To make physicians in Internal Medicine competent to care for geriatrics patients by equipping them with requisite knowledge, skills, character qualities, and habits essential for them to demonstrate competence in patient care, knowledge, practice-based learning and improvement, systems-based practice, professionalism, and interpersonal and communication skills relevant to the treatment of health problems in acutely ill inpatients.
Competence 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 in adults.
Learning Objectives - Residents are taught the following patient management skills.
Each resident is taught how to:

Demonstrate the ability to provide patient care in a geriatrics inpatient ward.
MPC,LSC,WR/DO,MSF,LB,CA, MINICEX

Demonstrate accurate, complete, and relevant history-taking, including family, genetic, psychosocial, and environmental histories. MPC,LSC,WR/ DO,CA,
MINICEX,

Demonstrate the ability to perform a comprehensive and accurate physical examination. MPC,LSC,WR/DO, CA, MINICEX

Demonstrate the ability to arrive at an appropriate differential diagnosis, outline a logical plan for specific and targeted investigations pertaining to the patient’s complaints, and formulate a plan for management and follow-up treatment of the patient. MPC,LSC,WR/DO, CA, MINICEX

Demonstrate the ability to provide patient care in a variety of roles, to include serving as the direct provider, member of a multi-disciplinary team of providers, and a teacher to the patient and other physicians. MPC,LSC,WR/DO,MSF, TOC

Demonstrate proficiency on interprofessional geriatric teams including geriatrician, nurse, social worker/case manager, physical therapist, occupational therapist, dietician, and pastoral care with contributions from pharmacy, and other medical disciplines. MPC,LSC,WR/DO,MSF

Demonstrate the ability to perform procedures such as venipuncture, arterial puncture for ABG, PAP smear, and ultrasound guided procedures: peripheral and central intravenous access, paracentesis, thoracentesis, and lumbar puncture.
MPC,LSC,WR, ProSim/DO ,LB,

Demonstrate the ability to treat patients with practices that are safe, scientifically based, effective, efficient, timely, and cost effective. MPC,LSC,WR/DO
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Outcomes Assessments (Milestones) – Residents are evaluated through the assessment tools for the achievement of the following PGY-2 Patient Care Milestones:
Historical Data Gathering
PC-A3 Obtain relevant historical subtleties that inform and prioritize both differential diagnoses and diagnostic plans, including sensitive, complicated, and detailed information that may not often be volunteered by the patient. (18 months)
Performing a physical exam
PC-B3 Demonstrate and teach how to elicit important physical findings for junior members of the healthcare team. (24 months)
Clinical Reasoning
PC-C3 Modify differential diagnosis and care plan based upon clinical course and data as appropriate. (24 months)
Invasive procedures
PC-D1 Appropriately perform invasive procedures and provide post-procedure management for common procedures. (18 months)
Diagnostic tests
PC-E2 Make appropriate clinical decision based upon the results of more advanced diagnostic tests. (18 months)
Patient Management
PC-F5 With minimal supervision, manage patients with common and complex clinical disorders seen in the practice of inpatient and ambulatory general internal medicine. (18 months)
PC-F6 Initiate management and stabilize patients with emergent medical conditions. (18 months)
Consultative care
PC-G1 Provide specific, responsive consultation to other services. (24 months)
Competence Goal
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, relevant to the care of geriatrics patients.
Learning Objectives– Residents are taught to be competent in the knowledge of these areas. Each resident is given multiple opportunities to demonstrate competence in:

Demonstrate a core fund of knowledge of the physiology and natural history of aging, pathologic changes with aging, epidemiology of aging populations, and diseases of the aged. MPC,LSC,WR/DO, WT

Demonstrate a core fund of knowledge of geriatric assessment, including medical, affective, cognitive, functional status, social support, economic, and environmental aspects related to health; activities of daily living (ADL); the instrumental activities of daily living (IADL); medication review, the appropriate use of the history; physical and mental examination; and laboratory.
MPC,LSC,WR/DO

Demonstrate a core fund of knowledge of topics of special interest to geriatric medicine, including cognitive impairment, depression, falls, incontinence, osteoporosis, fractures, sensory impairment, pressure ulcers, sleep disorders, pain, senior (elder) abuse, malnutrition, and functional impairment. MPC,LSC,WR/DO

Demonstrate a core fund of knowledge of diseases that are especially prominent in the elderly including neoplastic, cardiovascular, neurologic, musculoskeletal,
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metabolic, and infectious disorders. MPC,LSC,WR/DO

Demonstrate a core fund of knowledge of pharmacologic problems associated with aging, including changes in pharmacokinetics and pharmacodynamics, drug interactions, appropriate prescribing, and adherence. MPC,LSC,WR/DO
Demonstrate a core fund of knowledge of psychosocial aspects of aging, including interpersonal and family relationships, living situations, adjustment disorders, depression, bereavement, and anxiety. MPC,LSC,WR/DO

Demonstrate a core fund of knowledge of ethical and legal issues especially pertinent to geriatric medicine, including limitation of treatment, decision making capacity, guardianship, right to refuse treatment, advance directives, designation of a surrogate decision maker for health care, wills, and durable power of attorney for medical affairs. MPC,LSC,WR/DO

Demonstrate a core fund of knowledge of general principles of geriatric rehabilitation, including those applicable to patients with orthopedic, rheumatologic, cardiac, pulmonary, and neurologic impairments.
MPC,LSC,WR/DO

Demonstrate a core fund of knowledge of perioperative assessment and involvement in management. MPC,LSC,WR/DO
Outcomes Assessments (Milestones) – Residents are assessed through the assessment tools for the achievement of the following PGY-2 Knowledge Milestones :
Knowledge of core content
MK-A1 Understand the relevant pathophysiology and basic science for common medical conditions. (6 months)
MK-A1.1 Understand the relevant pathophysiology and basic science for common critical conditions that require ICU care. (6 months)
MK-A2 Demonstrate sufficient knowledge to diagnose and treat common conditions that require hospitalization. (12 months)
MK-A2.2 Demonstrate sufficient knowledge to diagnose and treat common conditions that require ICU care. (12 months)
Diagnostic tests
MK-B1 Understand indications for and basic interpretation of common diagnostic testing, including but not limited to routine blood chemistries, hematologic studies, coagulation tests, arterial blood gases, ECG, chest radiographs, pulmonary function tests, urinalysis and other body fluids. (12 months)
Competence Goal
Residents must demonstrate the skills and habits 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.
Learning Objectives – Residents are taught the following skills and habits. Each resident is given multiple opportunities to demonstrate:

The skill and habit of identifying strengths, deficiencies and limits in their knowledge and expertise, to set learning improvement goals, to use information technology to locate scientific studies related to their patients’ health problems, to
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critically appraise clinical studies, to teach and to facilitate the learning of other students and health care professionals. MPC,LSC,WR/DO, PBLM
 The skill and habit of systematically analyzing practice using quality improvement methods, and implementing changes with the goal of practice improvement.
MPC,LSC,QI course/DO
 The skill and habit of incorporating formative evaluation feedback into daily practice. MPC,LSC,/DO, PBLM
 The skill and habit of participating in the education of patients, families, students, residents and other health professionals.
MPC,LSC/DO, PBLM , MINICEX
Outcomes Assessments (Milestones) – Residents are assessed through the assessment tools for the achievement of the following PGY-2 PBLI Milestones:
Improve the quality of care for a panel of patients
PBLI-A2 Perform or review audit of a panel of patients using standardized, disease-specific, and evidence-based criteria. (24 months)
PBLI-A3 Reflect on audit compared with local or national benchmarks and explore possible explanations for deficiencies, including doctor-related, system-related, and patient related factors.
(24 months)
Ask answerable questions for emerging information needs
PBLI-B2 Classify and precisely articulate clinical questions. (24 months)
PBLI-B3 Develop a system to track, pursue, and reflect on clinical questions. (24 months)
Acquires the best evidence
PBLI-C3 Effectively and efficiently search evidence-based summary medical information resources. (24 months)
Appraises the evidence for validity and usefulness
PBLI-D2 With assistance, appraise clinical guideline recommendations for bias. (24 months)
PBLI-D2.1 With assistance, appraise clinical research papers for validity, usefulness and general ability. (24 months)
Applies the evidence to decision-making for individual patients
PBLI-E2 Customize clinical evidence for an individual patient. (24 months)
Improves via feedback
PBLI-F2 Actively seeks feedback from all members of the health care team. (18 months)
PBLI-F3 Calibrate self-assessment with feedback and other external data. (24 months)
PBLI-F4 Reflect on feedback in developing plans for improvement. (24 months)
Improves via self-assessment
PBLI-G1 Maintain awareness of the situation in the moment, and respond to meet situational needs. (24 months)
Participates in the education of all members of the health care team
PBLI-H2 Integrate teaching, feedback, and evaluation with supervision of interns’ and students’ patient care. (24 months)
Competence 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.
Learning Objectives - Residents are taught the following skills. Each resident is given
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multiple opportunities to demonstrate competence in:

The ability to work effectively in an inpatient setting, using systems relevant to that setting. MPC/DO,MSF ,TOC
 The ability to coordinate patient care within the health care system.
MPC,LSC,/DO,MSF ,TOC
 The ability to incorporate considerations of cost awareness and risk-benefit analysis in patient-based care as appropriate.
MPC,LSC,/DO,MSF ,TOC
 The ability to advocate for quality patient care and optimal patient care systems.
MPC,LSC,QIcourse/DO,MSF,
 The ability to work in interprofessional teams to enhance patient safety and improve patient care quality.
MPC,LSC,/DO,MSF ,TOC
 The ability to participate in identifying system errors and implementing potential systems solutions.
MPC,LSC,QIcourse/DO,MSF
 The ability to work in teams and effectively transmit necessary clinical information to ensure safe and proper care of patients including the transition of care between settings.
MPC,LSC,/DO,MSF ,TOC
 The ability to recognize and function effectively in high-quality care systems.
MPC,LSC,/DO,MSF ,TOC, NFCA, NFMR
Outcomes Assessments (Milestones) – Residents are assessed through the assessment tools for the achievement of the following PGY-2 SBP Milestones :
Works effectively within multiple health delivery systems
SBP-A2 Manage and coordinate care and care transitions across multiple delivery systems, including ambulatory, subacute, acute, rehabilitation, and skilled nursing. (24 months)
Works effectively within an interprofessional team
SBP-B3 Consider alternative solutions provided by other teammates. (18 months)
Recognizes system error and advocates for system improvement
SBP-C3 Dialogue with care team members to identify risk for and prevention of medical error.
(24 months)
SBP-C4 Understand mechanisms for analysis and correction of systems errors. (24 months)
Identifies forces that impact the cost of health care and advocates for cost-effective care
SBP-D3 Identify the role of various health care stakeholders including providers, suppliers, financiers, purchasers and consumers and their varied impact on the cost of and access to health care. (24 months)
SBP-D4 Understand coding and reimbursement principles. (24 months)
Practices cost-effective care
SBP-E3 Demonstrate the incorporation of cost-awareness principles into standard clinical judgments and decision making. (18 months)
Competency Goal
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles.
Learning Objectives – Residents are taught to seek and possess the following character traits. Each resident is given multiple opportunities to demonstrate:
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 Compassion, integrity, and respect for others.
MPC,LSC/DO,MSF,
 Responsiveness to patient needs that supersedes self-interest.
MPC,LSC/DO,MSF
 Respect for patient privacy and autonomy.
MPC,LSC/DO,MSF
 Accountability to patients, society and the profession.
MPC,LSC/DO,MSF
 Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation. MPC,LSC/DO,MSF
Outcomes Assessments (Milestones) – Residents are assessed through the assessment tools for the achievement of the following PGY-2 Professionalism Milestones :
Demonstrate compassion and respect to patients
P-B3 Provide support (physical, psychological, social and spiritual) for suffering patients and their families. (24 months)
P-B4 Provide leadership for a team that respects patient dignity and autonomy. (24 months)
Provide timely, constructive feedback to colleagues
P-C2 Recognize, respond to and report impairment in colleagues or substandard care via peer review process. (18 months)
Demonstrate personal accountability
P-F5.5 Demonstrate professional conduct at all times. (18 months)
P-F5.6 Demonstrate good judgment to call for faculty assistance when appropriate. (18 months)
Comply with public health policies
P-H1 Recognize and take responsibility for situations where public health supersedes individual health (e.g. reportable infectious diseases) (24 months)
Confidentiality
P-J2 Educate and hold others accountable for patient confidentiality. (18 months)
Communicate effectively
ICS-A4 Engage patients/advocates in shared decision making for uncomplicated diagnostic and therapeutic scenarios. (24 months)
ICS-A5 Utilize patient-centered education strategies. (24 months)
Transitions of care
ICS-C2 Role model and teach effective communication with next caregivers during transitions of care. (24 months)
Competency Goal
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals.
Learning Objectives - Residents are taught the following skills. Each resident is given multiple opportunities to demonstrate competence in:
 Communicating effectively with patients and families across a broad range of socioeconomic and cultural backgrounds. MPC,LSC, /DO,MSF ,MINICEX
 Communicating effectively with physicians, other health professionals, and health related agencies.
MPC,LSC /DO,MSF, CA, PBLM, TOC
 Working effectively as a member of a health care team.
MPC,LSC/DO,MSF,
TOC
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 Maintaining comprehensive, timely, and legible medical records.
MPC,LSC /DO,
CA, TOC
Outcomes Assessments (Milestones) – Residents are assessed through the assessment tools for the achievement of the following PGY-2 IPCS Milestones :
Communicate effectively
ICS-A4 Engage patients/advocates in shared decision making for uncomplicated diagnostic and therapeutic scenarios. (24 months)
ICS-A5 Utilize patient-centered education strategies. (24 months)
Transitions of care
ICS-C2 Role model and teach effective communication with next caregivers during transitions of care. (24 months)
Health records
ICS-F2 Ensure succinct, relevant, and patient-specific written communication. (24 months)
ICS-F2.1 Write authentic, personal, and original EMR notes that contain data highly relevant to the date and time of the note. (18 Months)

MPC – Mentored Patient Care: Practical teaching and role modeling during direct patient care during clinical rotations.

LSC - Lectures/Seminars/Conferences
 Grand Rounds

Noon Conference

Residents Conference

Clinic Conference

Morning Report

Journal Club

Morbidity and Mortality

Clinical-Pathological Conference

Board Review Sessions

Quality Improvement Course
 Palliative Care Course

Ultrasound Course

Procedure Simulation

Coding Course

Professionalism

WRT - Weekly Reading/Testing/Feedback

WT – Weekly Tests evaluating knowledge base for all competencies and subspecialties.

DO - Direct Observation of competency-based performance by qualified faculty guided by PGY-specific, milestone-based assessment tools. Included in MSF.

DO –P - Direct Observation by Peers evaluation of competency-based performance, guided by PGY-specific, milestone-based assessment tools.
Included in MSF.
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
ITE - In-Training Exam

LB - Log Books for procedures

NPF – Non-Physician Feedback (360° evaluation) evaluation by nurses, case managers, allied health personnel, and other team members assessing competency-based performance guided by PGY-specific, milestone-based assessment tool. Included in MSF.

CA – Chart Audit (H&P; Progress Note) evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

PBLM - Problem Based Learning and Improvement module evaluation by qualified faculty assessing competency-based performance, guided by PGYspecific, milestone-based assessment tools.

Mini-CEX – Mini Clinical Evaluation Exercise evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestonebased assessment tools with explicit performance criteria.

TOC – Transition of Care evaluation by qualified faculty assessing competencybased performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

NFCA – Night Float Chart Audit (H&P) evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tool with explicit performance criteria.

NFMR – Night Float Morning Report evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

TPT – Teaching Presentation Tool evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

JCP – Journal Club Presentation evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

JCR – Journal Club Reflection evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

MM – Morbidity and Mortality reflection tool self-evaluation guided by PGYspecific, milestone-based assessment tools with explicit performance criteria.

CPI – Clinic Practice Improvement evaluation by qualified faculty assessing competency-based performance, guided by PGY-specific, milestone-based assessment tools with explicit performance criteria.

QI Course Test

The residency program follows the ACGME Duty Hour Requirements.

Duty hours are limited to 80 hours per week, averaged over a four-week period, inclusive of all in-house call and moonlighting activities.

Residents must be scheduled for a minimum of one day free of duty every week
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(when averaged over four weeks). At-home call cannot be assigned on these free days.

Duty periods of PGY-1 residents must not exceed 16 hours in duration.

Duty periods of PGY-2 residents and above may be scheduled to a maximum of
24 hours of continuous duty in the hospital. Programs must encourage residents to use alertness management strategies in the context of patient care responsibilities.
Strategic napping, especially after 16hours of continuous duty and between the hours of 10:00p.m. and 8:00 a.m., is strongly suggested.

It is essential for patient safety and resident education that effective transitions in care occur. Residents may be allowed to remain on-site in order to accomplish these tasks; however, this period of time must be no longer than an additional four hours.

Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.

In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to continue to provide care to a single patient.
Justifications for such extensions of duty are limited to reasons of required continuity for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of a patient or family. Under those circumstances, the resident must: appropriately hand over the care of all other patients to the team responsible for their continuing care; and, document the reasons for remaining to care for the patient in question and submit that documentation in every circumstance to the program director.

PGY-1 residents should have 10 hours, and must have eight hours, free of duty between scheduled duty periods.

Residents in the final years of education (PGY2 and 3) must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or extended periods. This preparation must occur within the context of the80-hour, maximum duty period length, and one-day off-in-seven standards.

While it is desirable that residents in their final years of education have eight hours free of duty between scheduled duty periods, there may be circumstances when these residents must stay on duty to care for their patients or return to the hospital with fewer than eight hours free of duty.

In unusual circumstances, residents may remain beyond their scheduled period of duty or return after their scheduled period of duty to provide care to a single patient. Justifications for such extensions of duty are limited to reasons of required continuity of care for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic attention to the needs of the patient or family. Such episodes should be rare, must be of the residents’ own initiative, and need not initiate a new ‘off-duty period’ nor require a change in the scheduled ‘off duty period.’

Residents must not be scheduled for more than six consecutive nights of night float.

PGY-2 residents and above must be scheduled for in-house call no more frequently than every-third-night.
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1. Team Composition:
The typical ward team will consist of:
1 Attending (Faculty)
1 PGY-II or PGY-III (Resident)
1-2 PGY-I (Intern)
0-4 Junior Medical Students (JMS)
0-1 Acting Interns (Senior Medical Students, A I s)
Other team members such as Case Managers, Nurses, Dieticians,
Social Workers, etc.
2. Responsibilities of Members: a. Attending:
 Oversees team function and overall patient care
 Teaches house staff and medical students
 Monitors discharge planning and expeditious care of patient
 Accepts ultimate legal responsibility for patient's welfare
 Learns from other team members
 Assures attendance of team members at all required conferences. b. Resident:
 Is directly accountable to the attending for the entire service
 Writes a Resident Admit Note (RAN) on each admission.
 Communicates diagnosis and plan of care to the patient's primary care physician.
 Leads work rounds by evaluating the intern treatment plan
 Plans discharges and coordinates patient follow-up
 Teaches interns and students, and sometimes faculty
 Assures attendance of self and team members to all required conferences.
Faculty Notification: It is the responsibility of the resident to contact faculty immediately for the following issues:
 Potentially unstable patients
 Transfers to intensive care
 Deaths (expected and unexpected)
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 Changes in patient status
 Procedures
 Unpleasant social issues
 Risk management issues
 Patients leaving or declining urgent treatment against medical advice
 Restricted drug/treatment approval
 Potential admissions better served on another service or with short-term outpatient follow-up c. Intern:
 Performs and records the admitting H & P on each patient
 Evaluates patients prior to work rounds so that he/she may develop a treatment plan for each of their patients
 Writes orders and daily notes
 Calls consultants
 "Checks out" the patients to the on call intern
 Teaches students, sometimes teaches resident and faculty

UTMB Library Homepage with access to filtered and unfiltered resources, including: o ACP Pier o DynaMed o Textbooks o Up-to-Date o Cochrane o PubMed
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