UTMB Internal Medicine Residency
Geriatrics Inpatient Ward – PGY3
Competency-Based Goals, Objectives, Milestones, Teaching
Methods, and Milestone-Based Assessment Tools
Overall Goal
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.
Patient Care
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-3 Patient Care Milestones:
Historical Data Gathering
PC-A4 Role model gathering subtle and reliable information from the patient for junior members
of the healthcare team. (30 months)
Performing a physical exam
PC-B4 Routinely identify subtle or unusual physical findings that may influence clinical decision
making, using advanced maneuvers where applicable. (30 months)
Clinical Reasoning
PC-C4 Recognize disease presentations that deviate from common patterns and that require
complex decision making. (36 months)
Invasive procedures
PC-D2 Appropriately performs point-of-care ultrasound and provides post-procedure
management for this procedure. (36 months)
Diagnostic tests
PC-E4 Make appropriate clinical decision based upon the results of point-of-care ultrasound. (36
months)
Patient Management
PC-F7 Manage patients with conditions that require intensive care. (36 months)
PC-F8 Independently manage patients with a broad spectrum of clinical disorders seen in the
practice of general internal medicine. (36 months)
PC-F9 Manage complex or rare medical conditions. (36 months)
PC-F10 Customize care in the context of the patient’s preferences and overall health. (36 months)
Consultative care
PC-G2 Provide internal medicine consultation for patients with more complex clinical problems
requiring detailed risk assessment. (36 months)
PC-G3 Provide internal medicine consultation with point-of-care ultrasound for patients with
more complex clinical problems requiring detailed risk assessment. (36 months)
Medical Knowledge
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
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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,
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-3 Knowledge Milestones:
Knowledge of core content
MK-A7 Demonstrate sufficient knowledge to evaluate complex or rare medical conditions and
multiple coexistent conditions. (36 months)
MK-A8 Understand the relevant pathophysiology and basic science for uncommon or complex
medical conditions. (36 months)
MK-A9 Demonstrate sufficient knowledge of socio-behavioral sciences including but not limited
to health care economics, medical ethics, and medical education. (36 months)
Diagnostic tests
MK-B5 Understand prior probability and test performance characteristics. (36 months)
Practice-Based Learning and Improvement
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-3 PBLI Milestones:
Improve the quality of care for a panel of patients
PBLI-A4 Identify areas in resident’s own practice and local system that can be changed to
improve affect of the processes and outcomes of care. (36 months)
PBLI-A5 Engage in a quality improvement intervention. (36 months)
Acquires the best evidence
PBLI-C4 Appraise the quality of medical information resources and select among them based on
the characteristics of the clinical question. (36 month)
Appraises the evidence for validity and usefulness
PBLI-D3 With assistance, appraise study design, conduct, and statistical analysis in clinical
research papers. (36 months)
PBLI-D4 Independently, appraise clinical guideline recommendations for bias and cost-benefit
considerations. (36 months)
Applies the evidence to decision-making for individual patients
PBLI-E3 Communicate risks and benefits of alternatives to patients. (36 months)
PBLI-E4 Integrate clinical evidence, clinical context, and patient preferences into decisionmaking. (36 months)
Improves via self-assessment
PBLI-G2 Reflect (in action) when surprised, applies new insights to future clinical scenarios, and
reflects (on action) back on the process. (36 months)
Participates in the education of all members of the health care team
PBLI-H2.1 Give honest assessment and feedback for interns who are supervised. (36 months)
PBLI-H3 Take a leadership role in the education of all members of the health care team. (30
months)
Systems-Based Practice
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
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
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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-3 SBP Milestones:
Works effectively within multiple health delivery systems
SBP-A3 Negotiate patient-centered care among multiple care providers. (36 months)
Works effectively within an interprofessional team
SBP-B4 Demonstrate how to manage the team by utilizing the skills and coordinating the
activities of interprofessional team members. (36 months)
Recognizes system error and advocates for system improvement
SBP-C5 Demonstrate ability to understand and engage in a system level quality improvement
intervention. (36 months)
SBP-C6 Partner with other healthcare professionals to identify, propose improvement
opportunities within the system. (36 months)
Identifies forces that impact the cost of health care and advocates for cost-effective care
SBP-D5 Write notes with documentation appropriate for disease severity and coding. (30 months)
Practices cost-effective care
SBP-E4 Demonstrate the incorporation of cost-awareness principles into complex clinical
scenarios. (36 months)
Professionalism
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:
 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
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Outcomes Assessments (Milestones) – Residents are assessed through the assessment
tools for the achievement of the following PGY-3 Professionalism Milestones:
Adhere to basic ethical principles
P-A4 Uphold ethical expectations of research and scholarly activity. (36 months)
Recognize conflicts of interest
P-E2 Maintain ethical relationships with industry. (30 months)
P-E3 Recognize and manage subtler conflicts of interest. (30 months)
Demonstrate personal accountability
P-F6 Serve as a professional role model for more junior colleagues (e.g., medical students,
interns). (30 months)
P-F7 Recognize the need to assist colleagues in the provision of duties. (30 months)
Practice individual patient advocacy
P-G2 Effectively advocate for individual patient needs. (30 months)
Respect the dignity, culture, beliefs, values and opinions of the patient
P-I2 Recognize and manage conflict when patient values differ from their own. (30 months)
Recognize and address disparities in health care
P-K2 Embrace physicians’ role in assisting the public and policy makers in understanding and
addressing causes of disparity in disease and suffering. (36 months)
P-K3 Advocates for appropriate allocation of limited health care resources. (36 months)
Interpersonal and Communication Skills
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
 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-3 IPCS Milestones:
Communicate effectively
ICS-A6 Engage patients/advocates in shared decision making for difficult, ambiguous or
controversial scenarios. (36 months)
ICS-A7 Appropriately counsel patients about the risks and benefits of tests and procedures
highlighting cost awareness and resource allocation. (36 months)
ICS-A8 Role model effective communication skills in challenging situations. (36 months)
Intercultural sensitivity
ICS-B3 Actively seek to understand patient differences and views and reflects this in respectful
communication and shared decision-making with the patient and the healthcare team. (30 months)
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Interprofessional team
ICS-D3 Engage in collaborative communication with all members of the health care team. (30
months)
Consultation
ICS-E3 Communicate consultative recommendations to the referring team in an effective manner.
(36 months)
Health records
ICS-F3 Write notes with appropriate details for disease severity/complexity, essential
communication and coding/reimbursement. (30 months)
ICS-F3.1 Provide EMR notes that conscientiously include all necessary details for current
medical decisions while avoiding entries that confuse, delay or discourage care. (36 months)
Learning Activities
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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
Methods and Tools for Assessing Residents
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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.
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
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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
Duty Hours for Interns and Residents
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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
(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
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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.
Responsibilities, Supervision and Lines of Authority for Clinical
Rotations
1. Team Composition:
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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:
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Potentially unstable patients
Transfers to intensive care
Deaths (expected and unexpected)
Changes in patient status
Procedures
Unpleasant social issues
Risk management issues
Patients leaving or declining urgent treatment against
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medical advice
Restricted drug/treatment approval
Potential admissions better served on another service or
with short-term outpatient follow-up
c. Intern:
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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
Educational Resources
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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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