Geriatrics PGY-3

Description of Rotation or Educational Experience

·         Geriatrics PGY III: The care of elderly patients is an increasing responsibility of family physicians. Care of the elderly patient occurs longitudinally throughout the three years of training in inpatient, outpatient and nursing home sites. The geriatrics block rotation will occur during the PGYIII year and will be for two-weeks in duration. The resident will participate in the care of the geriatric inpatients on the 5200 ward of Washington Regional Medical Center which is the designated geriatric ward. The primary preceptor for this rotation is Dr. Randy Shinn, Geriatrician.

PGY-III resident is expected to:

• Round on geriatric inpatients on 5200 ward of WRMC beginning at 8:00 a.m. each morning Monday through Friday, and actively participate in the care of these patients.
• Participate in multidisciplinary staff sessions at 11:00 a.m. each day.
• Maintain problem list/medication profile for all patients in the resident’s care
• On Tuesday afternoon at 1:00 p.m. residents will work with Dr. Randy Shinn in the evaluation of a new patient in the Memory Center at WRMC.
• On Thursday afternoon at 1:00 p.m. residents will work with Dr. Stephen Gemmell, Geriatric Neuropsychologist, for Neuropsych evaluations on new patients.
• On Friday at 2:30 p.m. the resident will take part in the multidisciplinary staffing meeting at the Memory Center
• The resident will have continuity clinic at the FMC on Monday p.m. and Wednesday p.m.

Goal I: Provide optimal and comprehensive care to elderly patients within the context of family medicine.

Goal II: To achieve competence in systems based practice working with placement coordination with social services, pharmacy, and other community-based providers.

Goal III: To achieve competence in recognizing and referring complex problems

Patient Care

Goal

Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health.  Residents are expected to have a measurable and progressive knowledge of the following.

Competencies

• Communicate to the patient and/or caregivers the proposed investigation and treatment plans in such a way as to promote understanding, compliance and appropriate attitudes.
• Counsel about psychologic, social and physical stresses and changes of age, dying and death.
• Coordinate the range of services with the patient's support systems and needs.
• Integrate factors in the patient's family, home and general lifestyle into the diagnostic and therapeutic process.
• Consult with physicians and other healthcare professionals, including the critical evaluation and selective use of consultant advice and the integration of management in critical care situations.

Medical Knowledge

Goal

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 the elderly patient.  Residents are expected to demonstrate knowledge and understanding in the diagnosis and management of the following:

• The underlying physiological changes of aging in the body systems including diminished abilities, altered metabolism and effects of drugs, and other atypical presentations of common diseases and changes that directly related to the assessment and treatment of elderly patients.
• The normal psychological, social and environmental changes of aging including reactions to common stresses and changes such as retirement, bereavement, relocation and ill health, and the changes in family relationships that affect health care of the elderly.
• Pharmacology and prescription writing in the elderly.
• The tendency of elderly patients toward iatrogenic disease, immobilization and its consequences, dependency or long-term institutionalization while in the process of receiving medical care.
• The means for promoting health and health maintenance through screening, preventive care and early diagnosis, and the assessment of risk factors. (iatrogenic disease, immobilization, incontinence, and inappropriate institutionalization)
• The means to actively promote health in the elderly through exercise, nutrition and psycho-social counseling.
• The evaluation of the functional status of the elderly patient.

The following problems, which are either especially characteristic of older patients, or differ significantly in their presentation and/or management in order adults:

1. Abuse of the elderly, both physical and psychological
2. Acute abdominal problems
3. Alcoholism and other substance abuse
4. Altered mental status
5. Anemia 
6. Bacteriuria
7. Bereavement
8. Catheterization
9. Completed stroke
10. Confusion
11. Congestive heart failure
12. Constipation
13. Contractures
14. Degenerative joint disease
15. Dehydration
16. Dementia
17. Dentition
18. Depression
19. Diabetes
20. Dizziness
21. Drug-induced illness
22. Falls
23. Fecal impaction
24. Femoral (and other) fractures
25. Gait disorders
26. Hearing loss
27. Hypertension 
28. Hypothyroidism 
29. Incontinence
30. Malnutrition/anorexia
31. Memory loss
32. Myocardial infarction
33. Osteopenia/osteoporosis
34. Pneumonia and other respiratory infections
35. Podiatric problems
36. Postural hypotension
37. Pressure sores 
38. Skin cancers
39. Speech disorders
40. Terminal care
41. Transient ischemic attacks
42. Tremor/parkinsonism
43. Thromboembolism
44. Urinary tract infection
45. Visual loss

The Family Medicine resident should:

A.      Obtain a comprehensive history and mental status examination, utilizing all available sources of information.

B.      Comprehensively conduct an efficient physical examination, mindful of the patient's modesty and mobility while balancing the need for full examination.

C.      Select and interpret diagnostic procedures.

D.      Develop an awareness of his/her own attitudes to aging, disability and death.

E.      Promote the individual’s dignity through self-care and self-determination.

F.      Recognize the importance of the family and home in the overall life and health of patients.

G.     Display an awareness of the importance of a multi-disciplinary approach to the enhancement of individualized care.

H.      Develop problem lists in practical, clinical, functional, psychological and social terms.

Practice- Based Learning and Improvement

Goal

Residents must demonstrate the ability to investigate and evaluate their care of 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:

·         Locate, appraise and assimilate evidence from scientific studies related to their patient’ health problems

·         Use information technology to manage information and access on-line medical information.

Objectives

• The resident becomes competent in the use of UpToDate, DynaMed, and journal searches.  The resident will learn to utilize of availability of a variety of knowledge sources.
• The resident will become competent in the use of EMR to track patients, recover lab data and medical reports.  The resident will become competent to use the PDA with Epocrates and 5-Minute Medical Consult.

Systems Based Practice

Goal

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.  Residents are expected to:

• Understand the range of services available to promote rehabilitation or maintenance of an independent lifestyle for elderly people, increasing their ability to function as long as possible in their existing family, home and social environments.
• Understand characteristics of the various types of long-term care facilities and alternative housings available to the elderly. 
• Demonstrate knowledge of specific regulations for the care of patients in long-term facilities.
• Demonstrate understanding of financial implications of geriatric care such as polypharmacy, iatrogenic illness, over-dependency, inappropriate institutionalization, nonrecognition of treatable illness, over treatment, the unsupported family, etc.
• Understand the benefits and limitations of advanced directives, living wills and durable powers of attorney.

Professionalism

Goal

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

Competencies

• Compassion, integrity, and respect for others.

Objectives

The resident will:

• Demonstrate adherence to ethical principles
• Show sensitivity and respect to diverse patient populations.
• Know when to seek consultation from other appropriate specialists to either manage or co-manage a patient for optimal care.
• Respond to pages and other consultations in a timely manner.
• Dictate comprehensive history and physical exams and discharge summaries in a timely manner

Interpersonal and Communication Skills

Goal

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:

Competencies

• Communicate effectively with physicians, other health professionals, and health related agencies.

o        Demonstrate an awareness of the importance of physician and patient working as partners to promote optimal health.

o        Demonstrate interpersonal and communication skills that result in effective information exchange with patients, families and colleagues

o        Work effectively with others as a member of a healthcare team.

o        Recognize the psychosocial and economic impact of disease on the individual and family.

Objectives

The resident will learn appropriate consultation, timely transfers, and other options of care for acute and chronic problems.

Assessment Method

At the conclusion of each resident rotation, the residency coordinator sends a formative-type, rotation-specific performance evaluation form to the rotations’ supervising physician.  When the completed evaluation is returned, the resident physician and the resident’s faculty advisor review the evaluation and attest to reviewing it by signing/initialing the form.  Next, the program director reviews and attests to the document.  Once all three have reviewed and attested the evaluation, it is included in the resident’s permanent file. 

Each resident is asked to evaluate the rotation and supervising physician(s) at the end of the rotation.  The resident’s faculty advisor and program director review the evaluation and attest to reviewing it by signing/initialing the form. These evaluations are filed together by resident year.

Dr. Randy Shinn, Geriatrician, will be the primary preceptor.

Educational Resources

References available at the AHEC Library:

Merck Manual of Geriatrics

Principles of Geriatric Medicine and Gerontology

Resources available on line:

UpToDate

DynaMed

Geriatrics at Your Fingertips now only available on the internet at: www.Geriatricsatyourfingertips.org

Http://www.familypractice.com online In Service Training Exam excerpted questions.