Geriatric Medicine: Acute Care of the Elderly Service
Educational Program and Curriculum For Geriatric Fellows
Description of the Service:
The Acute Care of the Elderly (ACE) Service, or Medicine A, is an inpatient
service that is staffed by a faculty member within the Division of Geriatric
Medicine, a Nurse Practitioner, an upper level Internal Medicine resident, and
two interns. There are usually 1-2 third year medical students and occasionally
a fourth year, Acting Intern, medical student. In addition, students and residents
from other disciplines including PMR, pharmacy, and nursing may be present.
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Orientation:
Location: Most of our patients are on 8 Bedtower of the Main Hospital. There are
2 nursing stations, a conference room, and a central resource room for use on the
floor.
Schedule:
7:45-8:30 am: Resident Morning Report (fellow may attend report, or work with
interns to see night floats or ill patients; this is to be discussed with the attending
at the start of the service)
8:30-11:00: Morning work rounds
11:30: Interdisciplinary Team Rounds
Teaching Session: Either 11:30-12 or later in the afternoon, depending upon the
team’s schedule
12-1: Intern and resident conferences; Grand Rounds for all on Thursdays
3-3:30 Check out and interdisciplinary rounds
Goals for the Fellow on service:
1. Develop teaching skills
2. Develop leadership skills
3. Improve upon physical exam skills
4. Improve communication skills
5. Gain an awareness of skills needed to supervise an interdisciplinary medical
team caring for acutely ill older patients in the hospital
Specific Learning Objectives for each ACGME core competency:
The fellow is expected to demonstrate an appropriate level of Competency in
the following areas:
1. Patient Care:
a. The fellow will be able to appropriate triage and care for older
patients who are acutely ill and hospitalized
b. The fellow will be able to appropriately identify the care needs of a
patient at discharge from the hospital
c. Specifically, the fellow will be able to identify and manage patients at
risk for and with delirium, falls, malnutrition, pressure ulcers, and
infections, recognizing these as common complications from
hospitalization in elders
d. The fellow will be able to manage the most common acute medical
illnesses that lead to admission in older patients (for example, CHF,
pneumonia, syncope, sodium disorders, urinary infections)
e. The fellow will be able to perform a complete geriatric functional
assessment, including assessment for cognitive impairment, delirium,
gait, functional status prior to hospitalization, and social support
2. Medical Knowledge:
a. The fellow will demonstrate knowledge in the specialized care of
older patients by leading rounds and teaching residents and students
3. Practice Based Learning and Improvement
a. The fellow will initially compose an individual learning plan for the
month that will include a plan for self assessment and reflection
b. The fellow will participate in the education of patients, families,
students, and residents by:
i. Leading family and patient discussions pertaining to discharge
planning, end of life decisions, advanced directives
ii. Observing the medical students during a History and Physical
exam exercise and giving the student feedback on performance
iii. Working with the attending to lead teaching rounds/conference
4. Interpersonal and communication skills:
a. The fellow will demonstrate the ability to work with the
interdisciplinary team, including the nurse practioner and therapists, in
the care of hospitalized older patients
b. The fellow will demonstrate the ability to work with the supervising
resident on the service in a collaborative manner
c. The fellow will be able lead interdisciplinary team rounds
d. The fellow will be able to discuss patient care needs with a referring
physician as follow up and/or part of the discharge process
e. The fellow will demonstrate ability to document geriatric assessments
and advanced planning/family discussions in the electronic medical
record
5. Professionalism
a. The fellow will demonstrate professional behavior to patients,
families, students, and residents
6. Systems Based Practice
a. The fellow will demonstrate an appreciation for the Health Care
system and its role in the care of older adults in the hospital setting
b. The fellow will review discharge summaries for errors and medication
reconciliation, and will discuss errors with the team of
interns/residents with the goal of improving overall care
Specific Expectations and Responsibilities of Fellows:
1. The fellow will attend and participate in morning rounds each day. The
fellow should be in the role to make treatment and management decisions
with the team in a supervised setting. The fellow should discuss their
specific role on rounds with the attending and resident at the beginning of
the rotation.
2. Although the fellow will need to continue to have an afternoon clinic and an
afternoon session at their Long Term Care facility, the remainder of their
time during the month should be dedicated to the inpatient service.
3. The fellow is expected to help with admissions and report back to the
attending with a summary, including a proposed treatment and management
plans. The fellow and attending should work out a plan for admissions that
arrive after standard work hours, balancing the need for continued patient
care with the necessary resident work hours and other obligations.
4. The fellow should expect to come in at least one weekend day each week
(preferably the day when the supervising resident is off). Fellows should
expect at least one day off each week, which should be a mutually agreed
upon day with the attending. Fellows are expected to work within the hour
and time guidelines as established by the ACGME – this includes a
maximum of 80 hours per week and at least one day off each week.
5. The fellow is expected to lead in an educational role. Fellows should lead
attending/teaching rounds, bringing articles and other information to
the team based upon the patients that are seen. Fellows are expected to
prepare several such teaching sessions each week, based upon a
curriculum for the rotation established in conjunction with the attending on
service.
6. The fellow should work specifically with the medical students, and
should help them to complete their observed History and Physical.
7. The fellow will perform complete geriatric assessments on at least 3
complicated patients, identified by the team as patients in need of a more
detailed assessment, and record their findings as a Generic Note in
Webcis.
8. The fellow will take a leading role in at least 2 family and patient
discussions, and record these discussions in the Advanced Directives
section of the electronic medical record.
9. The fellow is responsible for attending the daily Interdisciplinary team
meetings and contributing to the team discussions and management plans for
patient care.
10.The fellow should serve as a liaison with outside physicians and consultants
in order to ensure that continuity of care is provided during transitions to
other settings of care.
11.The fellow should review the discharge summary and medications for
each patient on the day of discharge with the intern to ensure that
medications are reconciled, appropriate follow up is arranged, and patient
plans are clear and complete.
12.Each day, the fellow should review with the team for each patient the
following:
a.
b.
c.
d.
e.
f.
g.
h.
i.
Presence of lines: are they needed?
Foley catheter: why?
Telemetry box: needed or not?
Falls and gait assessment: Has it been done? Is the patient safe for
d/c?
Cognitive assessment: has it been done? Is it needed? Is the patient at
risk for delirium?
Medication review and reconciliation
Advanced directives and code status
Contact with primary physician
Discharge planning needs
Specific Expectations for Attendings who work with Fellows
1. Attendings should provide appropriate autonomy in addition to supervision
for the fellow on service
2. Attendings should foster the development of leadership skills for the fellow
3. Attendings should observe the fellow’s clinical exam skills and give
feedback
4. The attending should observe the fellow in their role of teacher, and give
specific feedback on how the fellow is performing with teaching during
conference, rounds, and at the bedside
5. The attending should review the geriatric assessments for content, clarity,
and documentation.
6. The attending should observe at least one fellow directed family meeting and
give feedback on performance.
7. The Attending should observe at least one complete geriatric assessment by
the fellow and give feedback on performance.
8. The Attending is expected to complete written evaluations of fellows in a
timely manner, in addition to providing verbal feedback to the fellows.
These evaluations are expected to be returned to the Fellowship Coordinator
within two weeks of completing the rotation.
Evaluation of the Fellow by the attending should include an assessment of the
Fellows competency in the following areas:
1. Patient Care:
a. Evaluations will include the input of the nurse practitioner and others
on the team
b. The attending will observe the fellow as a manager of patient care on
rounds each morning
c. The attending will review assessments on geriatric patients as
documented by the fellow in the electronic medical record system
2. Medical Knowledge
a. The attending will review the fellow’s knowledge as demonstrated on
morning rounds and during teaching conferences, as well as by review
of notes documented as described above
3. Practice Based Learning and Improvement
a. The attending will review the individual learning plan established by
the fellow at the beginning of the month
b. The attending will be present for the teaching conferences led by the
fellow and given to the interns, resident and medical students and will
give feedback relating to content and effectiveness for immediate,
formative review
c. Materials used in teaching conferences designed by the fellow will be
submitted to the Program Director for review and to be used as part of
the summative evaluation of the fellow
4. Interpersonal and Communication Skills
a. The attending will observe at least one family/patient discussion led
by the fellow in order to give feedback and to serve as a component of
the formative evaluation process
b. The attending will observe the ability of the fellow to work with the
team and families
5. Professionalism
a. The attending is expected to observe the fellow and be in a position to
give feedback on professionalism and modeling behaviors
6. Systems Based Practice:
a. The attending should review with the fellow systemic errors and
issues for the service
b. The attending should evaluate the fellow’s ability to critically assess
the system and ability to work within the system to improve patient
care
Reading List:
1. Augaard E, Teherani A, Irby DM. Effectiveness of the One-Minute
Preceptor Model for Diagnosing the Patient and the Learner: Proof of
Concept. Acad. Med. 2004; 79: 42-49.
2. Stenert Y, Snell LS. Interactive lecturing: strategies for increasing
participation in large group presentations. Medical Teacher. 1999; 21(1):
37-42.
3. Vickery AW, Lake FR. Teaching on the run tips 10: giving feedback. MJA.
2005; 183 (5): 267-268.
4. Wong JD, Bajcar JM, Wong GG, Alibhai SMH, Huh J, Cesta A, Pond GR,
Fernandes OA. Medication reconciliation at hospital discharge: evaluating
discrepencies. The Ann of Pharm. 2008; 42: 1373-9.