Geriatrics

Geriatrics Competency Based Curriculum

Educational Rationale

The percentage and number of older adults in our society is steadily increasing, elderly persons occupy a largenumber of acute care hospital beds, comprise the largest percentage of nursing home residents and make more visits to physicians office than any other segment of the population. Yet the health care system has become geared to acute and episodic rather than preventative comprehensive care. The elderly population is expected to increase dramatically in absolute numbers as well as in proportion to the rest of the population. There are many subtle and significant differences in the approach to diagnosis and management of older patient as opposed to younger patient.

The overall goal is to assist elderly persons to function independently with self-respect and to preserve their lifestyle as much as possible.

The goals of the Geriatrics educational program for Internal Medicine residents is to facilitate their acquisition of knowledge, development of skills and learning the proper attitudes necessary to care for the elderly, under the supervision of a geriatrician role model.

Goals

A. KNOWLEDGE

On completion of their geriatric training experience, the Internal Medicine residents should have a sound understanding of:

  1. The underlying physiology of normal aging changes in the various body systems.
  2. The diminished homeostatic abilities, altered metabolism and effects of drugs and other changes related to the assessment and treatment of elderly patients.
  3. The social and environmental changes of aging, including reactions to common stressors such as bereavement, relocation and changes in the family relationships.
  4. The range of services available to promote rehabilitation or maintenance of an independent lifestyle for elderly people.
  5. The means to actively promote health in the elderly through exercise, nutrition and psychosocial counseling.
  6. The characteristics of the various types of long term care facilities and assisted living available to the elderly.
  7. Skills involved in the diagnosis and management of problems characteristic to older patients such as:
    a. Hearing and vision loss, speech disorders, decubiti gait disorders
    b. Pneumonia
    c. Hypertension, cerebral vascular accidents, postural hypotension, congestive heart failure, temporal arteritis, transient ischemic attacks, myocardial infarction.
    d. Acute abdomen, anorexia, constipation, fecal impaction.
    e. Incontinence, Urinary tract infection, Sexual dysfunction.
    f. Degenerative joint disease, fractures contractures, osteoporosis, osteopenia.
    g. Delirium, dementia, dizziness, tremor, memory loss.
    h. Dehydration, diabetes hypothyroidism, drug induced illness, malnutrition, anemia, and malignancies.
    i. Depression, alcoholism and other substance abuse, grief reaction.
    j. Physical abuse and neglect.

B. SKILLS

The residents should develop skills in:

  1. Obtaining a comprehensive history and physical examination in office, hospital and nursing home.
  2. Developing problem list in practical, clinical, functional, psychological and social terms.
  3. Develop good communication skills to communicate to patients or care givers.
  4. To be able to set appropriate priorities and limitation for investigations and treatment.
  5. Counseling about psychological, social and physical stresses and changes of age.
  6. Integrating patient's family, home and general lifestyle into the diagnostic and therapeutic process.
  7. Able to deal with issues of death and dying.

C. ATTITUDES

The residents should develop:

  1. Attitudes that encompass compassion and humanism, balancing realism and practicality in the consideration of inevitable decline and loss.
  2. Recognition of awareness of importance of a multi disciplinary approach to the enhancement of individual care.
  3. An understanding of appropriate limitation of investigation and treatment for the benefit of the patient.

An understanding of the importance of dignity through self-care, and the role of family and home in the overall health of patients

Educational Experience

Geriatrics is taught throughout the residency training with specific concentrations during the ambulatory months of their PGY2 and PGY3 years and Weiss Service during their senior year

Settings include:

  1. Daughters of Israel (DOI) skilled nursing facility
  2. Inglemoor Rehabilitation & Care Center (IRCC)
  3. Care One at Livingston (COL)
  4. RWJBarnabas Health Hospice and Palliative Care (HPC)
  5. Internal Medicine Faculty Practice (IMFP)
  6. Weiss Inpatient Service (WIS)

1. Inpatient Experience:
A significant number of admissions to our inpatient teaching service are geriatric patients treated by inter-disciplinary teams under the supervision of attending geriatricians. During the Weiss service month senior residents work one on one with geriatricians to take are of inpatient geriatric patients.

2. Nursing facilities:
The residents have one month PGY2 and PGY 3 Ambulatory Care Block rotations, where they spend time at several long term care facilities. During this time, they work at the Geriatric Assessment Center, as well as do Inpatient nursing home rounds. Residents also have exposure to an adult day center at the nursing home, in addition to assisting in the management for long term care residents.

3. Ambulatory Experience:
Out patient geriatric assessment and consultation is done throughout residency in the Internal Medicine Faculty Practice ambulatory care clinic. During the ambulatory months residents also spend time with the RWJBarnabas Health Hospice and Palliative Care team. They participate in home visits and interdisciplinary team meetings with the Hospice team.

4. Didactic Conferences (DC)
Numerous monthly conferences are held for the residents throughout the month. They cover a variety of topics in all the major medical subspecialties. Residents will be required to attend each of the conferences that do not conflict with their clinical duties

The residents are expected to:

  1. Provide direct patient care (DPC) for hospitalized, nursing facility, and ambulatory patients under attending supervision
  2. Perform consultations and provide care for patients at the end of life under the guidance of the palliative care team
  3. Evaluate nursing home residents under the supervision of geriatricians and internists
  4. Participate in conferences including but not limited to monthly ethics rounds, end-of life conferences, humanities lecture series, as well as grand rounds, noon conferences, EBM conferences, journal club, and autopsy rounds.
  5. Understand the principles of safe transitions of care of the geriatric patient to and from home, hospital, rehabilitation facility, skilled nursing facility, nursing home.
  6. Apply concepts to geriatric continuity patients at the Internal Medicine Faculty Practice (IMFP)
  7. Perform home visits with HPC when feasible.

Evaluations

Assessment Methods (of Resident)

The evaluation methods that apply to these rotations include some or all of the following:

  • Evaluation of resident competence by faculty attendings (AE)-Formal formative evaluations should occur at the completion of the specific rotation. It is to be based on direct observation on rounds, at conferences, and at the bedside. All faculty members are encouraged to complete the form prior to the completion of the rotation and review their impressions directly with the resident. All completed evaluation forms are returned to the Program Director for review and placed in the resident's permanent file.
  • Mini CEXs may be used when warranted, particularly in the beginning of the academic year.
  • Self-evaluation by In-service training examination scores
  • MKSAP study plan (MKSAP)
  • Participation and presentations at didactic conferences (DC)
  • Multi Source evaluations by patients and staff (MS)

Assessment Method (of Program)

Residents have the ability to evaluate teaching faculty and experience at the end of each rotation. They are encouraged to use this opportunity to give constructive feedback.

Residents are encouraged to maintain a high level of communication with the Program Director and faculty. These informal meetings can be used to disseminate information, receive timely feedback, and for other purposes.

Annually, all residents are required to complete and return an evaluation form of the faculty and the program. Evaluations are collected in a fashion to assure the anonymity of the resident. The feedback received during informal meetings, formal meetings, and the semi-annual evaluation form will be used to make programmatic change.

Competency Based Goals & Objectives:

Patient Care

Residents must be able to provide care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health in elderly patients. This rotation increases resident's exposure to common geriatric conditions in a variety of venues. Residents are better able to recognize and manage these diseases after participating in this rotation. Specific objectives are for residents to:

  • Recognize, evaluate and initiate appropriate treatment for geriatric syndromes (DOI, IRCC, WIS, DPC, IMFP).
  • Promote wellness and maintenance of function in elderly patients, including direction of patients to community resources related to wellness (DOI, IMFP, DPC).
  • Appropriately prescribe medications in elderly patients (DOI, IRCC, WIS, DPC,
    IMFP).
  • Refer patients appropriately for home care, hospice, and rehabilitation services (DPC, WIS).
Goals and Objectives-PGY1 Learning Activities* Assessment
1. Demonstrate ability to initially identify and care for patients with geriatric syndromes. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
2. In the context of care for individual patients, promote wellness and maintenance of function, including awareness of community resources related to wellness. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
3. Demonstrate appropriately medication prescribing and oversee medication reconciliation prior to discharge from the hospital. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
1. Exhibit proficiency in the recognition, evaluation and initiation of appropriate treatment for geriatric syndromes. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP

2. Discuss with patients, family and other medical staff wellness promotion and maintenance of function in elderly patients, including facilitation of patients' participation in community resources related to wellness.
DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
3. Teach and assure appropriate medication prescribing and medication monitoring in elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
4. Refer patients appropriately for home care, hospice, and rehabilitation services with awareness of social and financial issues. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP

Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and social-behavioral sciences, as well as the application of this knowledge to care of elderly patients. Residents are expected to review relevant articles from the literature as they pertain to the cases discussed. Specific objectives for residents include:

  • Expand clinically applicable knowledge base of the basic and clinical sciences
    underlying the care of elderly patients (DOI, COL, DPC, IMFP, conferences).
  • Access and critically evaluate current medical information and scientific evidence relevant to elderly patients (DOI, COL, DPC, IMFP, conferences, self directed reading)
  • Understand the concept of wellness and appreciate the importance of maintenance of function in elderly patients (DOI, COL, DPC, IMFP, conferences)
  • Understand the important alterations in pharmacokinetics and pharmacological effect of medications commonly prescribed for elderly (DOI, COL, DPC, IMFP)
Goals and Objectives-PGY1 Learning Activities* Assessment
Expand clinically applicable knowledge base of the basic and clinical sciences underlying the care of elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Access and critically evaluate current medical information and scientific evidence relevant to elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Understand the concept of wellness and appreciate the importance of maintenance of function in elderly. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Understand the important alterations in pharmacokinetics and pharmacological effect of medications commonly prescribed for elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
Further improve clinically applicable knowledge base of the basic and clinical sciences underlying the care of elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP

Identify, access and critically evaluate current medical information and scientific evidence relevant to elderly patients.
DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Teach and apply the concept of wellness and the importance of maintenance of function in elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Mastery of important alterations in pharmacokinetics and pharmacological effect of medications commonly prescribed for elderly patients DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP

Practice-Based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate their care of elderly patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life long learning. Residents are expected to develop skills and habits to be able to :

  • Identify and acknowledge gaps in personal knowledge and skills in the care of elderly patients ((DOI, COL, IRCC, DPC, IMFP)
  • Develop evidence-based strategies for filling gaps in personal knowledge and skills in the care of elderly patients (DOI, COL, DPC, IMFP)
Goals and Objectives-PGY1 Learning Activities* Assessment
1. Demonstrate ability to formulate a focused clinical question based on the care of elderly patients. DOI, HPC, IRCC, WIS, COL, AE, DC, MKSAP
2. Engage in the process of seeking feedback, accept and respond to constructive feedback and commit to improving identified areas of weakness. DOI, HPC, IRCC, WIS, COL, AE, DC, MKSAP

3. Utilize evidence-based strategies for filling gaps in personal knowledge and skills in the care of elderly patients
DOI, HPC, IRCC, WIS, COL, AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
1. Mastery of formulating focused clinical questions based on the care of elderly patients. DOI, IRCC, WIS, COL, HPC AE, DC, MKSAP
2. Engage in the process of seeking and providing feedback. Provide role modeling in the acceptance and responsiveness to constructive feedback DOI, IRCC, WIS, COL, HPC AE, DC, MKSAP
3. Identify and improve knowledge and skill gaps in caring for elderly patients with evidence-based strategies. DOI, IRCC, WIS, COL, HPC AE, DC, MKSAP
4. Demonstrate the ability to utilize the medical literature in caring for elderly patients by sharing selected individual articles with other professionals in their geriatrics rotation. DOI, IRCC, WIS, COL, HPC AE, DC, MKSAP
5. Develop and maintain a willingness to learn from errors, and use errors to improve the system or processes of care DOI, IRCC, WIS, COL, HPC AE, DC, MKSAP

Systems Based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care for elderly patients. Residents are expected to:

  • Understand and utilize the multidisciplinary resources necessary to care optimally for elderly patients (DOI, COL, DPC, IMFP, HPC, WIS).
  • Collaborate with other members of the health care team to ensure comprehensive care for elderly patients (DOI, COL, DPC, IMFP, HPC, WIS).
  • Use evidence-based, cost-conscious strategies in the care of elderly patients (DOI, COL, DPC, IMFP, HPC, WIS).
  • Understand the full range of living options for elderly persons and the cognitive and functional abilities required for successful living in these various settings (DOI, COL, DPC, IMFP, HPC, WIS).
  • Distinguish between and know how to use the services provided by certified home health agencies, respite services, day hospital or day care, hospice, hospital, consultant care providers, private hire agencies, geriatric care managers, and equipment suppliers (DOI, COL, DPC, IMFP, HPC, WIS)
Goals and Objectives-PGY1 Learning Activities* Assessment
1. Understand and utilize the multidisciplinary resources necessary to care optimally for elderly patients DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
2. Collaborate with other members of the health care team to ensure comprehensive care for elderly patients. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
3. Appreciate evidence-based, cost-conscious strategies in the care of elderly patients. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
4. Understand the full range of living options for elderly persons and the cognitive and functional abilities required for successful living in these various settings. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
5. Distinguish between and know how to use the services provided by certified home health agencies, respite services, day hospital or day care, hospice, hospital, consultant care providers, private hire agencies, geriatric care managers, and equipment suppliers. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
1. Facilitate PGY-1 resident understanding and utilization of the multidisciplinary resources necessary to care optimally for elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
2. Assure collaborate with other members of the health care team to ensure comprehensive care for elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
3. Use evidence-based, cost-conscious strategies in the care of elderly patient. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
4. Exhibit sophisticated understanding of the full range of living options for elderly persons and the cognitive and functional abilities required for successful living in these various settings. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
5. Demonstrate use of the different services provided by certified home health agencies, respite services, day hospital or day care, hospice, hospital, consultant care providers, private hire agencies, geriatric care managers, and equipment suppliers. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP
1. Facilitate PGY-1 resident understanding and utilization of the multidisciplinary resources necessary to care optimally for elderly patients. DOI, IRCC, HPC, IMFP, WIS, COL, AE, DC, MKSAP

Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate:

  • Compassion, integrity, and respect for others including patients, families, ALL colleagues, and all members of the health care team (DOI, COL, DPC, IMFP, HPC, WIS).
  • Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual (DOI, COL, DPC, IMFP, HPC, WIS).
Goals and Objectives-PGY1 Learning Activities* Assessment
1. Demonstrate compassion and respect and for other individuals (patients, families, peers, attendings and other staff). DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
2. Provide sensitivity and responsiveness towards diverse patients and their families. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
3. Exhibit integrity in acknowledging personal knowledge and experience limitations. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
1. Be a role model in demonstrating respect and compassion in caring for diverse individuals (patients, families, peers, attendings and other staff) even those with different personal beliefs. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
2. Contribute as a team member in assuring patients and their families, as well as staff, are treated with compassion, integrity and respect. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
3. Provide leadership in acknowledging limitations in personal knowledge and experience with other health professionals and patients. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP

Interpersonal and Communication Skills
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and teaming with patients, their families, and professional associates. Residents are expected to:

  • Communicate effectively with elderly patients and their families across a broad range of socioeconomic and cultural backgrounds (DOI, COL, DPC, IMFP, HPC, WIS).
  • Recognize and deal effectively with the communication challenges resulting from
    cognitive impairment in elderly patients (DOI, COL, DPC, IMFP, HPC, WIS).
  • Communicate effectively with physician colleagues and members of other health care professions to ensure timely, comprehensive care and safe transitions for elderly patients (DOI, COL, DPC, IMFP, HPC, WIS).
  • Teach colleagues about important topics in Geriatrics (DOI, COL, IMFP , WIS).
Goals and Objectives-PGY1 Learning Activities* Assessment
1. Communicate effectively with elderly patients and their families across a broad range of socioeconomic and cultural backgrounds. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP

2. Recognize and work to deal effectively with the communication challenges resulting from cognitive impairment in elderly patients.
DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
3. Collaborate and communicate effectively with physician colleagues and members of other health care professions to ensure timely, comprehensive care and safe transitions for elderly patients. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
4. Present cases to the attending using accurate medical terms, concise time lines, and focused as well as pertinent history of present illness, past medical history, review of systems and social history.
Goals AND Objectives-PGY2/3 (In addition to above) Learning Activities* Assessment
1. Demonstrate effective communication with elderly patients and their families across a broad range of socioeconomic and cultural backgrounds in language that is understood. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP

2. Screen for, recognize and work to deal effectively with the communication challenges resulting from cognitive impairment in elderly patients.
DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
3. Provide leadership in effective collaboration and communication with PGY-1 residents, medical students, physician colleagues and members of other health care professions to ensure timely, comprehensive care and safe transitions for elderly patients DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP
4. Provide teaching with the liberal use of literature for the practice of evidence based medicine and including short talks for interns and students apart from attending rounds. DOI, IRCC, WIS, COL, HPC, IMFP AE, DC, MKSAP

Teaching Methods

All residents participate in patient care duties, didactic conferences and independent reading. They will learn at the bedside from attendings, nurses and physician extenders, pharmacists, social workers, case managers, peers, and patients.

Level of Supervision

Interns are supervised in their care of patients by more senior medical house staff (PGY2/3 and Chief Residents) and faculty.

PGY2/3 residents have direct and indirect supervision by Chief Resident and Faculty

Educational Resources

  1. Supervising clinicians
  2. Medical literature including assessment of knowledge using the MKSAP
  3. Bedside rounds with team and faculty.
  4. Medical Grand Rounds weekly.
  5. Ethics, end-of-life, and geriatric didactic conferences
  6. Medicine morning report, journal club, ambulatory care conference, EBM conference
  7. Saint Barnabas Medical Center library, librarians, and online references/resources.

References

  1. A Reichel,W. ed Care of the elderly: Clinical Aspects of Aging. Baltimore: Williams & Wilkins.
  2. Ham, RJ, Sloane PD, eds Primary Care Geriatrics: A case based approach. St Louis: Mosby-year book
  3. MKSAP: General Internal Medicine

Faculty

Emily Bahler, DO, Education Coordinator
Muthu Arunachalam, MD
AnneMarie Gracia, MD
Jacqueline Haloubka, MD