Geriatrics Curriculum - Emory University School of Medicine
Geriatrics I.Rationale By the year 2030 the current geriatric population will have doubled and represent close to 25% of our total population within the US. At present more than 40% of hospital days and 36% of our national healthcare dollars are consumed by our geriatric patients while they currently compose less than 15% of our total present population. With the graying of America, the Family Practice resident must cultivate knowledge and skills that can maximize both function and quality existence, as well as treat conditions and diseases common to the elderly. II.Goals Patient care/Medical knowledgeA. Acquire the knowledge base and skills to provide care to the elderly. B. Learn appropriate incorporation of health promotion and disease prevention into elder care. Interpersonal Skills/Communication Skills A. Develop patient sensitive skills for interviewing that provide accurate, complete collection of information regarding symptoms, family, and environment that affect the patient’s health and well-being. B. Develop skills in communicating findings, educating both patients and their families, discussing sensitive issues, including end-of-life issues and negotiating a plan of action. C. Develop a therapeutic relationship with both the patient and family. D. Develop experience in planning and coordinating multiple healthcare providers to accomplish comprehensive care for elderly patients. Practice-Based Learning and ImprovementA. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices.B. Develop resources for life-long learning in geriatrics.Systems Based Practice A. Communicate verbally and document within the patient’s record clearly and completely both to facilitate care and meet the documentation billing requirements of Medicare. B. Develop an understanding of the high cost of modern medicine both in monetary and human terms and apply principles of cost containment. C. Understand the elements of various support systems of the older patient, including geriatric medical services, community services, family support systems, respite care.Professionalism A. Develop a personal ethic within the framework of modern medicine that will permit appropriate elder care and assessment of decision-making and end-of-life decisions. III.Objectives Patient care/Medical knowledgeA. To acquire the knowledge base and skills to provide care to the elder patient. Core knowledge areas toinclude diagnosis, natural course and management of common complaints in the elderly including: Abuse: psychological, physical; and neglect Abdominal pain: missed perforation, aneurysm, diverticulitis, malignancies, etc. Aging physiology and pharmacokinetic changesAlcoholism and substance abuse Altered mental status and non-specific disease presentations Anorexia, dehydration, dentition, nutritional disorders and malnutrition CVA, TIA, RIND and Lacunae CHF Chest pain: angina, MI, aneurysm Constipation, impaction, & anorectal disorders DJD Delirium, Dementia Depression Diabetes Dizziness, syncope and orthostatic hypotension Falls and gait disorders Femoral and other common fractures Hearing and visual changes/losses Hypertension Hypothermia Hypothyroidism Iatrogenic illnesses Incontinence, use of catheterization and alternatives Life cycle changes of retirement, bereavement, relocation, loss of healthy self- image and institutionalization, etc. Osteoporosis/Osteopenia Respiratory infections and prevention Perioperative evaluation and preparation Podiatric problems Prostatic disorders Sores, ulcers and decubitus Sexual dysfunction/modifications Skin cancers and actinic/keratotic changes Speech and swallowing disorders Stroke and TIA Tremors, Parkinsonism and pseudo-Parkinsonism UTI vs asymptomatic bacteria B. Competencies necessary for the management of the frail elderly, especially in the long-term care setting: Concepts of rehabilitation and/or maximizing function Consequences of institutionalization, immobilization and incontinence Alternatives to ECF’s (Extended care facilities)Optimal use of problem lists and medication lists Polypharmacy Last Updated September 26, 2006C. Completely utilize assessment tools: MMSE ADL Nutritional assessment Depression inventory Home visit and Safety evaluation D. Learn appropriate incorporation of health promotion and disease prevention into the care of the elder patient. 1. Immunizations 2. Screening guidelines 3. Exercise, nutrition and counseling to promote quality of life 4. Environmental safety and risk reduction 5. Proactive discussion/planning for end-of-life decisions E. Learn elements of support services and systems 1. Interview patient including financial, family, and community support systems. 2. Evaluate the patient’s home or physical environment as it promotes or detracts from the patient’s health. 3. Identify isolating factors for the patient. Learning ActivitiesXAttending RoundsResearch ConferenceOutpatient ClinicsXMultidisciplinary RoundsEthics/Comm ConferenceXDirect Patient careGrand RoundsSpecialty ConferenceResident SeminarSub-Specialty ConferenceXNoon ConferenceJournal ClubMorning ReportXFaculty SupervisionXReadingsXDidacticsXProceduresOtherEvaluation MethodsXAttending EvaluationXDirectly Supervised ProceduresMorning ReportProgram DirectorReviewXIn-Training ExamXFaculty Supervision and Feedback360 ? evaluationVideotape ReviewQuarterly ReviewOtherInterpersonal Skills/Communication A. Develop patient sensitive skills for interviewing that allow accurate, complete collection of informationregarding the patient’s symptoms, family or care giver issues, environmental concerns or supports,especially modifying techniques to allow for slowed spontaneity, disabilities or dementia.Direct the history taking process in such a fashion that accurate data is collected and thespontaneity of the patient is not stifled. Gather information from the demented person and/or the family/patient advocate. Knowledge and appreciation of the developmental tasks of the older person. Use varied methods of communication and data collection for speech-impaired persons. B. Develop skills in communicating results, educating patients and their families, dealing with sensitiveissues for patients and families, and negotiating a plan of treatment with the patient. Negotiate care options, plan of work-up, and management with the patient and family,discussing possible outcomes, risks, and benefits. Clearly communicate follow-up plan and desire to take care of the patient. Counsel patient regarding life cycle changes and retirement planning. C. Develop therapeutic doctor-patient and doctor-family relationships. Educate the patient and family to set achievable goals for improvement or maintenance of health.Recognize that chronic disease is managed and that the emphasis is on care not cure, and effectively communicate that to the patient and/or family. Make contact with family of nursing home patients as appropriate and as needed to notify family of change in condition or needs for change in the care plan. 4. Encourage continued independence and maintenance of self care and self determination for the patient. D. The resident will have experience planning care and collaborating with multiple health care professionals in providing comprehensive health care to older persons. Utilizes family practice center faculty and staff or staff in long term care facilities to organizecommunity or facility resources needed for the patient’s care. Utilizes skills of long term care nursing staff to learn patient care plan construction. Assists the patient in negotiating a changing health care system and environment. Critically evaluates and select consultant advice for integration into patient management. Learning ActivitiesXAttending RoundsResearch ConferenceOutpatient ClinicsXMultidisciplinary RoundsEthics/Comm ConferenceXDirect Patient careGrand RoundsSpecialty ConferenceResident SeminarSub-Specialty ConferenceNoon ConferenceJournal ClubMorning ReportXFaculty SupervisionXReadingsXDidacticsProceduresOtherEvaluation MethodsXAttending EvaluationDirectly Supervised ProceduresMorning ReportProgram DirectorReviewXIn-Training ExamXFaculty Supervision and Feedback360 ? evaluationXVideotape ReviewQuarterly ReviewOtherPractice-Based Learning and ImprovementA. Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:Analyze practice experience and perform practice-based improvement activities using a systematic methodology.Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems.Obtain and use information about their own population of patients and the larger population from which their patients are drawn.Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.Use information technology to manage information, access on-line medical information; and support their own education. Learn to incorporate health promotion and disease prevention into patient care.Use evidence-based medicine, evaluation of available evidence, and use of best-available evidence at morning report meetings and during routine clinical care. Learning ActivitiesXAttending RoundsResearch ConferenceOutpatient ClinicsXMultidisciplinary RoundsEthics/Comm ConferenceXDirect Patient careGrand RoundsSpecialty ConferenceResident SeminarSub-Specialty ConferenceNoon ConferenceJournal ClubMorning ReportXFaculty SupervisionXReadingsXDidacticsProceduresOtherEvaluation MethodsXAttending EvaluationDirectly Supervised ProceduresMorning ReportProgram DirectorReviewXIn-Training ExamXFaculty Supervision and Feedback360 ? evaluationXVideotape ReviewQuarterly ReviewOtherSystems-Based Practice Develop understanding of components of Medicare, the impact of these components on access tomedical services for the elderly patient.Develop understanding of the physicians obligations and responsibilities under Medicare contract;become familiar with information sources which can inform the physician regarding these obligations and municate and document clearly and completely by written and verbal methods. Document thoroughly to meet Medicare guidelines for patient care and billing classification. Appropriately prescreen patients needing hospitalization according to Medicare or secondary insurer guidelines. Keep problem and medication list up-to-date. Understand the high cost of medical care and applies principles of cost containment to decisionmaking. Understand the elements of various support systems of the older patient, including geriatric medical services, community services, family support systems, respite careLearning ActivitiesXAttending RoundsResearch ConferenceOutpatient ClinicsXMultidisciplinary RoundsEthics/Comm ConferenceDirect Patient careGrand RoundsSpecialty ConferenceResident SeminarSub-Specialty ConferenceNoon ConferenceJournal ClubMorning ReportXFaculty SupervisionXReadingsXDidacticsProceduresOtherEvaluation MethodsXAttending EvaluationDirectly Supervised ProceduresMorning ReportProgram DirectorReviewXIn-Training ExamXFaculty Supervision and Feedback360 ? evaluationXVideotape ReviewQuarterly ReviewOtherProfessionalism Develop interview skills, communication skills and a personal ethic for patient care and care decision-making. Assist the patient and family in weighing decisions about patient care with integration of basic bioethical concepts. Guide patients and their families in using legal resources including advanced directives asliving wills, guardianship, and evaluation of competence. Do not resuscitate, CPR, intubation, ER transfer, surgery, I.V.’s, lab tests, tube feedings and medical interventions. Respect patient privacy by guarding medical information that the patient does not wish to share with their family. Identify personal attitudes to aging, disability, and death as distinguished from the patient’s attitude. Last Updated September 26, 2006 B. Develop a base of resources for personal education and develop a plan for ongoing education. Identify CME materials and meetings for continued information gathering. Set goals for future practice environment and direct learning to those goals. C. Teach others Participate in teaching geriatric care principles to medical students, nurse practitioner students, and physician assistant students. Learning ActivitiesXAttending RoundsResearch ConferenceOutpatient ClinicsXMultidisciplinary RoundsEthics/Comm ConferenceDirect Patient careGrand RoundsSpecialty ConferenceResident SeminarSub-Specialty ConferenceNoon ConferenceJournal ClubMorning ReportXFaculty SupervisionXReadingsXDidacticsProceduresOtherEvaluation MethodsXAttending EvaluationDirectly Supervised ProceduresMorning ReportProgram DirectorReviewXIn-Training ExamXFaculty Supervision and Feedback360 ? evaluationXVideotape ReviewQuarterly ReviewOther:1) Topic presentation (longitudinal rotation) 2) research project presentation (block rotation)IV.Instructional Strategies (see aboveProvide continuity of care in the out-patient setting by following elders assigned in the FPC. Participate in the in-patient service, focusing on the management of acute exacerbation of chronicdisease and the management of chronically ill patients who have higher levels of acuity or more co-morbid conditions. Includes a minimum of two pre-op evaluations, at least one over the age of 80.Geriatric home visits / environmental safety evaluations, as specified in Behavioral Medicine curriculum.Monthly nursing home visits with assigned continuity patients and didactic rounds with Dr DarradjiAssociated rotations for additional experience: ER, Inpatient FMS, FP center, ICU, medical subspecialties, dermatology and General surgery. Core series of readings. See Reading list belowV.Evaluation Strategies (see above) Block Rotation/VA Nursing Home Direct observation of patient care by precepting faculty. Direct observation of communication skills, teamwork ability and professionalismOngoing review of resident’s documentation by precepting facultyComplete geriatric medicine knowledge pre and post testComplete geriatric medicine computer based learning modules as assigned by the course coordinatorEvaluation of case presentations on roundsEvaluation of topic presentationFaculty evaluation of resident upon completion of rotation.Resident evaluation of rotation and faculty. Performance on the geriatrics section of the in-training exam and mini-quizzes. Longitudinal Rotation/Monthly Nursing home visitsDirect observation of patient care by precepting faculty. Ongoing review of resident’s documentation by precepting facultyEvaluation of case presentations Evaluation of topic presentationFaculty evaluation of resident upon completion of rotation.Resident evaluation of rotation and faculty. Performance on the geriatrics section of the in-training exam and mini-quizzes.VI.Implementation MethodsA. Four week block rotation during second year of residency which will include: Eight half-days of participation per week in the nursing home at The Veteran’s Administration Hospital in Atlanta, GA. Liaison: Anna Mirk, MD contact: Felicia Williams fax Geriatrics & Extended Care Felicia.williams@ Atlanta VA Hospital (404) 321-6111 x 17867 1670 Clairmont Road (404) 728-779 fax Decatur, GA 30033The above includes one to two half-days per week rotating through several or all of the following clinics/departments: continence clinic, hospice and pain management, wound clinic, OT/PT, speech therapy, geriatric outpatient clinic. On remaining half days, the resident will be assigned 10 to 12 patients. The resident will manage these patients, round on these patients and write a monthly progress note. Residents will present their assigned patients during formal monthly rounds to Geriatric team at the end of their rotation.Hospice management of a terminal patient(s). Weekly wound care rounds with Dr Kim House.Admission and management of respite care patients, not to exceed two per week.Formal geriatric topic presentation to Dr. Mirk and other care team members, assigned by rotation coordinator. Didactic meetings with Dr. Mirk every other week.Daily Internal Medicine Noon conference as duties allow.Attend Thursday morning Geriatrics didactic sessions and resident roundtable sessions During this block, weekend calls are taken as upper level on the FMS at EUHM.One half day of Family Practice Continuity Clinic per week at Emory Dunwoody.Reading List:Recommended Readings: Last Updated April 25, 2012 AAFP Monograph #389, Dementia, 2011.AAFP monograph #344, Healthy Older Adult, 2008.AAFP monograph #336, End of Life Care, 2007.AAFP monograph #315, The Patient in The Long term Care Facility, 2005.AAFP monograph #297, Caring for Elderly Individuals, 2004.AAFP monograph #315, Arthritis, 2010. Websites:Geriatrics journal: American Geriatrics Society: American Geriatrics Society’s Clinical Geriatrics journal: & Aging journal: Geriatrics Society: at the Emory Library, “geriatrics”. Search results on 4-25-2012:Drugs for the Geriatric Patient, edited by R.I. Shorr et al, 2007MD ConsultPrimary Care Geriatrics: a Case-Based Approach, 5th ed, edited by R.J. Ham et al, 2006MD ConsultBrocklehurst's Textbook of Geriatric Medicine and Gerontology, 7th ed, edited by H.M. Fillit et al, 2010MD ConsultEvidence-Based Geriatric Nursing Protocols for Best Practice, 3rd ed, edited by E. Capezuti et al, 2008R2 LibraryHazzard's Geriatric Medicine and Gerontology, 6e ed., edited by J.B. Halter et al, 2009AccessMedicineAmerican Psychiatric Publishing Textbook of Geriatric Psychiatry, 4th Ed., edited by D.G. Blazer and D.C. Steffens, 2009Psychiatry OnlinePractice of Geriatrics, 4th ed, edited by E.H. Duthie et al, 2007MD ConsultGeriatric Medicine: an Evidence Based Approach, 4th ed, edited by C.K. Cassel, 2003STAT!RefA Practical Guide to Heart Failure in Older People, 1st ed, edited by C. Ward and M. Witham, 2009R2 LibraryArt of Dementia Care, by J. Verity and D. Kuhn, 2008R2 Library ................
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