Geriatric Fellowship Learning Objectives Linked to ACGME Competencies
The learning objectives contained in this document are intended to provide a framework for geriatric fellowship program directors. The program directors can adapt these learning objectives for use with their specific programs. The program directors can develop overarching goals which are appropriate for their specific programs and rotations.
NOTE: It is assumed that each geriatrics fellow will already be proficient in the competencies taught in internal medicine and family medicine residencies, and these will not be repeated here. Only competencies that are expected at a higher level upon completion of geriatric fellowship are included in this list.
Gerontology
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Describe the major demographic trends in the US, with a particular focus on the aged, and explain the societal implications of those changes.
• Rotation Sites: Didactic/seminar
• ACGME Competencies: Medical knowledge/skill
2. Describe the primary physiologic changes of aging of each organ system and their clinical implications.
• Rotation Sites: Didactic/seminar
• ACGME Competencies: Medical knowledge/skill
3. Discuss the major psychological changes that occur with aging; be able to articulate Ericksonian approaches as they are relevant to specific patient cases in ambulatory, long term care and hospice settings.
• Rotation Sites: Didactics; hospice; long term care sites; ambulatory clinic.
• ACGME Competencies: Professionalism, Communication.
4. List the most commonly accepted theories of biologic aging and discuss evidence that supports each theory.
• Rotation Sites: Didactic/seminar
• ACGME Competencies: Medical knowledge/skill
5. Discuss cultural aspects of aging, including knowledge about demographics, health care status of older persons of diverse ethnicities, access to health care, cross-cultural assessment of culture-specific beliefs and attitudes towards aging and healthcare, and its impact on patient and family experiences in different clinical settings.
• Rotation Sites: Didactic/multiple clinic settings.
• ACGME Competencies: Professionalism, Cultural competency, Communication, Patient care.
6. Demonstrate the ability to critically analyze the medical literature and apply it appropriately to clinical practice.
• Rotation Sites: Didactic/seminar; longitudinal ambulatory and long term care settings.
• ACGME Competencies: Systems-based practice, Practice-based learning.
Diseases in the Elderly
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
General:
1. Describe and interpret the most common atypical presentations of disease among elders.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge
2. Compare and contrast the pathophysiology, presentation, and management of the most common diseases between elders and younger adults (including but not limited to: HTN, CAD, hypothyroidism, infections, and the acute abdomen)
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
3. Identify clinical situations where life expectancy, functional status, and patient preferences should override standard treatment recommendations, and implement appropriate management strategies in those cases.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Cardiovascular Diseases and Disorders:
1. Diagnose and manage the most common CV diseases of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
2. Discuss the pathophysiology, diagnosis, sequelae, and management of systolic hypertension in elders.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
3. Discuss diagnosis and management of atrial fibrillation in elders, including strategies for determining risks and benefits of warfarin use in individual cases.
• Rotation Sites: Ambulatory Care
• ACGME Competencies: Medical knowledge, Patient care
4. Identify elders for whom hypertension should be managed more or less aggressively based on age, functional status, and comorbidities.
• Rotation Sites: Ambulatory Care, Home Visit, Neuropsych
• ACGME Competencies: Medical knowledge, Patient care
Dermatologic Diseases and Disorders:
Diagnose and manage the most common dermatologic diseases of elders
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Endocrinologic Diseases and Disorders:
Diagnose and manage the most common endocrine diseases of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Gastrointestinal Diseases and Disorders:
Diagnose and manage the most common gastrointestinal diseases of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Genitourinary Diseases and Disorders:
Diagnose and manage the most common genitourinary diseases of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Hematologic Diseases and Disorders:
Diagnose and manage the most common hematologic diseases of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Infectious Diseases:
Diagnose and manage the most common infectious diseases of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Kidney Diseases and Electrolytes Disorders:
Diagnose and manage the most common kidney/electrolyte disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Neurologic Diseases and Disorders:
Diagnose and manage the most common neurologic disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Oncologic Diseases and Disorders:
Diagnose and manage the most common oncologic disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Ophthalmologic Diseases and Disorders:
Diagnose and manage the most common ophthalmologic disorders of elders.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Medical Knowledge, Patient care
Oral/Dental Diseases and Disorders:
Diagnose and manage the most common oral and dental disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Medical Knowledge, Patient care
Otologic Diseases and Disorders:
Diagnose and manage the most common otologic disorders of elders.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Medical Knowledge, Patient care
Podiatric Diseases and Disorders:
Diagnose and manage the most common foot disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Medical Knowledge, Patient care
Pulmonary Diseases and Disorders:
Diagnose and manage the most common pulmonary disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Rheumatologic/Musculoskeletal Diseases and Disorders:
Diagnose and manage the most common rheumatologic/musculoskeletal disorders of elders and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Gynecologic Diseases and Disorders:
Diagnose and manage the most common gynecologic disorders of elderly women and identify instances in which those diseases might present or be managed differently than in younger individuals.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Geriatric Psychiatry
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Appropriately identify clinical situations where a neuropsychological assessment is indicated and integrate the findings into the patient's plan of care.
• Rotation Sites: Psychiatry, Geriatrics inpatient, Ambulatory care, Neurology, Consults
• ACGME Competencies: Patient care
2. Determine whether the patient has capacity to make a specific medical decision and identify strategies for dealing with patients who lack decision making capacity.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care, Interpersonal communication
3. Define competence, describe the methods for determining legal competence, and identify resources for assisting patients who lack legal competence.
• Rotation Sites: Didactic/seminar, All or multiple sites
• ACGME Competencies: Medical knowledge
4. Distinguish among the clinical presentations of normal aging, mild cognitive impairment, delirium, and dementia.
• Rotation Sites: Ambulatory care, Neurology, Psychiatry, Geriatrics consultation or Inpatient service
• ACGME Competencies: Medical knowledge, Patient care
5. Perform, interpret, and articulate limitations of common cognitive screens, including the mini-cog and the MMSE, based on pattern, age norms, and education norms.
• Rotation Sites: All or multiple sites, Neurology, Psychiatry, Consults
• ACGME Competencies: Medical knowledge, Patient care
6. Diagnose and manage the major causes of dementia, including Alzheimer's disease, vascular dementia, Lewy body dementia, dementia of Parkinson's disease, and frontotemporal dementia. Recognize and appropriately refer ambiguous cases for further evaluation.
• Rotation Sites: Neurology, Psychiatry, Geriatrics inpatient, Outpatient, Specialty clinics, Consults
• ACGME Competencies: Medical knowledge, Patient care
7. Formulate a differential diagnosis and implement an evaluation and management plan for patients with mild, moderate and severe dementia.
• Rotation Sites: Ambulatory care, Neurology, Psychiatry, Home care, Nursing home, Transitional care, Long term care, Palliative medicine
• ACGME Competencies: Medical knowledge, Patient care
8. Assess and manage cognitive and behavioral manifestations of dementia, both behaviorally and pharmacologically, based on current best evidence.
• Rotation Sites: Ambulatory care, Neurology, Psychiatry
• ACGME Competencies: Medical knowledge, Patient care
9. Identify dementia patients who might be appropriate for hospice care, and initiate discussions with caregivers.
• Rotation Sites: All or multiple sites, Palliative Care/Hospice
• ACGME Competencies: Medical knowledge, Patient care, Systems-based practice, Interpersonal communication
10. Formulate a differential diagnosis and implement an evaluation and management plan for depressive symptoms and major depression.
• Rotation Sites: Ambulatory care, Neurology, Psychiatry, Nursing home, Home care, Long term care, Consults
• ACGME Competencies: Medical knowledge, Patient care
11. Diagnose anxiety and anxiety related disorders and implement a management plan.
• Rotation Sites: Neurology, Psychiatry, Ambulatory care
• ACGME Competencies: Medical knowledge, Patient care
12. Formulate a differential diagnosis for causes of mood disorders and personality changes in older adults.
• Rotation Sites: Neurology, Psychiatry, Ambulatory care
• ACGME Competencies: Medical knowledge, Patient care
13. Formulate a differential diagnosis and implement an evaluation and management plan for psychotic symptoms and hallucinations.
• Rotation Sites: Neurology, Psychiatry
• ACGME Competencies: Medical knowledge, Patient care
14. Diagnose and manage substance abuse in older adults.
• Rotation Sites: Psychiatry, Ambulatory care
• ACGME Competencies: Medical knowledge, Patient care
15. Formulate mental health care plans that include cultural aspects of mental health among differing ethnicities, culture-specific beliefs and attitudes towards mental health care
• Rotation Sites: Psychiatry
• ACGME Competencies: Medical knowledge, Patient care, Professionalism, Cultural competency
16. Formulate, evaluate, and manage medical causes of cognitive changes in older adults
• Rotation Sites: Multiple, Neurology, Psychiatry, Nursing home care, Long term care, Ambulatory Care, Consults
• ACGME Competencies: Medical knowledge, Patient care
17. Demonstrate effective communication and care planning with inter-professional team members in the care of older adults with mental health disorders
• Rotation Sites: Psychiatry, Inpatient care, Nursing home care
• ACGME Competencies: Professionalism, Systems-based practice
18. Demonstrate proper documentation in mental health care plans
• Rotation Sites: Psychiatry
• ACGME Competencies: Systems-based practice
Geropharmacology
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Describe age related changes in pharmacokinetics (renal, hepatic, body composition) and pharmacodynamics in older adults, and justify drug selection and dosing regimens based on these changes.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
2. Identify medications that should be avoided or used with caution in older adults, and discuss the principles behind those recommendations.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
3. Apply best practices of medication management in older adults when prescribing (including starting low, going slow, but giving adequate therapeutic trial, decreasing polypharmacy when possible).
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication
4. Identify possible reasons for nonadherence and institute strategies to maximize medication adherence.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication
5. Conduct a medication reconciliation whenever transferring a patient to a different care system.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication, Systems-based practice
6. Regularly review all medications, including OTC and CAM, for drug-drug, drug-disease and drug-food interactions.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication
7. Recommend appropriate versus inappropriate use of vitamin and mineral supplements based on available evidence.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Geriatric Syndromes
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
Frailty:
1. Identify the elements that characterize the frailty syndrome and describe the consequences of frailty.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge
2. Implement strategies to manage patients who are frail or at risk of becoming frail.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care
3. Estimate a patient's life expectancy and whether s/he is vulnerable for developing functional decline in the next few years.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Patient care; Systems-based practice
Sensory loss:
1. Perform and interpret brief screens for sensory loss and make appropriate recommendations based on results.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Interpersonal communication, Patient care
2. Describe and implement strategies to enhance communication with patients with sensory impairments.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Interpersonal communication, Patient care
3. List indications for referral to ENT, audiology, neurology, ophthalmology/optometry or low vision services for patients with vision and/or hearing loss.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Systems-based practice, Patient care, Medical knowledge
4. Discuss the magnitude and impact of sensory loss on function and quality of life in older adults.
• Rotation Sites: Didactic/seminar
• ACGME Competencies: Medical knowledge
5. Interpret results of an audiology evaluation.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Patient care
Pain:
1. Manage pain effectively, including differentiating between acute/chronic pain, different types of pain, choose appropriate medications, change medications as required using dosing equivalence, and indications/contraindications for different analgesics.
• Rotation Sites: All or multiple sites, Palliative Care/Hospice
• ACGME Competencies: Patient care
2. Utilize nonpharmacologic strategies for managing pain, working with other team members when appropriate.
• Rotation Sites: All or multiple sites, Palliative Care/Hospice
• ACGME Competencies: Patient care, Interpersonal and Communication skills, Systems-based practice, Professionalism
3. Manage common complications of pain medications, including constipation, nausea, fatigue, and myoclonus.
• Rotation Sites: All or multiple sites, Palliative Care/Hospice
• ACGME Competencies: Patient care, Medical knowledge
Delirium:
1. Perform and interpret common delirium screening tools, including the CAM (confusion assessment method) and act on its results.
• Rotation Sites: All or multiple sites, Geriatrics consultation or Inpatient service
• ACGME Competencies: Patient care, Medical knowledge
2. Execute an urgent diagnostic work up for delirium and implement a management plan.
• Rotation Sites: All or multiple sites, Geriatrics consultation or Inpatient service
• ACGME Competencies: Patient care
3. Implement strategies to prevent and reduce delirium in older patients.
• Rotation Sites: All or multiple sites, Geriatrics consultation or Inpatient service
• ACGME Competencies: Patient care, Systems-based practice
Sleep disorders:
1. Describe sleep changes with aging.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge
2. Diagnose and manage common sleep disorders associated with aging, using nonpharmacologic methods, and when indicated, pharmacologic methods.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal and Communication skills
Pressure ulcers:
1. Describe the complications (medical and economic) of skin ulcers
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Medical knowledge
2. Describe the risk factors (intrinsic and extrinsic) and perform/interpret a risk assessment tool (ex: Braden scale)
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Medical knowledge
3. Work with medical teams to implement strategies to prevent and reduce pressure ulcers in older patients.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal and Communication skills, Systems-based practice, Professionalism
4. Demonstrate proficiency in the indications for and applications of non-surgical and surgical treatments for ulcers.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Medical knowledge
Geriatric Syndromes II
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
Incontinence:
1. Identify and treat potentially reversible causes of incontinence.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
2. Diagnose and treat urge incontinence and mixed incontinence with nonpharmacological and pharmacological techniques.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
3. Diagnose and treat stress incontinence, including nonpharmacological and pharmacological techniques.
• Rotation Sites:
• ACGME Competencies: Medical knowledge, Patient care
4. Identify indications for a specialty/surgical referral for incontinence.
• Rotation Sites:
• ACGME Competencies: Patient care, Systems-based practice
5. Manage incontinence nonpharmacologically in patients with cognitive and/or functional impairment.
• Rotation Sites:
• ACGME Competencies:
6. Identify when longterm indwelling bladder catheters are necessary and manage them appropriately.
• Rotation Sites:
• ACGME Competencies:
Malnutrition:
1. Evaluate for nutritional disorders using BMI, weight loss criteria, and standard tools.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
2. Describe appropriate indications for nutritional supplementation, enteral tube feeding, and parenteral nutrition.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Falls and Gait Disorders:
1. Perform and interpret common gait assessments, including the "get up and go", "timed up and go", "Tinetti", and iPOMA.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
2. Implement evidence-based strategies to reduce falls and fractures in patients in all health care settings.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Practice-based learning
3. Design an appropriate workup for patients who fall and implement strategies to reduce future falls, injuries, and fractures.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care
4. Describe the magnitude and consequences of falls, including fear of falling, hip and other fragility fractures, and nursing home placement.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge
Consequences of immobility:
1. Describe consequences of immobility, and implement strategies for reducing and preventing immobility.
• Rotation Sites: Geriatrics consult or Inpatient service, All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care, Practice-based learning
Dizziness/Lightheadedness:
1. Recognize that the most common causes of dizziness in elders is multifactorial, and implement management strategies for dealing with multifactorial dizziness.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
2. Recognize the symptoms of dizziness that may point to a single or serious disorder, including vertigo and near syncope, and institute an appropriate workup, referral, and management plan based on symptoms and physical findings.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care
Functional Assessment and Rehabilitation
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Demonstrate the ability to perform a functional assessment that is appropriate to the health care setting.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care
2. Recognize when a referral to PT, OT, or Speech Therapy is appropriate.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice
3. Recognize indications for specific assistive devices, and be proficient in educating patients in the appropriate use of canes and walkers.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care
4. Identify patients who are appropriate for inpatient rehabilitation units, home rehabilitation, outpatient rehabilitation, and nursing home rehabilitation.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice, Patient care
5. Demonstrate the ability to assess for functional impairment (including ADLs and IADLS) and changes in functional status, using both historical and physical examination data, make appropriate recommendations based on abnormal results, and monitor changes.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care
6. Describe the rehabilitation program and prognosis for older adults with common conditions such as stroke, hip fracture, deconditioning from illness, rotator cuff injury
• Rotation Sites:
• ACGME Competencies:
Caring for the Elderly Patient
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Demonstrate ability to respectfully, effectively and consistently communicate with all members of inter and multidisciplinary teams, reflecting knowledge of other disciplines' scope of care and commitment to shared problem solving.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice, Professionalism, Interpersonal communication
2. Explain the role of geriatrics in the overall health care system.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice
3. Demonstrate sensitivity and expertise in communicating with patients and families of different cultural backgrounds, social status and literacy levels, as well as with individuals affected by sensory and/or cognitive impairments.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Professionalism, Interpersonal communication
4. Demonstrate the ability to sensitively deliver bad news to patients/families, being aware of culture, social status, literacy, personality traits, and coping style.
• Rotation Sites: All or multiple sites, Palliative Care/Hospice
• ACGME Competencies: Professionalism, Interpersonal communication
5. Exhibit respectful behaviors toward older adults.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Professionalism, Interpersonal communication
6. Dispel stereotypes related to older people during clinical encounters and structured teachings.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Professionalism
7. Educate learners, patients and families, while remaining sensitive to cultural background, social status and literacy.
• Rotation Sites:
• ACGME Competencies: Systems-based practice, Professionalism, Interpersonal communication, Practice-based learning
8. Demonstrate skills to explore and discuss advance care planning with elderly individuals who are healthy or suffer from chronic, progressive illness and those in long-term care or their caregivers.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Interpersonal and Communication skills, Professionalism
Hospital Care
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Implement strategies for preventing the most common potential hazards of hospitalization among elders (including immobility, falls, delirium, pressure ulcers, malnutrition, procedures, indwelling catheters, nosocomial infections).
• Rotation Sites: Geriatrics consultation or Inpatient service
• ACGME Competencies: Practice-based learning, Patient care
2. Implement strategies to minimize indwelling urinary catheter use, and identify the indications for indwelling catheter use.
• Rotation Sites: Geriatrics consultation or Inpatient service
• ACGME Competencies: Practice-based learning, Patient care
3. Formulate safe discharge plans, including working with other team members to choose the most appropriate discharge setting and services for the patient.
• Rotation Sites: Geriatrics consultation or Inpatient service
• ACGME Competencies: Systems-based practice, Patient care, Interpersonal communication
4. Perform pre-operative assessments for older patients and make specific recommendations based on type of surgery and patient characteristics.
• Rotation Sites: Geriatrics consultation or Inpatient service
• ACGME Competencies: Patient care
5. Recognize the risks of, and indications for, restraint use, and implement strategies to minimize restraint use.
• Rotation Sites: Geriatrics consultation or Inpatient service
• ACGME Competencies: Patient care, Practice-based learning
6. Implement strategies to reduce the most common post operative complications in older adults (including delirium, pain, deconditioning, urinary tract infection).
• Rotation Sites: Geriatrics consultation or Inpatient service
• ACGME Competencies: Patient care, Practice-based learning
Ambulatory Geriatrics
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Perform an efficient outpatient geriatric assessment, and implement a management plan based on the findings, working with other team members as appropriate and available.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Patient care
2. Demonstrate the ability to manage multiple comorbidities, utilizing evidence, patient’s goals, and estimated life expectancy.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Patient care, Interpersonal communication
3. Choose appropriate billing codes for outpatient visits.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Systems-based practice
4. Demonstrate the ability to manage time efficiently in the outpatient setting.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Practice-based learning, Patient Care
5. Utilize consultants and other team members appropriately for ambulatory patients.
• Rotation Sites: Ambulatory care
• ACGME Competencies: Systems-based practice
Home Care
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Describe indications and potential benefits of a physician home care visit.
• Rotation Sites: Home visit
• ACGME Competencies: Systems-based practice, Patient care
2. Execute a home care visit, including modifying the physical exam for the home care setting, and performing a home safety assessment.
• Rotation Sites: Home visit
• ACGME Competencies: Patient care
3. Explain home care regulations and reimbursement guidelines under Medicare and Medicaid.
• Rotation Sites: Home visit
• ACGME Competencies: Systems-based practice
4. Utilize the home health and support services available to help frail elders maintain independence.
• Rotation Sites: Home visit
• ACGME Competencies: Systems-based practice, Interpersonal communication, Professionalism
Long Term Care and Nursing Home Care
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Modify management of common medical problems in the nursing home setting based on prognosis, comorbidity, patient goals, and resource limitations.
• Rotation Sites: Long term care
• ACGME Competencies: Patient care
2. Prioritize appropriate long term care settings for the patient, including independent living, assisted living, nursing home, skilled nursing home care, subacute care, adult day care, and rehabilitation unit.
• Rotation Sites: Long term care
• ACGME Competencies: Systems-based practice
3. Describe responsibilities of a nursing home medical director.
• Rotation Sites: Long term care
• ACGME Competencies: Systems-based practice
4. Prevent and manage common problems in the nursing home, including functional decline, falls, incontinence, pressure ulcers, and malnutrition.
• Rotation Sites: Long term care
• ACGME Competencies: Patient care
5. Manage common acute problems in nursing homes via phone call, incorporating patient preferences and staffing/technological limitations into the management plan.
• Rotation Sites: Long term care
• ACGME Competencies: Patient care
6. Describe the most common payment sources for different long term care venues.
• Rotation Sites: Long term care
• ACGME Competencies: Systems-based practice
7. Summarize important nursing home regulations, the minimum data set, the physician's role in nursing homes, and requirements under OBRA.
• Rotation Sites: Long term care
• ACGME Competencies: Systems-based practice, Practice-based learning
Palliative Care
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Discuss patients' values, including cultural values, and spiritual needs and goals of care.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication, Professionalism
2. Discuss advance directives with patients and/or surrogates, using existing tools as appropriate.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Medical knowledge, Patient care, Interpersonal communication, Systems-based practice
3. Manage Pain [See Geriatric Syndromes]
4. Assess and manage common non pain symptoms at the end of life care, including nausea, constipation, dyspnea, partial/complete bowel obstruction, delirium, depression, fatigue, anxiety, and sleeplessness.
• Rotation Sites: All or multiple sites, Palliative Care/Hospice
• ACGME Competencies: Patient care
5. Recognize and manage common side effects of opioids, including constipation, nausea, sedation, fatigue, and myoclonus.
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Patient care
6. Recognize and manage the imminently dying patient; support caregivers.
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Patient care
7. Distinguish and explain the concepts of palliative care, hospice care, Medicare hospice benefit to all stakeholders; select different sites for end of life care according to patients’/caregivers’ values and wishes; discuss the financial implications of each.
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Systems-based practice
8. Demonstrate sensitivity to the impact that death has on family and team members (death reviews and grief interventions).
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Professionalism, Interpersonal communication, Patient care
9. Utilize the interdisciplinary team according to their expertise and patient needs.
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Professionalism, Interpersonal communication, Patient care
10. Manage terminal malnutrition and dehydration.
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Patient care
11. Recognize patients likely to benefit from hospice care, including those with non-cancer diagnoses (end-stage dementia, COPD, CHF, etc.).
• Rotation Sites: Palliative Care/Hospice
• ACGME Competencies: Systems-based practice
Economic Aspects of Care
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Demonstrate the ability to bill Medicare appropriately for outpatient, home, inpatient, and nursing home care.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice
2. Summarize the basic structure of Medicare, including Medicare A, B, D, Medicare Advantage, PACE, hospice, and Medigap policies.
• Rotation Sites: Didactic/seminar
• ACGME Competencies: Systems-based practice
3. Describe the basic structure of Medicaid for older adults, Medi-Medi coverage, and long term care benefits.
• Rotation Sites: Didactic/seminar
• ACGME Competencies: Systems-based practice
4. Outline the components of a quality improvement program to address a specific issue in geriatric care.
• Rotation Sites: Didactic/seminar, Longitudinal geriatric site (LTC or ambulatory)
• ACGME Competencies: Systems-based practice
5. Demonstrate understanding of the systems approach to medical errors, and participate in a (real or simulated) case that explores the underlying system and context surrounding the occurrence of suboptimal care.
• Rotation Sites: Didactic/seminar, Longitudinal geriatric site (LTC)
• ACGME Competencies: Systems-based practice, Professionalism, Interpersonal communication, Practice-based learning
Preventive Medicine
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Demonstrate appropriate utilization of health promotion and screening interventions for older adults, taking into account comorbidities, life expectancy, patient preferences, and site of care.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care, Systems-based practice
2. Choose appropriate exercise therapies based upon the patient's comorbidities and level of function.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Patient care
3. Write an appropriate exercise prescription based on patient's ability, including precautions.
• Rotation Sites: Longitudinal care (Ambulatory)
• ACGME Competencies: Patient care
4. Provide counseling and education regarding the risks of overuse/misuse of substances such as alcohol, cigarettes, over-the-counter and prescription medicines (e.g. benzodiazepines), especially with respect to the unique features of their metabolism and risks in elder patients.
• Rotation Sites: Long term care, Ambulatory, Inpatient
• ACGME Competencies: Patient care, Medical knowledge, Interpersonal communication
5. Discuss goals of care, patient preferences and values with patients in the context of discussing screening tests (such as colonoscopy, mammogram, PSA, etc).
• Rotation Sites: Didactics/seminars, Longitudinal care (Ambulatory)
• ACGME Competencies: Patient care, Interpersonal communication.
Caregiver, Family, and Community Concerns
The graduating geriatric fellow, in the context of a specific older adult patient scenario (real or simulated), must be able to:
1. Assess for caregiver stress, and utilize team and community resources to reduce caregiver stress, when it is identified.
• Rotation Sites: Ambulatory care, All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication, Systems-based practice
2. Incorporate caregiver needs and limitations into the management plan for homebound patients, utilizing team and community resources when appropriate.
• Rotation Sites: Home visit, Ambulatory care
• ACGME Competencies: Patient care, Interpersonal communication, Systems-based practice
3. Identify patients who are potentially hazardous drivers, institute management strategies to reduce risk, and comply with state and local laws surrounding at-risk drivers.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice
4. List indications for referral to adult protective services for suspected elder abuse and neglect.
• Rotation Sites: All or multiple sites
• ACGME Competencies: Systems-based practice
5. Participate in activities in which a geriatrician acts as a leader or advocate for the elders in their community/region; for example, as a community leader in activities at local hospital or senior center, county council of aging, Alzheimer, and other associations, as well as through collegial interaction with local primary care physicians.
• Rotation Sites: Didactic sessions (e.g. "Fellow Scholarly/Community Projects")
• ACGME Competencies: Professionalism, Systems-based practice
6. Prepare and present lay education talk(s) regarding wellness or preventive medicine topics in geriatrics.
• Rotation Sites:
• ACGME Competencies: Professionalism, Interpersonal communication
7. Recognize and describe age-ism and its impact on patients, their families, physicians and the health care system.
• Rotation Sites: Didactic sessions, All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication, Systems-based practice, Professionalism
8. Recognize, and adjust accordingly to, cultural differences in the meaning and experience of aging, illness, and death, as well as the cultural differences in the role(s) of elders in diverse communities.
• Rotation Sites: Didactic sessions, All or multiple sites
• ACGME Competencies: Patient care, Interpersonal communication, Professionalism
Acknowledgements
A workgroup was convened during the Fellowship Director’s Pre-conference Meeting at the 2007 American Geriatrics Society Annual Meeting. The charge for this workgroup was to identify relevant content domains for geriatrics fellowship training and to develop a set of competency-based learning objectives for each of those domains. The material included is intended to be a resource and a potential starting point for program directors who may be starting a fellowship program or revising an existing curriculum. It is not intended to be a prescription for what should be taught and learned during fellowship training. The workgroup felt that each individual program director would need to develop their own learning goals to match their individual programs and curricula.
The document is now available to all program directors on POGOe. We hope that you find it useful in developing learning objectives for your programs. Thank you to the entire workgroup for their time and efforts in developing this toolkit.
The workgroup included:
Bree Johnston (co-Chair)
Susan Parks (co-Chair)
Adnan Arseven
Claudia Beghe
Diane Chau
Paul Eleazer
Helen Fernandez
Mike Harper
Zhenya Hurd
Liz Herskovits
Rosanne Leipzig
Jonathan Nebeker
Donna Ray
Jorge Ruiz
Karen Sauvigne
David Sengstock
Michi Yukawa
| Attachment | Size |
|---|---|
| Geriatrics Fellowship Objectives Linked to ACGME Competencies 1209.doc | 210.5 KB |
| Geriatrics Fellowship Objectives Linked to ACGME Competencies 1209.pdf | 118.62 KB |