal educational activities offered by the fellowship program or other educational organizations (PBLI, P) Supervision and Assessment: All fellows are directly supervised by one of the full-time Geriatrics faculty members who serve as attendings on the Geriatrics inpatient services. Attendings round with the team daily, and each attending who has worked with a fellow for > 1 week duration must complete an on-line evaluation of the fellow through the Department of Medicine s website after each fellow s rotation. The on-line evaluation scores the fellow s performance in each of the six core competencies. Completed evaluations are provided to the fellow by, and discussed with, the Director of the Training Program during scheduled evaluations. In addition, fellows may choose to perform their mini-cex with a provider on this service. Two completed mini-cex evaluations are required each academic year. In addition, interdisciplinary team members complete a 360 degree evaluation of each fellow following the rotation. This evaluation focuses on professionalism, communications skills, and systems based practice competencies.

8 VUMC, Geriatric Medicine Fellowship program, page 8 B. Vanderbilt Geriatric Medicine Consult Service A fellow and an attending are assigned to the consult service. The goal of this portion of the Geriatric Medicine fellowship is to produce expert clinicians in the field of inpatient consultative geriatric medicine who can provide care for elderly patients as a consultant, providing expert assessments and recommendations in the unique care needs of elderly hospitalized patients. The fellow is exposed to and taught the benefits of, and need for, an interdisciplinary team approach inherent in a consultative service to delivery of care for the elderly hospitalized patient with multiple Geriatric Syndromes. Learning objectives: 2 1. To demonstrate his or her ability to apply medical knowledge about geriatrics, a fellow would be expected to describe and discuss: a. Describe and be able to discuss topics of special interest to geriatric patients, including but not limited to cognitive impairment, delirium, depression, falls, incontinence, osteoporosis, fractures, sensory impairment, pressure ulcers, sleep disorders, pain, malnutrition, and functional impairment. (MK) b. Demonstrate expertise in Geriatric assessment, including medical, affective, cognitive, functional status, social support, economic, and environmental aspects related to health; activities of daily living (ADL); the instrumental activities of daily living (IADL); this includes the appropriate use of the history; physical and mental examination; and laboratory. (MK) c. Current scientific knowledge of aging and longevity, including theories of aging, the physiology and natural history of aging, pathologic changes with aging, epidemiology of aging populations, and diseases of the elderly. (MK) 2. To demonstrate his or her ability to diagnose a wide variety of acute and chronic geriatric problems in hospitalized adult patients, a fellow would be expected to: a. Obtain, document and present an age-appropriate medical history that differentiates among etiologies of a variety of clinical presentations (PC, MK, CS) b. Perform a physical exam to establish the diagnosis and severity of disease (PC, MK) c. Generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology (PC, MK) 2 Each learning objective is categorized as one or more of the ACGME core competencies in parentheses after the objective statement. Abbreviations for each of the core competencies are as follows: PC = Patient Care, P = Professionalism, MK = Medical Knowledge, PBLI = Practice-Based Learning and Improvement, CS = Communication Skills, SBP = Systems-Based Practice

9 VUMC, Geriatric Medicine Fellowship program, page 9 d. Access and use appropriate information systems and resources to help delineate issues related to geriatrics (PC, MK) e. Define indications for, order, and interpret results of diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis, justify ordering them, including consideration of test cost and performance characteristics as well as patient preferences (PC, MK) f. Perform basic procedural skills (PC) g. Identify the patient s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients (PC, MK) h. Communicate the diagnosis in a caring and compassionate way, recognizing the impact that the diagnosis has on a patient s quality of life, well-being, ability to work, and family (MK, P, CS) 3. To demonstrate his or her ability to manage geriatric consult patients, a fellow would be expected to: a. Develop an appropriate treatment plan based on the patient s identified problem. 1) Incorporate patient preferences in clinical decision making. (PC, P, CS) 2) Access and use appropriate information systems to ascertain information about health system and community resources. (SBP) 3) Use risk-benefit, cost-benefit, and evidence-based considerations in the selection of diagnostic and therapeutic interventions. (PBLI, P) b. Record, present, research, critique, and manage information about the patient and clinical decision-making. (PC) c. Communicate with the patient and his or her family in a caring and compassionate manner that facilitates understanding of the diagnosis, treatment plan, subsequent follow-up plan, preventive measures and prognosis (PC, CS) d. Communicate with the physician who requested the consultation concisely in a written report that reviews results of the history and physical examination, laboratory and imaging data and then formulates a differential diagnosis and recommendations for treatment. (CS, P) e. Review performance, identify opportunities for improvement, and pursue learning activities focused on improvement that include, but are not limited to reading, conversations with attending and peers, and participation in formal educational activities offered by the fellowship program or other educational organizations. (PBLI, P) f. Provide leadership and teacher for residents and medical students rotating on the consult service. (P) Supervision and Assessment: All fellows are directly supervised during each four-week rotation by one of the full-time Geriatrics faculty members who serve as attending on this services. Attendings round with the team daily, and each attending who has worked with a fellow for > 1 week duration must complete an on-line evaluation of the fellow through the Department of Medicine s website after each fellow s 4-week long rotation. The on-line evaluation

10 VUMC, Geriatric Medicine Fellowship program, page 10 scores the fellow s performance in each of the six core competencies. Completed evaluations are provided to the fellow by, and discussed with, the Director of the Training Program during scheduled evaluations. In addition, fellows may choose to perform their mini-cex with a provider on this service. Two completed mini-cex evaluations are required each academic year. C. Geropsychiatry Service The Geriatric Psychiatry Services maintains inpatient, outpatient and consultation services as part of the fellowship program in Geriatric Psychiatry. Geriatric Medicine residents will spend a one-month block in Geriatric Psychiatry with experiences in psychiatric management of older patients across the care continuum. This is multicampus rotation; 50% inpatient and 50% outpatient. Learning objectives: 3 1. To demonstrate his or her ability to apply medical knowledge concerning Geropsychiatry, a fellow would be expected to describe and discuss: a. Contemporary approaches to the outpatient management of the broad spectrum of mental disease in the elderly, including the role of the outpatient clinic, partial hospitalization, and home health services. (MK) b. The integration of psychosocial and biological forms of therapeutic interactions, and the role of psychotherapeutic techniques and individual, group, and family settings. (MK) c. Diagnostic evaluation, pharmacotherapy, brief focused psychotherapy, neuropsychological evaluation, and family counseling. (MK) d. Formal and informal psychiatric consultation (including a detailed medicalpsychiatric and social development history, comprehensive neuropsychiatric mental state delineation and description, and physical exam pertinent to the differential diagnosis. (MK) e. Ongoing psychiatric liaison to the treatment team. (MK) f. Complex psychopharmacologic management of outpatients; learning when referral is appropriate to psychiatric services, such as the Inpatient Service; and may include specialized counseling (e.g., to concerned caregivers, driving, early dementia, levels of care, community resources, hearing and vision loss). (MK, SBP, C) 3 Each learning objective is categorized as one or more of the ACGME core competencies in parentheses after the objective statement. Abbreviations for each of the core competencies are as follows: PC = Patient Care, P = ProfessionalismMK = Medical Knowledge, PBLI = Practice-Based Learning and Improvemen, tcs = Communication Skill, ssbp = Systems-Based Practice

11 VUMC, Geriatric Medicine Fellowship program, page To demonstrate his or her ability to diagnose psychiatric conditions in geriatric patients a fellow would be expected to: a. Obtain, document and present an age-appropriate medical history that differentiates among etiologies of a variety of clinical presentations (PC, CS, MK) b. Perform a physical exam, mental status exam, and psychiatric interview to establish the diagnosis and severity of disease (PC, MK) c. Generate a prioritized differential diagnosis (PC, MK) d. Access and use appropriate information systems and resources to help delineate issues related to psychiatric conditions in geriatric patients (PC, MK) e. Define indications for, order, and interpret results of diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis, justify ordering them, including consideration of test cost and performance characteristics as well as patient preferences (PC, MK) f. Identify the patient s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients (PC, MK) g. Communicate the diagnosis in a caring and compassionate way, recognizing the impact that the diagnosis has on a patient s quality of life, well-being, ability to work, and family (CS, P, MK) 3. To demonstrate his or her ability to manage patients with psychiatric disease, a fellow would be expected to: a. Develop an appropriate treatment plan based on the patient s identified problem. 1) Incorporate patient preferences in clinical decision making (PC,P,CS) 2) Access and use appropriate information systems to ascertain information about health system and community resources (SBP) 3) Use risk-benefit, cost-benefit, and evidence-based considerations in the selection of diagnostic and therapeutic interventions (PBLI, P) b. Record, present, research, critique, and manage information about the patient and clinical decision-making c. Communicate with the patient and his or her family in a caring and compassionate manner that facilitates understanding of the diagnosis, treatment plan, subsequent follow-up plan, preventive measures and prognosis, with special emphasis on risks of exposure in the hospital, at home, and in the community (PC, CS) d. Communicate with the transplant team concisely in a written report that summarizes the diagnosis and treatment (CS, P) e. Review performance, identify opportunities for improvement, and pursue learning activities focused on improvement that include, but are not limited to reading, conversations with attending and peers, and participation in formal educational activities offered by the fellowship program or other educational organizations. (PBLI, P) Supervision and Assessment: All fellows are directly supervised during each rotation by a Geriatric Psychiatrist.

12 VUMC, Geriatric Medicine Fellowship program, page 12 Resident performance is evaluated on a daily basis by all faculty who come in contact with him/her. These impressions are subsequently translated into a written evaluation, which is submitted upon completion of each rotation, generally quarterly, or semiannually from individual supervisors who are assigned to the resident for the whole year. These evaluations are reviewed upon receipt by the Geriatric Medicine Training Director. Unless one is unsatisfactory, these evaluations are compiled in the residents personnel file, and reviewed semi-annually in a formal, scheduled meeting between the Geriatric Medicine Training Director and the resident. The resident has an opportunity to review each evaluation, and may have copies if requested. Faculty members are encouraged to share their evaluations with the resident at the time they are made. D. Hospice and Palliative Care It is crucial for geriatric fellows to gain experience in evaluation and treatment of terminal patients, to understand pain and symptom management, and to appreciate the importance of palliative care in advanced disease processes. Death is a natural part of life. We believe that every person is entitled to participate fully in this part of life and to prepare for death in a way that is personally satisfying. Hospice and palliative care exist not to postpone death, but with special skills and therapies, to help the patient and family live as fully as possible. Death is not denied. Life is affirmed and lived until death comes. We believe that we are all dependent on one another. Therefore, it is crucial, in the last few months of life, to help develop a caring community that can provide comprehensive services to patients and their families. Hospice and palliative care is a special kind of care for dying people, their families and their caregivers that: Treats the physical needs of patients and their emotional and spiritual needs. Takes place in the patient s home, or in a home-life setting. Concentrates on making patients as free of pain and as comfortable as they want to be so they can make the most of the time that remains to them. Considers helping family members an essential part of its mission. Believes the quality of life to be as important as the length of life. Learning objectives: 4 1. To demonstrate his or her ability to apply medical knowledge about palliative care, a fellow would be expected to describe and discuss: 4 Each learning objective is categorized as one or more of the ACGME core competencies in parentheses after the objective statement. Abbreviations for each of the core competencies are as follows: PC = Patient Care, P = ProfessionalismMK = Medical Knowledge, PBLI = Practice-Based Learning and Improvemen, tcs = Communication Skills, SBP = Systems-Based Practice

13 VUMC, Geriatric Medicine Fellowship program, page 13 a. Presentation of palliative care (including hospice) as a positive, active treatment option for a patient with advanced disease (MK) a. Describe the social, cultural, and spiritual context of terminal illness (MK) b. Identify the psychological, social, and spiritual needs of patients with advanced illness and their family members, and link these identified needs with the appropriate interdisciplinary team members (MK) c. Effective communication with terminal patients and caregivers (MK, CS) d. Accurately identify clinical situations where life expectancy, functional status, patient preference or goals of care should override standard recommendations for screening tests in older adults (MK) e. Assessment and management of pain and key non-pain symptoms based on patient s goals of care (MK) f. The definition and differences among types of code status, health care proxies, and advanced directives in the state where one is training (MK) g. The continuum of palliative care delivery in different levels of care (MK, SBP) 2. To demonstrate his or her ability to diagnose terminal illness, a fellow would be expected to: a. Obtain, document and present an age-appropriate medical history, which special focus on psycho-social issues deriving from military service, that differentiates among etiologies of a variety of clinical presentations (PC, CS, MK) b. Perform a physical exam to establish the diagnosis and severity of disease (PC, MK) c. Generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology (PC, MK) d. Access and use appropriate information systems and resources to help delineate issues related to palliative care and terminal illness (PC, MK) e. Define indications for, order, and interpret results of diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis, justify ordering them, including consideration of test cost and performance characteristics as well as patient preferences and quality of life (PC, MK) f. Identify the patient s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients (PC, MK) g. Communicate the diagnosis in a caring and compassionate way, recognizing the impact that the diagnosis has on a patient s quality of life, well-being, ability to work, and family (CS, P, MK) 3. To demonstrate his or her ability to manage patients with terminal disease, a fellow would be expected to: a. Develop an appropriate treatment plan based on the patient s identified problem. 1) Incorporate patient preferences in clinical decision making (PC,P, CS) 2) Access and use appropriate information systems to ascertain information about health system and community resources (SBP)

14 VUMC, Geriatric Medicine Fellowship program, page 14 3) Use risk-benefit, cost-benefit, and evidence-based considerations in the selection of diagnostic and therapeutic interventions (PBLI, P) b. Record, present, research, critique, and manage information about the patient and clinical decision-making (PC) c. Communicate with the patient and his or her family in a caring and compassionate manner that facilitates understanding of the diagnosis, treatment plan, subsequent follow-up plan, comfort measures and prognosis (PC, CS) d. Demonstrate proficiency in pain and symptom management for hospice and palliative care patients e. Review performance, identify opportunities for improvement, and pursue learning activities focused on improvement that include, but are not limited to reading, conversations with attending and peers, and participation in formal educational activities offered by the fellowship program or other educational organizations. (PBLI, P) f. Provide leadership to a team of health care providers (P) Supervision and Assessment: All fellows are directly supervised during each rotation by one of the full-time Geriatrics or Palliative Care faculty members. Attendings interact with the fellow daily, and each attending who has worked with a fellow for > 1 week duration must complete an on-line evaluation of the fellow through the Department of Medicine s website after each fellow s 4-week long rotation. The on-line evaluation scores the fellow s performance in each of the six core competencies. Completed evaluations are provided to the fellow by, and discussed with, the Director of the Training Program during scheduled evaluations. In addition, fellows may choose to perform their mini-cex with a provider on this service. Two completed mini-cex evaluations are required each academic year. E. Outpatient Care The Senior Care Services at both Vanderbilt and the Nashville VA have large primary care and specialty geriatric outpatient practices. Fellows and residents participate in a collaborative practice with geriatricians, nurse practitioners and social workers as well as other members of the geriatric team in the longitudinal care of elderly outpatients. Fellows participate three half days weekly in each clinic. Both block and longitudinal second clinic experiences are available for resident trainees. Learning objectives: 5 1. To demonstrate his or her ability to apply medical knowledge about outpatient care for geriatric patients, a fellow would be expected to describe and discuss: 5 Each learning objective is categorized as one or more of the ACGME core competencies in parentheses after the objective statement. Abbreviations for each of the core competencies are as follows: PC = Patient Care, P = Professionalism, MK = Medical Knowledge, PBLI = Practice-Based Learning and Improvement, CS = Communication Skills, SBP = Systems-Based Practice

15 VUMC, Geriatric Medicine Fellowship program, page 15 a. Topics of special interest to geriatric patients, including but not limited to cognitive impairment, delirium, depression, falls, incontinence, osteoporosis, fractures, sensory impairment, pressure ulcers, sleep disorders, pain, malnutrition, and functional impairment. (MK) b. Current scientific knowledge of aging and longevity, including theories of aging, the physiology and natural history of aging, pathologic changes with aging, epidemiology of aging populations, and diseases of the elderly. (MK) c. Appropriate patient criteria for comprehensive geriatric assessment (MK, SBP) d. Outpatient geriatric syndrome evaluation and management (i.e. osteoporosis, incontinence, dementia, frailty, falls, decubiti, polypharmacy, weight loss, caregiver support) (MK) 2. To demonstrate his or her ability to diagnose a wide variety of acute and chronic diseases in geriatric out-patients, a fellow would be expected to: a. Obtain, document and present an age-appropriate medical history in a timely way that differentiates among etiologies of a variety of clinical presentations (PC, CS, MK) b. Demonstrate expertise in Geriatric assessment, including medical, affective, cognitive, functional status, social support, economic, and environmental aspects related to health; activities of daily living (ADL); the instrumental activities of daily living (IADL); this includes the appropriate use of the history; physical and mental examination; and laboratory. (MK) c. Perform a physical exam, mental status exam, and functional assessment in a timely way to establish the diagnosis and severity of disease (PC, MK) d. Generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest a specific etiology (PC, MK) e. Access and use appropriate information systems and resources to help delineate issues related to acute and chronic disease in geriatric outpatients (PC, MK) f. Define indications for, order, and interpret results of diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis, justify ordering them, including consideration of test cost and performance characteristics as well as patient preferences (PC, MK) g. Perform basic procedural skills (PC) h. Identify the patient s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients (PC, MK) i. Communicate the diagnosis in a caring and compassionate way, recognizing the impact that the diagnosis has on a patient s quality of life, well-being, ability to work, and family (CS, MK) 3. To demonstrate his or her ability to manage a wide variety of acute and chronic diseases in geriatric out-patients, a fellow would be expected to: a. Develop an appropriate treatment plan based on the patient s identified problem. 1) Incorporate patient preferences in clinical decision making (PC, P, CS)

16 VUMC, Geriatric Medicine Fellowship program, page 16 2) Access and use appropriate information systems to ascertain information about health system and community resources (SBP) 3) Use risk-benefit, cost-benefit, and evidence-based considerations in the selection of diagnostic and therapeutic interventions (PBLI, P) b. Record, present, research, critique, and manage information about the patient and clinical decision-making (PC) c. Communicate with the patient and his or her family in a caring and compassionate manner that facilitates understanding of the diagnosis, treatment plan, subsequent follow-up plan, preventive measures and prognosis (PC, CS) d. Review performance, identify opportunities for improvement, and pursue learning activities focused on improvement that include, but are not limited to reading, conversations with attending and peers, and participation in formal educational activities offered by the fellowship program or other educational organizations. (PBLI, P) Supervision and Assessment: Fellows in the clinics are directly supervised by full-time faculty members within the Department of Medicine. Attendings must be present during the entire duration of the clinic visit while fellows are seeing patients in the clinics. Each attending who has worked with a fellow must complete an on-line evaluation of the fellow through the Department of Medicine s website at the end of the fellowship experience. The on-line evaluation scores the fellow s performance in each of the six core competencies. Completed evaluations are provided to the fellow by, and discussed with, the Director of the Training Program during scheduled evaluations. In addition, fellows may choose to perform their mini-cex with a provider on this service. Two completed mini-cex evaluations are required each academic year. F. Long Term Care All fellows must show proficiency in the care of elderly patients in the long term care setting. Geriatric fellows are exposed to management skills in rehabilitation and restorative care. Additionally they learn to work as a member of the interdisciplinary team, participating in family conferences, discharge planning, and quality improvement meetings. Fellows rotate 8 weeks in long term care under the direction of faculty geriatricians. Learning objectives 6 : 1. To demonstrate his or her ability to apply medical knowledge about Long Term Care, a fellow would be expected to describe and discuss application to practice: 6 Each learning objective is categorized as one or more of the ACGME core competencies in parentheses after the objective statement. Abbreviations for each of the core competencies are as follows: PC = Patient Care, P = Professionalism, MK = Medical Knowledge, PBLI = Practice-Based Learning and Improvement, CS = Communication Skills, SBP = Systems-Based Practice

17 VUMC, Geriatric Medicine Fellowship program, page 17 a. Principles of subacute and rehabilitation care (for example: post stroke, status post orthopedic surgery) (MK) b. Complex wound care c. Geriatric Assessment in Long Term Care (for example: assessment of functional status, nutritional assessment, provisional of restorative care) (MK, SBP) d. Levels of care (MK, SBP) e. Behavioral problems in dementia (MK) f. Nutritional care of the Long Term Care Patient (MK) 2. To demonstrate his or her ability to diagnose problems encountered in Long Term Care Patients, a fellow would be expected to: a. Obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease (PC, CS, MK) b. Perform a physical exam to establish the diagnosis and severity of disease, including (PC, MK) c. Generate a prioritized differential diagnosis recognizing specific history and physical exam, mental status, and functional assessment findings (PC, MK) d. Access and use appropriate information systems and resources to help delineate issues related to illness encountered in Long Term Care (PC, MK)

18 VUMC, Geriatric Medicine Fellowship program, page 18 e. Define indications for, order, and interpret results of diagnostic and laboratory tests both prior to and after initiating treatment, based on the differential diagnosis, justify ordering them, including consideration of test cost and performance characteristics as well as patient preferences (PC, MK) f. Perform basic procedural skills (PC) g. Identify the patient s problem from all of the problems listed in the differential diagnosis by combining scientific knowledge, information obtained in the clinical encounter and collective experience with similar patients (PC, MK) h. Communicate Long Term Care needs and diagnoses in a caring and compassionate way, recognizing the impact that the diagnosis has on a patient s quality of life, well-being, survival, and family (CS, PC, MK) i. Participate in medical directorship responsibilities (infection control, care planning, team leadership, quality improvement, policy development, regulatory review) (MK, SBP, PBLI) 3. To demonstrate his or her ability to manage a panel of Long Term Care patients, a fellow would be expected to: a. Develop an appropriate treatment plan for Long Term Care patients b. Draw on the expertise of other health care professions in the treatment of patients with HIV infection and its complications c. Consider use of consultants when necessary and referral to specialists, including psychological support, if indicated (PC, SBP) d. Access and use appropriate information systems to ascertain information about the health care system and community resources (SBP) e. Record, present, research, critique, and manage information about the patient and clinical decision-making f. Communicate with the patient and his or her family in a caring and compassionate manner, with appropriate cultural sensitivity, that facilitates understanding of the diagnosis, treatment plan, subsequent follow-up plan, rehabilitation measures and prognosis (PC, CS) g. Review performance, identify opportunities for improvement, and pursue learning activities focused on improvement that include, but are not limited to reading, conversations with attending and peers, and participation in formal educational activities offered by the fellowship program or other educational organizations. (PBLI, P) Supervision and Assessment: Fellows in the nursing home are directly supervised by full-time faculty members within the Department of Medicine. Each attending who has worked with a fellow must complete an on-line evaluation of the fellow through the Department of Medicine s website at the end of the fellowship experience. The on-line evaluation scores the fellow s performance in each of the six core competencies. Completed evaluations are provided to the fellow by, and discussed with, the Director of the Training Program during scheduled evaluations. In addition, fellows may choose to perform their mini-cex

19 VUMC, Geriatric Medicine Fellowship program, page 19 with a provider on this service. Two completed mini-cex evaluations are required each academic year. Fellowship Program Conferences A. Required Conferences (80% attendance is mandatory throughout the program.) 1. Geriatrics Core Curriculum GRECC Conference Room Thursdays at 9AM. Vanderbilt faculty give lectures on geriatrics topics. These lectures are given with the residents as the target audience. Lectures will include clinical topics and introduction to home health and community services. Fellows will be responsible for delivering some lectures as they progress in competency. Objectives: a. Describe and discuss the basic mechanisms of aging and response to disease. b. Describe and discuss the clinical syndromes associated with aging. c. Describe and discuss current options for diagnosis, management and therapy. d. Describe and discuss risk factors for and strategies to modify functional disability. 2. Geriatrics and Gerontology Interest Group Grand Rounds 8030 MCE Conference Room Alternate Tuesdays at Noon Vanderbilt faculty and invited lecturers speak on a variety of geriatrics topics and research activities. Each fellow is expected to present at Grand Rounds on a yearly basis. Objectives: a. Describe current research regarding the pathogenesis, evaluation, treatment, and prevention of illness relevant to geriatrics and discuss application in practice. b. Describe and discuss the most current information on the practice of geriatrics c. Describe the areas of expertise of faculty members. 3. Medical Grand Rounds 208 Light Hall Thursdays at 8:00 AM. Local and invited lecturers speak on a variety of topics and research activities in the field of medicine.