Geriatric Medicine Rotation Contact Person: Dr. Lotika Pandit General Information Geriatric medicine is an integral part of the Internal Medicine Residency Program. Our faculty includes four fellowship-trained geriatricians and four faculty with a current Certificate of Added Qualifications in Geriatric Medicine. We also have two faculty with certification in Palliative care. In addition to working with well-trained faculty in geriatrics, the house staff receives significant exposure to elderly patients and the disease processes associated with a geriatric medicine practice as they provide ambulatory care, hospitalization and consultation for elderly patients on multiple rotations. The house staff are required to complete a one month geriatric medicine block rotation during the PGY-2 or PGY-3 year with daily exposure to medically frail, complex geriatric patients in a variety of inpatient and outpatient settings which includes the Alexian Brothers Community Services Program of All-Inclusive Care for the Elderly (PACE), Hospice of Chattanooga, nursing home, private office and home visits. Objectives The objectives of the Geriatric Medicine rotation is to familiarize the resident with the unique challenges of day-to-day medical care of the frail, complex elderly patient and to help the housestaff develop a sense of applying the holistic or bio-psycho-social-spiritual concept of patient care in an interdisciplinary team model. Specific goals that will be addressed during the rotation are: Distinguish normal, usual and pathologic aging processes and learn how age affects disease. Develop the ability to obtain an accurate history from elderly patients that requires an appropriate attitude and interpersonal skills. Understand the current systems available for care of dependent elderly, including the eligibility and funding of different levels of care. Understanding the role of functional assessment and use of standardized tools. Use appropriate diagnostic tests and recognize proper interpretations. Recognize and analyze positive or negative attitudes and biases regarding the elderly and the problems this creates in the doctor-patient relationship. Distinguish subtle variations in geriatric medicine as it pertains to: o Altered disease presentations o Multiple diseases o Polypharmacy o Economic factors o Sociologic and humanistic factors
Value to the General Internist The majority of patients in the general internist s practice will be older patients and this rotation will establish a set of skills and attitudes necessary to maximize the appropriateness of geriatric care. Due to the complexity of these patients, it is sometimes necessary to solicit the assistance of community-based resources. This rotation will teach the internist what services are available in most communities nationwide and how to appropriately utilize them. This rotation will teach the philosophy of an interdisciplinary team to an internist in an effort to improve the communication between the internist and the paraprofessionals in the community who will also be involved in the care of this frail population. As Medicare and Medicaid become more complex and payment sources restructured, this rotation will teach the basics of reimbursement by Medicare and Medicaid and how this might apply to community-based elderly in various levels of care. Principal Teaching Methods. This course will be taught as a hands on experience in many settings including: The Program of All-inclusive Care for the Elderly (PACE) Nursing Homes Home Visits Hospice Private Practice UMA (residents continuity clinic) House staff will be required to see frail patients in each of these settings independently with immediate feedback by an attending physician. They will also be required to attend interdisciplinary team meetings at the PACE and hospice sites. Other meetings may include medical staff meetings, medical-nursing staff meetings, ethics committee meetings, family meeting and others. While at the PACE site, the housestaff will spend designated time in the Physical and Occupational therapy departments to learn principals of rehabilitation of the frail elderly and environmental (e.g. home) safety. The Housestaff will be provided with a series of questions related to each of the so-called geriatric syndromes to assess competency in these areas prior to and at the end of the rotation. Reading assignments will be given and video taped series of geriatric review material will be provided to expand on certain topics, as appropriate. Educational Content Residents will work with attending physicians in geriatric medicine and may also have on an optional basis opportunities to observe podiatry, ophthalmology, psychiatry and dentistry as part of a coordinated care delivery system at PACE. Topics in the resident lecture sessions will be discussed with designated faculty.
Components of the Physical Examination Stressed Geriatrics is a functionality based specialty; therefore focus will be given to assessing the functional status of each patient. Additionally, the Yale One Question, Caregiver Strain Questionnaire, Geriatric Depression Scale, Folstein Mini-mental State Examination and the Clock Drawing Test, Katz ADLs will be taught and the interpretation of each of these will be stressed. Opportunities to observe a full neuropsychological test battery will be available on a optional basis. During the time with physical and occupational therapy, the housestaff will improve assessment skills of falls, gait, strength, coordination and function and learn screening techniques to be used in private practice. Procedures Procedures will primarily focus on cognitive testing of elderly. Occasionally, the residents may have the opportunity to perform cryoablation, small shave or excisional skin biopsies and joint and trigger point injections. Ethical issues in the care of Geriatric Patient 1. Advance Directives: Living wills, Durable Power of Attorney for Healthcare, Physician s order for scope of treatment (POST) form Evaluation methods 1. Patient presentation to the attending 2. Discussions on assigned reading 3. Demonstration of use of geriatric assessment tools 4. Pre-test and Post-test Reading Selected readings from: 1. Kane, Robert, Joseph Ouslander and Itamar Abrass, Essentials of Clinical Geriatrics, 5 th edition. 2004 2. American Geriatric Society, Geriatric Review Syllabus, 6 th Edition. 2006. 3. Primer of Palliative Care, 3 rd edition, Peter Storey,MD
List of Resident Requirements Geriatric Medicine Rotation 1. A copy of Essentials of Clinical Geriatrics by Dr. Ouslander will be issued and will be returned at the end of the month. A completed resident evaluation will not be sent to the Department of Medicine until this book is returned. 2. A copy of a key to Alexian Brothers Community Services will be issued and will be returned at the end of the month. A completed resident evaluation will not be sent to the Department of Medicine until this key is returned. 3. The resident will be given a copy of a schedule outlining all of the clinical obligations for the month. This will include but not be limited to: a. Two full days with Dr. Walter Parkhurst in his office. b. Two full days with Dr. Terry Melvin at hospice. c. Telephone call during the week. d. All PACE time to include team meetings. e. The resident s clinic schedule. f. All days off scheduled during the rotation. These must be approved in advance according to the set policy of the Department of Internal Medicine. Time off not approved in this fashion will be counted against the resident according to the policy of the Department. g. The time scheduled to be spent with the rehabilitation dept at PACE 4. All residents will be required to perform a presentation during the month. The resident will be allowed to choose a topic but the emphasis must be on geriatric medicine. This presentation will be made at a conference for the house staff at Erlanger or will be presented as an in-service for the medical staff at Alexian Brothers Community Services. 5. All residents will take four days of weekday call with a faculty attending from Alexian Brothers Community Services. This will include after hours telephone calls, may include hospital rounds, nursing home rounds and home visits as required by the attending. The resident will consult the attending for every encounter. 6. A reading list will be provided. The contents of the list may vary slightly during the month depending on clinical encounters. Time for short didactic encounters should be expected near the end of each afternoon at the discretion of the attending. 7. A pre- and post-test will be required from each resident. This test will be done on site at Alexian Brothers Community Services. 8. The residents will receive training in the use of Electronic Medical Records while at PACE.
Geriatric Rotation Checklist Intern/Resident PGY 2 or 3 Supervising Faculty Month Rotation Check List Yes No Comments Reviewed the goals and objectives at the beginning of the rotation Evaluation and feedback mid month Evaluation and feedback at the end of rotation Attended all scheduled clinical sessions Completed assigned readings. Completed required presentation. Performed at or above the expected PGY level. Please check one. PGY-2 will have improved competence and demonstrate -improved data gathering and physical -examination skills -improved knowledge -improved decision making -enhanced ability to counseling PGY-3 will approach mastery and demonstrate the ability to function as consultant Reviewed and met the core competencies as outlined: A. Patient Care Residents will obtain and document appropriate history taking, physical exam and laboratory interpretation skills for geriatric patients Demonstrate ability to evaluate patient with history of falls Perform mental status evaluation including but not limited to Mini-Mental Status Exam for 3 patients B. Medical Knowledge Completed the pre and post test Distinguish facts and myths of aging Discuss topics assigned for resident lecture sessions C. Practice Based Learning Residents will develop and implement treatment plans by utilizing appropriate information systems and resources to help manage multiple illnesses Performed functional assessments for patients by doing geriatric screening on at least three patients including one of their primary care patients at UMA Undertakes self-evaluation with insight and initiative D. Interpersonal and Communication Skills Residents will communicate diagnosis, treatment plan and follow up care to patients and their families Residents will participate in the multidisciplinary rehabilitative care model of care Review advance directives with at least 3 patients/families.
Learn principles of conducting a family meeting Demonstrate approach to delivering bad news to patients/families E. Professionalism Residents will recognize the importance of patient preferences when selecting diagnostic and therapeutic options. Commitment to ethical principles pertaining to the provision or withholding of care, patient confidentiality and informed consent Returned the textbook and keys as instructed F. Systems-Based Practice Understand the basics of reimbursement by Medicare and Medicaid and how this might apply to community-based elderly in various levels of care Advocates for quality patient care and assists patients in dealing with health system complexity Understand the Hospice Medicare Benefit and when to make a hospice referral Utilized the electronic medical record Work with interdisciplinary team by attending at least one team planning meeting Understand role of physical therapist by observing evaluation and treatment of at least two geriatric patients Resident Signature Date Supervising Faculty Date All items must be completed for rotation credit and checklist returned to the Department of Medicine. Updated: August 2008