EDWARD VIA VIRGINIA COLLEGE OF OSTEOPATHIC MEDICINE
Geriatrics Fellowship Manual
Document Owner(s)
Project/Organization Role
Karol Gordon, DO
Program Director
John Kauffman, DO
Director of Medical Education
Signature
Geriatric Fellowship Manual Version Control
Version
Date
Author
Change Description
1
07/24/09
Dawn Stull
New
Note The content of a manual does not constitute nor should it be construed as a promise of
employment or as a contract between Edward Via Virginia College of Osteopathic Medicine –
Geriatric Fellowship Program and any of its employees.
Edward Via Virginia College of Osteopathic Medicine – Geriatric Fellowship Program at its
option, may change, delete, suspend, or discontinue parts or the policy in its entirety, at any time
without prior notice.
Effective 07/01/2010
Geri Residency Manual
Last printed 2/12/2016 10:24:00 AM
Geriatric Fellowship Manual
TABLE OF CONTENTS
1
2
3
4
5
INTRODUCTION ..................................................................................................................... 6
1.1
Welcome ...................................................................................................................... 6
1.2
Changes in Policies ........................................................................................................ 6
PROGRAM............................................................................................................................... 7
2.1
Program Overview ......................................................................................................... 7
2.2
Educational Purpose ...................................................................................................... 8
2.3
General Goals and Objectives ......................................................................................... 8
2.4
Program Administration – Program Director Job Description .......................................... 10
2.5
Fellow: Expected Outcomes – Cognitive Skills & Knowledge ......................................... 11
2.6
Reading Requirements ................................................................................................. 12
2.7
Program Expected Outcomes ........................................................................................ 22
2.8
On-site Review by ACOFP........................................................................................... 22
2.9
Orientation Schedule .................................................................................................... 22
2.10
Program Design ........................................................................................................... 24
APPOINTMENT .................................................................................................................... 26
3.1
Fellowship Appointment .............................................................................................. 26
3.2
Advanced Placement .................................................................................................... 26
3.3
Promotion Criteria ....................................................................................................... 27
3.4
Fellow Qualifications ................................................................................................... 29
3.5
Terms of Service ......................................................................................................... 30
EMPLOYMENT POLICIES ................................................................................................... 31
4.1
Status ......................................................................................................................... 31
4.2
Educational Stipend ..................................................................................................... 31
TIME-OFF BENEFITS ........................................................................................................... 33
5.1
Time Away ................................................................................................................. 33
5.2
Absences .................................................................................................................... 33
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 2
Geriatric Fellowship Manual
6
7
5.3
Illness ......................................................................................................................... 34
5.4
Unauthorized Absence ................................................................................................. 34
5.5
Revocation of Off-Duty Hours ...................................................................................... 34
PROGRAM CURRICULUM .................................................................................................. 35
6.1
Osteopathic Philosophy & OMM .................................................................................. 35
6.2
Continuity Clinic Experience ........................................................................................ 37
6.3
General Medicine and Geriatrics Consultation Service .................................................... 41
6.4
Preventive Medicine .................................................................................................... 45
6.5
Wound Care ................................................................................................................ 47
6.6
Geriatric Psychiatry ..................................................................................................... 50
6.7
Geriatric Urology ........................................................................................................ 55
6.8
Older Women’s Health and Urological Gynecology ....................................................... 58
6.9
Long-Term Care .......................................................................................................... 62
6.10
Geriatric Dermatology ................................................................................................. 68
6.11
Musculoskeletal Disorders in the Elderly ....................................................................... 72
6.12
Rehabilitation/Sub Acute Care ...................................................................................... 75
6.13
Consult Service ........................................................................................................... 79
6.14
Palliative Care ............................................................................................................. 83
6.15
Osteopathic Principles and Practice ............................................................................... 87
6.16
Geriatric Neurology ..................................................................................................... 87
DIDACTIC PROGRAMS ....................................................................................................... 93
7.1
Educational Experience ................................................................................................ 93
7.2
Meeting and Lecture Requirements ............................................................................... 93
7.3
Attendance Rosters ...................................................................................................... 94
7.4
Journal Club ................................................................................................................ 94
7.5
Geriatric Weekly Didactic Lecture Series ...................................................................... 95
7.6
OMM Lecture ............................................................................................................. 95
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 3
Geriatric Fellowship Manual
8
9
10
11
12
COMPORTMENT .................................................................................................................. 96
8.1
Core Competencies ...................................................................................................... 96
8.2
Call Responsibility ...................................................................................................... 98
8.3
Procedures .................................................................................................................. 99
8.4
Moonlighting ............................................................................................................ 100
8.5
Evaluation ................................................................................................................. 100
8.6
Fellow Evaluation of Faculty/Program ........................................................................ 100
8.7
Research Responsibility ............................................................................................. 101
CONTINUITY CLINIC ........................................................................................................ 104
9.1
Overview .................................................................................................................. 104
9.2
Teaching Objectives .................................................................................................. 104
9.3
Continuity Clinic Evaluation ...................................................................................... 105
9.4
Clinic Didactics ......................................................................................................... 105
9.5
Charting .................................................................................................................... 106
9.6
Clinic “After Hours” .................................................................................................. 106
9.7
Procedures ................................................................................................................ 106
9.8
Vacation/Time Off from Clinic ................................................................................... 106
LOGS.................................................................................................................................... 107
10.1
Important Points to Remember.................................................................................... 107
10.2
What to Log .............................................................................................................. 108
10.3
How to Log ............................................................................................................... 108
10.4
Policy Statement ........................................................................................................ 108
MEDICAL DOCUMENTATION .......................................................................................... 110
11.1
Medical Documentation ............................................................................................. 110
11.2
Medical Records ........................................................................................................ 111
11.3
Progress Notes .......................................................................................................... 112
ACKNOWLEDGMENT ....................................................................................................... 113
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 4
Geriatric Fellowship Manual
13
APPENDICES ...................................................................................................................... 114
13.1
Personal Information Sheet ......................................................................................... 114
13.2
Time Log .................................................................................................................. 114
13.3
Fellow Continuity Patient Log .................................................................................... 114
13.4
Attending Evaluation of Fellow Form.......................................................................... 114
13.5
Fellow Evaluation of Faculty Form ............................................................................. 114
13.6
Time Away Request Form .......................................................................................... 114
13.7
360° Evaluation Forms ............................................................................................... 114
13.8
Fellow End-of-Year Checklist .................................................................................... 114
13.9
Employee Expense Reimbursement Form .................................................................... 114
13.10
Patient Evaluation of Fellow ....................................................................................... 114
13.11
Fellow Exit Questionnaire .......................................................................................... 114
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 5
Geriatric Fellowship Manual
1
INTRODUCTION
This document has been developed for the Geriatric Fellowship Program in order to
familiarize fellows with Edward Via Virginia College of Osteopathic Medicine and
provide information about working conditions, key policies, procedures, and benefits
affecting fellowship at Edward Via Virginia College of Osteopathic Medicine.
1.1
Welcome
Welcome to Edward Via Virginia College of Osteopathic Medicine! We are happy to
have you as a new member of our family!
The mission of the Geriatric Fellowship Program is to provide fellows with training in the
development of the clinical competencies needed to diagnose and manage medical
illnesses and injuries related to geriatric medicine in both inpatient and outpatient settings
that will enable them to become competent, proficient and professional osteopathic
geriatric physicians.
1.2
Changes in Policies
This manual supersedes all previous Geriatric Fellowship manuals and memos.
While every effort is made to keep the contents of this document current, Edward Via
Virginia College of Osteopathic Medicine reserves the right to modify, suspend, or
terminate any of the policies, procedures, and/or benefits described in the manual with or
without prior notice to employees.
Return to the beginning of document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 6
Geriatric Fellowship Manual
2
PROGRAM
2.1
Program Overview
The one-year training period is designed to give geriatric medicine fellows a
comprehensive experience. Fellows are exposed to inpatient, ambulatory, consultative,
and long-term care geriatrics. They will interact with geriatrician, geriatric psychiatrists,
and allied health personnel in a multidisciplinary model. The curriculum combines
longitudinal and a rotational model. Concurrently, two half days each week is spent in a
continuity clinic.
There are thirteen four-week block rotations. Seven are required rotations with one block
as an elective rotation. The inpatient core for three months will be primarily based at the
long-term care facility at Warm Harth. The inpatient geriatric consults service will be
held at Montgomery Regional Hospital. The fellow will make the initial contact when a
geriatric consult is requested. The fellow will present to the geriatric attending physician
assigned to the geriatric consult service. The fellow will be involved in the initial care
and continuing responsibilities for all consult patients. The fellow will be a part of the
inpatient multidisciplinary team.
The longitudinal component includes an ambulatory and long-term care experience. The
fellow will have one to two half-day sessions in one of the primary care, family medicine,
or internal medicine clinics. In addition, the fellow will have one to two half-day
sessions in the Showalter consultation and assessment clinic. The conference schedule
will include a weekly conference of one to two hours with members of the faculty for
case presentations, death review and didactics presentations.
The long-term care rotation is four months and includes experiences in both institutional
and non-institutional settings. The fellow will spend four half-days at Warm Harth
Kroontje, a long-term care nursing facility. The remaining two half days will be divided
among experiences in Showalter adult care facility, Good Samaritan Hospice, Skilled
Long-Term Health, Home Care, and an intensive assisted living facility.
The Geriatric Psychiatry rotation is a one-block experience with a geriatric psychiatrist,
and the geriatric psychiatry fellow – if applicable. This will include inpatient, outpatient
and long-term care sites. The fellow will be exposed to a variety of patients and will
have the opportunity to observe electroconvulsive therapy (ECT).
A one-block rotation will be spent in the Salem VAMC Neurology department. The
fellow will work under the direction of a neurologist in the outpatient setting and will
participate in inpatient neurology consults.
The Rehabilitation/Subacute Unit at Pulaski Rehabilitation Center: The fellow will work
in the inpatient sub-acute skilled unit. The fellow will be able to observe and participate
in the subacute phase of care.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 7
Geriatric Fellowship Manual
The final block is reserved for an elective rotation which the fellow may use to enhance
experiences or focus on other clinical areas. The block rotation may be used for research
time or an appropriate clinical experience outside Blacksburg.
2.2
Educational Purpose
The Geriatric Fellowship Program is structured to provide fellows with the fundamental
knowledge, skills and attitudes and principles essential to the practice of geriatrics.
The basic techniques of physical examination, the necessary skills for performing clinical
procedures, and the capability to communicate clearly with patients, their families and
other members of the health care team are stressed in this fellowship.
The program will provide training in the development of the clinical competencies
needed to diagnose and manage medical illnesses and injuries related to geriatrics.
Clinical experience includes hospice care, long-term care and in- and out-patient care;
acute and chronic illness or injury, and rehabilitation as applied to a broad spectrum of
geriatrics patients.
2.3
General Goals and Objectives
The goal of the Geriatrics training program at the Edward Via Virginia College of
Osteopathic Medicine (VCOM) is to train physicians who are competent to deliver and
coordinate the highest quality care for the elderly. This program will provide training in
the development of the clinical competencies needed to diagnose and manage medical
illnesses and injuries related to geriatric medicine. Clinical experience will include longterm care, hospice care, skilled care, and rehabilitation.
Upon completion of the VCOM Program, the Geriatrics Specialist will have achieved the
knowledge and skills necessary to:
A.
Patient Care:
1. Communicate effectively as a geriatric provider recognizing interaction with
the patient, family and other caregivers is vital.
2. Demonstrate an ability to gather essential information.
3. Make informed decisions about diagnostic and therapeutic interventions, use
sound scientific judgment, care, and compassion with the patient and family.
4. Develop relevant plans and manage patients in a variety of settings including
acute care, consultative care, outpatient, long-term care and home care
settings.
5. Demonstrate and practice the important ability to educate patients and
families effectively.
6. Understand and use information technology to make patient care decisions.
7. Participate in comprehensive geriatric assessment and learn the tools utilized
and encountered in the consultation setting.
8. Recognize and practice preventive care in the elderly population.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 8
Geriatric Fellowship Manual
B.
C.
D.
E.
F.
9. Learn the role of the consultant to other primary care physicians as part of
the practice of geriatric medicine.
Medical Knowledge:
1. Understand and use evidence-based practice during care.
2. Learn the current state of epidemiology and demographics of the aging
population, physiologic changes related to aging, and diseases prevalent in
the geriatric population.
3. Recognize the differences in pharmacokinetics and pharmacodynamics that
make prescribing for the elderly particularly challenging.
Practice-based learning and improvement:
1. Participate in quality improvement activities. Use this process to improve
individual practice experience.
2. Locate, evaluate and utilize pertinent evidence from the scientific literature.
3. Obtain and use information about patients cared for in the nursing home, the
ambulatory office and the geriatric consultation center.
4. Be able to understand basics of study design, clinical epidemiology, and
statistical methods to appraise the medical literature. Participate in an
ongoing geriatric medicine journal club.
5. Learn to use the on-line resources for medical information and patient
information pertaining to geriatric topics.
6. Develop teaching skills with medical students, residents, attending and other
caregivers.
Interpersonal and communication skills:
1. Communicate with patients and families in a therapeutic and ethical manor,
learning the skills of a sound relationship, which enhance communication.
2. Demonstrate effective listening skills that provide useful information.
3. Work effectively as a member and/or leader of the geriatric health care team.
Professionalism:
1. Demonstrate respect, integrity and compassion in the care of patients.
2. Use ethical and legal principles pertinent in geriatric medicine. In particular,
be familiar with provision of and the withholding of medical care,
confidentiality of patient information, decision-making capacity and
informed consent.
3. Demonstrate a sensitivity and responsiveness to the patient’s age, disability,
gender and culture.
Systems-based practice:
1. Understand the role of the geriatrician in present healthcare system.
2. Gain an understanding of the different practice possibilities for the
geriatrician (primary care, consultant, academic) in a system that achieves
improved patient care and control cost.
3. Learn the economics involved from a patient and provider perspective,
assisting patients and families with resource allocation.
4. Understand the resources and the access to those resources that will assist
patients in the present healthcare system.
5. Gain an appreciation for the value of the multidisciplinary team assessment
and management of complex physical and social problems. Recognize the
important contributions of other health care professionals offer to elderly
patients.
General Goals and Objectives
Effective 07/01/2010
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Top of the Document
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 9
Geriatric Fellowship Manual
2.4
Program Administration – Program Director Job Description
The Clinical Program Director is directly responsible for the overall program administration of
the Geriatric Fellowship Program.
1. Qualifications:
a) The Program Director shall be actively engaged in the care of geriatric patients;
b) The Program Director shall demonstrate appropriate administrative ability and
practice expertise to implement a training program in Geriatrics;
c) The Program Director shall meet the training requirements as indicated in the
Fellowship Training Requirements of the AOA, as well as the AOA CME
requirements;
d) The Program Director must have licensure to practice medicine in the state where
the institution that sponsors the program is located;
e) The Program Director must have appointment in good standing to the medical staff
of the participating institution.
f) The Program Director must be certified by the AOA through the American
Osteopathic Board of Family Physicians (AOBFP) and hold a current CAQ in
geriatric medicine through the AOBFP;
g) The Program Director must meet the standards of the position as formulated in the
Basic Standards for Residency Training in Osteopathic Family Practice and
Manipulative Treatment of the ACOFP.
2. Responsibilities:
a) The Program Director and DME shall provide for the proper supervision and
clinical teaching of all training assignments and are responsible for the evaluation of
each fellow’s progress, verifying that he/she demonstrates proficiency in meeting or
exceeding the minimum standards for quality patient care;
b) The Program Director must prepare a written statement outlining the educational
goals of the program with respect to knowledge, skills, and other attributes of
fellows at each level of training and for each major rotation or other program
assignment. This statement must be distributed to fellows and members of the
teaching staff and be readily available for review;
c) The Program Director shall arrange affiliations and/or outside rotations necessary to
meet the program objectives;
d) The Program Director shall, in cooperation with the AOA Division of Postdoctoral
Training, prepare materials for program inspection;
e) The Program Director shall provide the fellow with documents pertaining to the
training program as well as requirements for satisfactory completion of the program
as required by the AOA;
f) The Program Director shall be required to submit quarterly evaluations to the DME
and administrator of the institution. Annual reports shall be submitted to the
fellow’s primary certifying board;
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 10
Geriatric Fellowship Manual
g) The Program Director must ensure that fellows are accorded meaningful patient
responsibility with the supervision of a faculty member at all facilities and sites;
h) The Program Director will report to the DME at the Edward Via Virginia College
of Osteopathic Medicine.
i)
Shall ensure oversight of the fellowship by qualified physicians in the area of
Geriatric Medicine.
j)
Design and implementation of a geriatrics curriculum as described in these
standards.
k) The Program Director’s authority in directing the training program must be defined
in the program documents of the institution.
l)
The Geriatrics Program Director must have a reporting relationship to the Family
Practice Program Director.
m) The Geriatrics Program Director will certify completion of the geriatric
fellowship requirements.
2.5
Fellow: Expected Outcomes – Cognitive Skills & Knowledge
At the completion of the training program, the graduate shall:
1. Accurately identify potential medical problems:
a. Describe the medical problems presented.
b. Define information in the patient record which aids in the diagnostic
evaluation.
c. Elicit and record appropriate history which defines the problem.
d. Perform an accurate physical examination to identify and confirm the
differential diagnosis (es).
2. Utilize and interpret laboratory and ancillary testing to define or discover
problems:
a. Accurately diagnose problems.
b. Describe potential etiologies for each presenting diagnosis.
c. Identify signs and symptoms for each diagnosis.
d. Prioritize findings with respect to potential etiologies.
e. Rank potential disorders by likelihood based on presence or absence of
findings.
3. Confirm the patient’s diagnosis:
a. Describe the diagnostic resources for each disorder.
b. Generate a diagnostic plan to appropriately confirm the disorder.
c. Perform diagnostic procedures where appropriate.
d. Properly interpret results of testing, recognizing the relative sensitivity
and specificity of the tests.
e. Understand cost effective diagnostic planning.
4. Competently treat the geriatrics patient:
a. Define the needs and circumstances of the patient.
b. Describe the conventional and alternative therapies for each diagnosis.
c. Generate treatment plans which are cost effective.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 11
Geriatric Fellowship Manual
d. Monitor response to treatment, including appropriate follow-up testing if
needed.
e. Determine efficacy of treatment plan.
5. Communicate effectively:
a. Use standard English effectively.
b. Use accepted medical terminology appropriately.
c. Develop listening skills for patient, family, and ancillary providers.
d. Respond to patient questions and concerns in an effective and sensitive
manner.
e. Record data and plans clearly and completely in progress notes,
summary reports, history and physicals as well as diagnostic and
procedural reports.
f. Respond promptly to requests for information.
g. Demonstrate reasonable facility in the use of computer network
information and record keeping systems.
6. Demonstrate professionalism:
a. Be characterized as competent, approachable, empathetic, conscientious,
and cooperative.
b. Develop sensitive, yet definitive leadership capabilities when dealing
with house staff, students, or ancillary staff.
c. Demonstrate honesty, reliability, and morality.
d. Develop a commitment to the medical community and the advancement
of medical care in the population.
7. Develop strong work habits:
a. Demonstrate ability and proficiency in the use of medical education
resources, such as journals, computer-assisted instruction, and
involvement in conference activities both as learner and instructor.
b. Recognize personal limitations and obtain appropriate assistance where
necessary.
c. Perform all record keeping activities promptly and thoroughly
d. Understand requirements of operating in the managed care environment,
and how to maximize efficiency.
e. Recognize the medico/legal aspects of care, and manage risks
appropriately.
2.6
Reading Requirements
The fellows are required to read the following textbooks as part of their training program:
1. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics, 6th Ed,
2009.
2. David B. Reuben MD, Keela A. Herr PhD RN, James T. Pacala MD MS, and
Bruce G. Pollock MD PhD (current edition) Geriatrics at Your Fingertips.
3. Ags and Grs (current edition) Geriatrics Review Syllabus: A Core
Curriculum in Geriatric Medicine, Sixth Edition (GRS6).
Besides the reading listed under each category in the “Program Curriculum” Section of
the manual, fellows should consider reading the following documents:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 12
Geriatric Fellowship Manual
A) Geriatric Evaluation and Management - Learn comprehensive geriatric evaluation
and management (GEM). Geriatric assessment (both cognitive and functional); the
assessment of basic and instrumental activities of daily living; the appropriate use of
history, physical, and mental examinations; appropriate, cost-effective use of
diagnostic tests.
1) The following textbook/article reading list is recommended to the fellow:
a) William TF. Comprehensive geriatric assessment. In: Duthie EH,
Katz PR (eds). Practice of Geriatrics, Third Edition, Philadelphia,
WB Saunders Company, 1998, p. 15.
b) Williams ME. Approach to managing the elderly patient. In:
Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG.
Principles of Geriatric Medicine and Gerontology, Fourth Edition,
New York, McGraw-Hill, Inc., 1999, p. 249.
c) Reuben DB. Principles of geriatric assessment. In: Hazzard WM,
Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 467.
d) Kane RA, Kane RL. Assessment of the Elderly: A Practical Guide to
Measurement. Lexington, MA, Lexington Books, 1981.
e) Palmer RM. Geriatric assessment. Med Clin North Am 1999; 83(6):
1503-23.
f) McGann PE. Geriatric assessment for the rheumatologist. Rhem Dis
Clin North Am 2000; 26(3): 415-432.
g) Fleming KC, Evans JM, Weber DC, Chutka DS. Practical functional
assessment of elderly persons: a primary-care approach. Mayo Clin
Proc 1995 Sep; 70(9):890-910.
B) Interdisciplinary Teamwork in Geriatrics – Learn to work effectively with different
members of the geriatric health-care team. Appropriate use of multiple professionals,
especially nurses, social workers, and rehabilitation personnel (PT, OT, Speech
Therapy), to assist in assessment and implementation of treatment.
1) The following textbook/article reading list is recommended to the fellow:
a) Kresevic D, Holder C. Interdisciplinary care. Clin Geriatr Med 1998
Nov; 14(4):787-98.
b) Clark PG. Values in health care professional socialization:
implications for geriatric education in interdisciplinary teamwork.
Gerontologist 1997 Aug; 37(4):441-51.
C) Financing of elder care in the United States - Understand the coverage and limitations
of Medicare Parts A and B for inpatient, outpatient, and long-term care; senior health
maintenance organizations; Medi-Cal.
1) The following textbook/article reading list is recommended to the fellow:
a) HCFA, “Medicare and You, 2002”
b) Peak T, Barusch A. Managed care: a critical review. J Health Soc
Policy 1999; 11(1):21-36.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 13
Geriatric Fellowship Manual
c) Beers MH, Baran RW, Frenia K. Drugs and the elderly, Part 1: The
problems facing managed care. Am J Manag Care 2000 Dec;
6(12):1313-20.
d) Beers MH, Baran RW, Frenia K. Drugs and the elderly, Part 2:
Strategies for improving prescribing in a managed care
environment. Am J Manag Care 2001 Jan; 7(1):69-72,
e) Coleman J. Social health maintenance organizations, Part II. Case
Manager 2001 Mar-Apr; 12(2):42-7.
f) Coleman J. PACE programs. Part 1. Case Manager 2000 May-Jun;
11(3):35-41.
g) Coleman J. PACE programs. Part II. Case Manager 2000 Jul-Aug;
11(4):34-7.
D) Cultural and ethnic factors in the care of older patients - Understand the importance
of assessing and addressing cultural biases, preferences, and attitudes regarding
illness and medical care.
1) The following textbook/article reading list is recommended to the fellow:
a) Lane DA, Lip GY. Ethnic differences in hypertension and blood
pressure control in the UK. QJM 2001 Jul; 94(7):391-6.
b) Janevic MR, Connell CM. Racial, ethnic, and cultural differences in
the dementia caregiving experience: recent findings. Gerontologist
2001 Jun; 41(3):334-47.
c) Kuczewski M, McCruden PJ. Informed consent: does it take a
village? The problem of culture and truth telling. Camb Q Healthc
Ethics 2001 Winter;10(1):34-46
E) The demography and epidemiology of aging
1) The following textbook/article reading list is recommended to the fellow:
a) Jackson SA. The epidemiology of aging. In: Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGrawHill, Inc., 1999, p. 203.
b) Population Estimates Program, Population Division, U.S. Census
Bureau, Washington, D.C. January 2, 2001 (Internet download).
F) The biology of aging - Current scientific knowledge of aging and longevity,
including theories of aging, physiologic and pathologic changes of aging, the concept
of frailty.
1) The following textbook/article reading list is recommended to the fellow:
a) Miller RA. Biology of aging and longevity. In: Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGrawHill, Inc., 1999, p. 3
b) Turker MS, Martin GM. Genetics of human disease, longevity, and
aging. In: Principles of Geriatric Medicine and Gerontology, Fourth
Edition, New York, McGraw-Hill, Inc., 1999, p. 21
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 14
Geriatric Fellowship Manual
c) Roth J., Yen C-J. The role of intercellular communication in diseases
of old age. In: Principles of Geriatric Medicine and Gerontology,
Fourth Edition, New York, McGraw-Hill, Inc., 1999, p. 45.
d) Hazzard WR. The gender differential in longevity. In: Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 69
e) Fiatarone-Singh MA, Rosenberg IH. Immunology of aging. In:
Principles of Geriatric Medicine and Gerontology, Fourth Edition,
New York, McGraw-Hill, Inc., 1999, p. 97.
f) Fried LP, Walston J. Frailty and failure to thrive. In: Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 1387.
g) Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C,
Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA;
Cardiovascular Health Study Collaborative Research Group. Frailty
in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med
Sci 2001 Mar; 56(3):M146-56.
h) Yung RL. Changes in immune function with age. Rheum Dis Clin
North Am 2000 Aug; 26(3):455-73.
G) Pharmacologic alterations with aging - Changes in pharmacodynamics,
pharmacokinetics, drug interactions, overmedication and polypharmacy, factors
associated with compliance and non-compliance.
1) The following textbook/article reading list is recommended to the fellow:
a) Beyth RJ, Shorr RI. Medication use. In: Duthie EH, Katz PR (eds).
Practice of Geriatrics, Third Edition, Philadelphia, WB Saunders
Company, 1998, p. 38.
b) Schwartz JB. Clinical pharmacology. In: Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGrawHill, Inc., 1999, p. 303.
c) DeVane CL, Pollock BG. Pharmacokinetic considerations of
antidepressant use in the elderly. J Clin Psychiatry 1999; 60 Suppl
20:38-44.
d) Hammerlein A, Derendorf H, Lowenthal DT. Pharmacokinetic and
pharmacodynamic changes in the elderly. Clinical implications. Clin
Pharmacokinet 1998 Jul; 35(1):49-64.
e) Podrazik PM, Schwartz JB. Cardiovascular pharmacology of aging.
Cardiol Clin 1999 Feb; 17(1):17-34.
f) Abrams WB, Beers MH. Clinical pharmacology in an aging
population. Clin Pharmacol Ther 1998 Mar; 63(3):281-4.
H) Psychosocial considerations in the care of older patients - The pivotal role of the
family or caregiver for dependent elderly; respite care and in-home supportive
services; elder abuse – recognition and prevention; bereavement and depression; care
of the dying patient (from perspective of caregiver – see also “hospice” under #5
above); “successful” aging.
1) The following textbook/article reading list is recommended to the fellow:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 15
Geriatric Fellowship Manual
a) Maddox GL, Glass TA. Sociology of aging. In: Hazzard WM, Blass
JP, Ettinger WH, Halter JB, Ouslander JG (eds). Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p.191.
b) Karuza J. Social support. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company,
1998, p. 23.
c) Blazer DG. Depression. In: Hazzard WM, Blass JP, Ettinger WH,
Halter JB, Ouslander JG (eds). Principles of Geriatric Medicine and
Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999,
p. 1331.
d) Zarit SH, Zarit JM. Mental Disorders in Older Adults. New York,
The Guilford Press, 1998.
e) Vaillant GE, Mukamal K. Successful aging. Am J Psychiatry 2001
Jun; 158(6):839-47.
f) Dunkin JJ, Anderson-Hanley C. Dementia caregiver burden: a
review of the literature and guidelines for assessment and
intervention. Neurology 1998 Jul; 51(1 Suppl 1):S53-60; discussion
S65-7.
g) Hirsch CH, Stratton S, Loewy R. The primary care of elder
mistreatment. West J Med 1999 Jun; 170(6):353-8.
h) Connell CM, Janevic MR, Gallant MP. The costs of caring: impact
of dementia on family caregivers. J Geriatr Psychiatry Neurol 2001
Winter; 14(4):179-87.
i) Parks SM, Novielli KD. A practical guide to caring for caregivers.
Am Fam Physician 2000 Dec 15; 62(12):2613-22.
j) American Family Physician 2000; 65 (12). Handout for patients:
“When You Are the Caregiver.”
k) Silliman RA. Caregiving issues in the geriatric medical encounter.
Clin Geriatr Med 2000 Feb; 16(1):51-60.
I) Ethical and legal issues - Incompetence, substitutive decision-making, advance
health-care directive, conservatorship, informed consent, living wills.
1) The following textbook/article reading list is recommended to the fellow:
a) Loewy, Erich H. The ethics of terminal care: orchestrating the end
of life. Erich H. Loewy and Roberta Springer Loewy. New York,
Kluwer Academic/Plenum Publishers, c2000.
b) Loewy, Erich H. Textbook of healthcare ethics. Erich H. Loewy.
New York: Plenum Press, c1996.
c) Ahronheim, Judith C. Ethics in clinical practice. Judith C.
Ahronheim, Jonathan D. Moreno, Connie Zuckerman. 2nd ed.
Gaithersburg, MD, Aspen Publishers, 2000.
d) Barnes A. Legal issues in geriatric medicine and gerontology. In:
Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds).
Principles of Geriatric Medicine and Gerontology, Fourth Edition,
New York, McGraw-Hill, Inc., 1999, p. 545.
e) Pearlman RA, Back AL. Ethical issues in geriatric care. In: Hazzard
WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds).
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 16
Geriatric Fellowship Manual
Principles of Geriatric Medicine and Gerontology, Fourth Edition,
New York, McGraw-Hill, Inc., 1999, p. 557.
f) Kapp MB. Ethical and legal issues. In: Duthie EH, Katz PR (eds).
Practice of Geriatrics, Third Edition, Philadelphia, WB Saunders
Company, 1998, p. 31.
g) ACP-ASIM Ethics Manual, 4th Edition
h) Crowe S. Obtaining consent in the elderly patient. Hosp Med 2002
Jan; 63(1):61.
J) Geriatric syndromes - Pathophysiology, screening, evaluation, and treatment
(underlying disorder); psychosocial issues in management; natural history of
Alzheimer disease; behavioral complications in dementia.
1) The following textbook/article reading list is recommended to the fellow:
a) Reichman WE, Cummings JL. Dementia. In: Duthie EH, Katz PR
(eds). Practice of Geriatrics, Third Edition, Philadelphia, WB
Saunders Company, 1998, p. 267.
b) Kawas CH. Alzheimer’s disease. In: Hazzard WM, Blass JP, Ettinger
WH, Halter JB, Ouslander JG (eds). Principles of Geriatric Medicine
and Gerontology, Fourth Edition, New York, McGraw-Hill, Inc.,
1999, p. 1257.
c) Snowden JS, Neary D, Mann DM. Frontotemporal dementia. Br J
Psychiatry 2002 Feb; 180:140-3.
d) Grossman M. Frontotemporal dementia: a review. J Int
Neuropsychol Soc 2002 May;8(4):566-83.
e) Cummings JL, Cole G. Alzheimer disease. JAMA 2002 May 8;
287(18):2335-8.
f) Govoni S, Lanni C, Racchi M. Advances in understanding the
pathogenetic mechanisms of Alzheimer's disease. Funct Neurol 2001;
16 Suppl 4:17-30.
g) Erkinjuntti T. Subcortical vascular dementia. Cerebrovasc Dis 2002;
13 Suppl 2:58-60.
h) Desmond DW. Cognition and white matter lesions. Cerebrovasc Dis
2002;13 Suppl 2:53-7.
i) Stewart R. Vascular dementia: a diagnosis running out of time. Br J
Psychiatry 2002 Feb; 180:152-6.
j) Chui H. Dementia due to subcortical ischemic vascular disease. Clin
Cornerstone 2001; 3(4):40-51.
k) Olin J, Schneider L. Galantamine for Alzheimer's disease (Cochrane
Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update
Software.
l) Raskind MA, Peskind ER. Alzheimer's disease and related disorders.
Med Clin North Am 2001 May; 85(3):803-17.
m) McKeith IG. Dementia with Lewy bodies. Br J Psychiatry 2002 Feb;
180:144-7.
n) Neugroschl J. Agitation. How to manage behavior disturbances in
the older patient with dementia. Geriatrics 2002 Apr; 57(4):33-7.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 17
Geriatric Fellowship Manual
o) Cohen-Mansfield J.
Nonpharmacologic
interventions
for
inappropriate behaviors in dementia: a review, summary, and
critique. Am J Geriatr Psychiatry 2001 Fall; 9(4):361-81.
p) Finkel SI. Behavioral and psychological symptoms of dementia: a
current focus for clinicians, researchers, and caregivers. J Clin
Psychiatry 2001; 62 Suppl 21:3-6.
q) Campbell S, Stephens S, Ballard C. Dementia with Lewy bodies:
clinical features and treatment. Drugs Aging 2001; 18(6):397-407.
r) Ernest R.L., Hay J.W. The US economic impact and social costs of
Alzheimer’s disease revisited. Am J Public Health 1994; 84: 12611264
K) Delirium
1) The following textbook/article reading list is recommended to the fellow:
a) Francis J, Jr. Delirium. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company,
1998, p. 267.
b) Tune LE. Delirium. In: Hazzard WM, Blass JP, Ettinger WH, Halter
JB, Ouslander JG (eds). Principles of Geriatric Medicine and
Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999,
p. 1229.
c) Zeleznik J. Effectiveness of interventions to prevent delirium in
hospitalized patients: a systemic review. J Am Geriatr Soc 2001 Dec;
49(12):1730-2.
d) Winawer N. Postoperative delirium. Med Clin North Am 2001 Sep;
85(5):1229-39.
e) Conn DK, Lieff S. Diagnosing and managing delirium in the elderly.
Can Fam Physician 2001 Jan; 47:101-8.
f) Meagher DJ. Delirium: optimising management. BMJ 2001 Jan 20;
322(7279):144-9. Inouye SK. Delirium in hospitalized older
patients: recognition and risk factors. J Geriatr Psychiatry Neurol
1998 Fall; 11(3):118-25; discussion 157-8.
g) Inouye SK, Charpentier PA. Precipitating factors for delirium in
hospitalized elderly persons. Predictive model and interrelationship
with baseline vulnerability. JAMA 1996 Mar 20; 275(11):852-7.
h) Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz
RI. Clarifying confusion: the confusion assessment method. A new
method for detection of delirium. Ann Intern Med 1990 Dec 15;
113(12):941-8.
L) Falls - Pathophysiology; risk factors; primary and secondary fall prevention.
1) The following textbook/article reading list is recommended to the fellow:
a) Coogler CE, Wolf SL. Falls. In: Hazzard WM, Blass JP, Ettinger
WH, Halter JB, Ouslander JG (eds). Principles of Geriatric Medicine
and Gerontology, Fourth Edition, New York, McGraw-Hill, Inc.,
1999, p. 1535.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 18
Geriatric Fellowship Manual
b) Kenny RA, O’Shea (Eds). Falls and Syncope in Elderly Patients.
Clin Geriatr Med 2002; 18(2).
c) Masud T, Morris RO. Epidemiology of falls. Age Ageing 2001
Nov;30 Suppl 4:3-7.
d) Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for
preventing hip fractures in the elderly (Cochrane Review). In: The
Cochrane Library, Issue 2, 2002. Oxford: Update Software.
e) Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming
RG, Rowe BH. Interventions for preventing falls in elderly people
(Cochrane Review). In: The Cochrane Library, Issue 2, 2002.
Oxford: Update Software.
f) Bassey JE. Exercise for prevention of osteoporotic fracture. Age
Ageing 2001 30: 29-31.
g) Wu G. Evaluation of the effectiveness of Tai Chi for improving
balance and preventing falls in the older population--a review. J Am
Geriatr Soc 2002 Apr; 50(4):746-54.
M) Osteoporosis
1) The following textbook/article reading list is recommended to the fellow:
a) Baylink DJ, Jennings JC, Mohan S. Calcium and bone homeostasis
and changes with aging. In: Hazzard WM, Blass JP, Ettinger WH,
Halter JB, Ouslander JG (eds). Principles of Geriatric Medicine and
Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999,
p. 1041.
b) Ott, SM. Osteoporosis and osteomalacia. n: Hazzard WM, Blass JP,
Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGrawHill, Inc., 1999, p. 1057.
c) Navas LR, Lyles KW. Osteoporosis. In: Duthie EH, Katz PR (eds).
Practice of Geriatrics, Third Edition, Philadelphia, WB Saunders
Company, 1998, p. 217.
d) Cummings SR, Melton LJ. Epidemiology and outcomes of
osteoporotic fractures. Lancet 2002 May 18; 359(9319):1761-7.
e) Seeman E. Pathogenesis of bone fragility in women and men. Lancet
2002 May 25; 359(9320):1841-50.
f) Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk.
Lancet 2002 Jun 1; 359(9321):1929-36.
g) Messinger-Rapport BJ, Thacker HL. Prevention for the older
woman. A practical guide to prevention and treatment of
osteoporosis. Geriatrics 2002 Apr; 57(4):16-8, 21-4, 27.
h) Theodorou DJ, Theodorou SJ, Duncan TD, Garfin SR, Wong WH.
Percutaneous balloon kyphoplasty for the correction of spinal
deformity in painful vertebral body compression fractures. Clin
Imaging 2002 Jan-Feb; 26(1):1-5.
i) Garfin SR, Yuan HA, Reiley MA. New technologies in spine:
kyphoplasty and vertebroplasty for the treatment of painful
osteoporotic compression fractures. Spine 2001 Jul 15; 26(14):15115.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 19
Geriatric Fellowship Manual
N) Dysthermias - Epidemiology, pathophysiology, assessment, management, and
prevention.
1) The following textbook/article reading list is recommended to the fellow:
a) Hirsch CH. Hypothermia and hyperthermia. In: Duthie EH, Katz PR
(eds). Practice of Geriatrics, Third Edition, Philadelphia, WB
Saunders Company, 1998, p. 244.
b) Ballester JM, Harchelroad FP. Hypothermia: an easy-to-miss,
dangerous disorder in winter weather. Geriatrics 1999 Feb;
54(2):51-2, 55-7.
c) McGugan EA. Hyperpyrexia in the emergency department. Emerg
Med (Fremantle) 2001 Mar; 13(1):116-20.
O) Sensory impairment - Epidemiology, pathophysiology, assessment, and management.
1) The following textbook/article reading list is recommended to the fellow:
a) Kalina RE. Aging and visual function. In: Hazzard WM, Blass JP,
Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGrawHill, Inc., 1999, p. 603.
b) Rees TS, Duckert LG, Carey JP. Auditory and vestibular
dysfunction. In: Hazzard WM, Blass JP, Ettinger WH, Halter JB,
Ouslander JG (eds). Principles of Geriatric Medicine and
Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999,
p. 617.
c) Watson GR. Low vision in the geriatric population: rehabilitation
and management. J Am Geriatr Soc 2001 Mar; 49(3):317-30.
d) Novack GD, O'Donnell MJ, Molloy DW. New glaucoma
medications in the geriatric population: efficacy and safety. J Am
Geriatr Soc 2002 May; 50(5):956-62.
e) Marcincuk MC, Roland PS. Geriatric hearing loss. Understanding
the causes and providing appropriate treatment. Geriatrics 2002
Apr; 57(4):44, 48-50, 55-6 passim.
P) Nutritional Issues in the Elderly
1) The following textbook/article reading list is recommended to the fellow:
a) Wallace JI. Malnutrition and enteral/parenteral alimentation. In:
Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds).
Principles of Geriatric Medicine and Gerontology, Fourth Edition,
New York, McGraw-Hill, Inc., 1999, p. 1455.
b) Fairfield KM, Fletcher RH. Vitamins for chronic disease prevention
in adults: scientific review. JAMA 2002 Jun 19; 287(23):3116-26.
c) Fletcher RH, Fairfield KM. Vitamins for Chronic Disease Prevention
in Adults: Clinical Applications. JAMA. 2002; 287:3127-3129.
d) Huffman GB. Evaluating and treating unintentional weight loss in
the elderly. Am Fam Physician 2002 Feb 15; 65(4):640-50.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 20
Geriatric Fellowship Manual
e) Enzi G, Sergi G, Coin A, Inelmen EM, Busetto L, Pisent C, Peruzza
S. Clinical aspects of malnutrition. J Nutr Health Aging 2001;
5(4):284-7.
Q) Dizziness and syncope - Epidemiology, types of “dizziness,” pathophysiology,
treatment.
1) The following textbook/article reading list is recommended to the fellow:
a) Aronow WS. Dizziness and syncope. In: Hazzard WM, Blass JP,
Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGrawHill, Inc., 1999, p. 1519.
b) Kenny RA, O’Shea (Eds). Falls and Syncope in Elderly Patients.
Clin Geriatr Med 2002; 18(2).
c) Sloane PD, Coeytaux RR, Beck RS, Dallara J. Dizziness: state of the
science. Ann Intern Med 2001 May 1; 134(9 Pt 2):823-32.
d) Isaacson JE, Rubin AM. Otolaryngologic management of dizziness
in the older patient. Clin Geriatr Med 1999 Feb; 15(1):179-91, viii.
e) Pollak L, Davies RA, Luxon LL. Effectiveness of the particle
repositioning maneuver in benign paroxysmal positional vertigo with
and without additional vestibular pathology. Otol Neurotol 2002 Jan;
23(1):79-83.
R) Sleep Disorders
1) The following textbook/article reading list is recommended to the fellow:
a) Haponik EF, McCall WV. Sleep problems. In: Hazzard WM, Blass
JP, Ettinger WH, Halter JB, Ouslander JG (eds). Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 1413.
b) Ancoli-Israel S, Kripke DF. Sleep and aging. In: Duthie EH, Katz
PR (eds). Practice of Geriatrics, Third Edition, Philadelphia, WB
Saunders Company, 1998, p. 237.
c) Schneider DL. Insomnia. Safe and effective therapy for sleep
problems in the older patient. Geriatrics 2002 May; 57(5):24-6, 29,
32 passim.
d) Montgomery P, Dennis J. Cognitive behavioral interventions for
sleep problems in adults aged 60+ (Cochrane Review). Cochrane
Database Syst Rev 2002; (2):CD003161.
e) Giron MS, Forsell Y, Bernsten C, Thorslund M, Winblad B, Fastbom
J. Sleep problems in a very old population: drug use and clinical
correlates. J Gerontol A Biol Sci Med Sci 2002 Apr; 57(4):M23640.
f) Janssens JP, Pautex S, Hilleret H, Michel JP. Sleep disordered
breathing in the elderly. Aging (Milano) 2000 Dec; 12(6):417-29.
g) Vitiello MV, Borson S. Sleep disturbances in patients with
Alzheimer's disease: epidemiology, pathophysiology and treatment.
CNS Drugs 2001; 15(10):777-96.
Top of the Document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 21
Geriatric Fellowship Manual
2.7
Program Expected Outcomes
A) To produce outstanding clinicians in the field of general Geriatrics.
B) To produce clinicians who are grounded in evidence based medicine.
C) To produce clinicians who are compassionate and embody what it means to be an
osteopathic geriatrics physician.
D) To view the patient in their entirety; mind, body and spirit.
E) To produce clinicians who are proficient in all seven AOA Core Competencies.
F) To have a program that is compliant with all AOA basic standards.
G) To create an environment that fosters research opportunities as well as other
scholarly pursuits.
H) To train quality primary care geriatrics physicians.
2.8
On-site Review by ACOFP
The AOA-ACOFP grants approval to geriatric residency training programs. Once a
program is approved for a specific duration, the AOA-ACOFP will conduct on-site
reviews based on the length of approval. The Geriatric Fellowship Program Director will
receive notification of the On-site Review via postal services. The Program Director will
then inform the Director of Medical Education, the geriatric fellows, senior
administration and faculty of the On-Site Review.
Regular meetings are held jointly to complete the inspection workbook, gather and
review all required documents. Logs/Evaluations are completed monthly by residents
and are reviewed for completeness. All required charts are requested from medical
records and all affiliation agreements are reviewed and confirmed. Input from members
of the GME Committee and geriatric faculty is sought for an internal review of the
program. This is normally completed at mid-cycle of an accreditation period, in
preparation for subsequent inspection.
2.9
Orientation Schedule
The Geriatric Fellowship Program begins July 1st of each academic year. On this day, the
fellows will participate in the following orientation schedule:
8:00 a.m.
Welcome and Introduction
DME, Program Directors, ADME, Administration, Nursing Division
Department Overviews – 15-30 minutes
Program Director Reviews Resident and Fellowship Manuals
1:00 p.m.
Human Resources
Tour, Badge, Benefits
Computer Training – Email assigned
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 22
Geriatric Fellowship Manual
2:00 p.m.
Administrative
Health Information
Compliance/HIPAA
3:00 p.m.
Library Overview – Access Forms Completed
4:00 p.m.
New Innovations Training
Content Outline:
1. Safety Education
a. Fire Safety/OSHA Requirements
b. Controlling Infectious Agents
c. Caring for Patients and Employees
d. Expected Employee Behavior
2. Risk Management
a. Quality
b. Risk Management
c. Patient Safety
d. Documentation
e. Communication
f. Informed Consent
g. SBAR Process
h. Incident Reporting
3. Infection Control
a. OSHA Blood Borne Pathogen Training
4. Health Information Management
a. Chart Completion Requirements
b. Digital Dictation System
c. Dangerous Abbreviations or Dose Designations
5. Laboratory
a. Ordering – Inpatient/Outpatient
b. Results Availability
c. Blood Bank
d. Specimen Collection
6. Compliance
a. HIPAA
b. Organizational Integrity Guidelines
7. DME/PD Overview
a. Resident Manual Review
b. Expectations
c. Duties and Responsibilities
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 23
Geriatric Fellowship Manual
d.
e.
f.
g.
h.
i.
j.
k.
Chain of Command
Evaluation Process
Lecture Expectations – Attendance/Presentation
Logs
Documentation
Goals and Objectives for each Rotation
Standards of Conduct
Sign-outs
8. ADME/MEC Overview
a. Standards of Conduct
b. Affiliation Agreements – Out Rotations
c. Lecture Expectations – Attendance
d. Administrative Duties & Responsibilities
e. Email/Intranet/Computer Overview
f. New Innovation Training
g. Lecture Assignment - Attendance
h. Logs
i. Activities
9. Medical Library
a. Access
b. What’s available
c. Overview
2.10
Program Design
The Geriatric Fellowship at VCOM will provide the educational experiences necessary
for the subspecialty fellow to achieve the cognitive knowledge, psychomotor skills,
interpersonal skills, professional attitudes, and practical experience required of physicians
to specialize in the care of elderly patients. The clinical faculty will provide didactic
learning as well as clinical opportunities and as integral parts of the required curriculum
for this program. The educational and clinical opportunities will be designed to allow the
fellow to assume progressive responsibility for patient care.
The fellow in geriatrics will gain expertise in the following areas:
a) Long-Term Care: The geriatric fellow will have appropriate authority and
responsibility to participate in the medical care of long-term care patients in the
nursing home.
b) Acute Care: The geriatrics fellow will have appropriate authority and responsibility
to participate in the medical care of the acute patient on-site in the nursing home,
home care and out-patient clinical settings.
c) Continuity Care: The geriatrics fellow will have the opportunity and responsibility to
participate in the continuity of care of the elderly patient as well as long-term medical
management of patient with chronic medical problems.
d) Geriatrics Clinical Experience: The fellow will participate in the care of their
patients in a comprehensive manner, in two ½ days weekly of clinical patient care.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 24
Geriatric Fellowship Manual
The fellow will provide comprehensive medical care, and health and therapeutic care.
If a patient is hospitalized, the fellow will participate in the inpatient care of the
patient.
e) On Site Home Care: The fellow will participate in the planning and implementation
of all aspects of medical care of the elderly patient in their home.
f) Skilled Care: The geriatric fellow will have appropriate authority and responsibility
to participate in the medical care of patients in the skilled care setting, including:
chronic disease management, acute illnesses, and rehabilitative progression in the
skilled facility.
g) Hospice Care: The geriatric fellow will have appropriate authority and responsibility
to participate in the full realm of hospice care including being familiar with the roles
of the Chaplin, social worker, nurse, volunteers, medical director and attending
physician in the team approach to hospice care.
Return to the beginning of document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 25
Geriatric Fellowship Manual
3
APPOINTMENT
3.1
Fellowship Appointment
Appointments to the Geriatric Fellowship program are made on the recommendation of
the Medical Education Committee, the Program Director and the Director of Medical
Education.
Edward Via Virginia College of Osteopathic Medicine is an equal opportunity employer
and does not discriminate on the basis of race, color, religion, sex, national origin or
handicapped persons who, with reasonable accommodation, can perform the essential
functions of the job.
The fellowship application process at Edward Via Virginia College of Osteopathic
Medicine is as follows:
a. Interested osteopathic medical school students must apply by completing a
fellowship application;
b. Required documents include: CV, personal statement, three letters of
professional reference, letter from the program director stating the resident is in
good standing, board scores, medical diploma and transcripts; at which time the
Department of Medical Education will contact applicants to arrange an
appointment for an interview;
c. Fellow applicants are interviewed by the Program Director, Director of Medical
Education, selected members of the Geriatrics Department and members of the
Medical Education Committee;
d. Applicants are discussed at the December Medical Education Selection
Committee and either accepted or denied and a rank order list is generated;
e. Once the applicant is selected, they will be issued a letter of agreement.
Appointment
3.2
Top of the Document
Advanced Placement
The Geriatric Fellowship Training Program follows the guidelines for fellows requesting
advanced placement of the AOA. A request for advanced placement must be received
from both the fellow and the program director at the advanced placement institution.
This request must include the program director’s assessment of the fellow’s academic
status/equivalency and the fellow’s academic level in comparison to other fellows at the
training level if advanced placement were to occur. Determination of advanced
placement within these guidelines shall be made by the Council on Education and
Evaluation of the AOAFP and reported to the COPT. These guidelines are as follows:
(Reference AOA-Basic Standards for Fellowship Training in Geriatrics).
1. Advanced placement from non-Geriatrics fields: A maximum of one-month of
credit may be awarded for each month of training in Geriatrics or its
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 26
Geriatric Fellowship Manual
subspecialties taken under the direction of a geriatric specialist in an AOA or
ACGME approved program.
2. Advanced placement from ACGME approved Geriatrics programs: A maximum
of one (1) month of credit may be granted for each month of post graduate
training satisfactorily completed in general or subspecialty Geriatrics in an
ACGME approved program as verified by the osteopathic program director.
3. Advanced placement from traditional osteopathic internship: One month of
credit may be awarded for each month of training in Geriatrics or a medical
subspecialty taken under the supervision of a geriatrics specialist during an AOA
rotating internship in an institution with an AOA or ACGME approved Geriatric
Fellowship. A maximum of one month credit may be granted under this
provision.
4. A request for advanced placement must be received from both the fellow and the
program director at the advanced placement institution. This request must include
the program director's assessment of the fellow's academic status/equivalency
and the fellow's academic level in comparison to other fellows at the training
level if advanced placement were to occur. Determination of advanced placement
within these guidelines shall be made by the Council on Education and
Evaluation of the AOAFP and reported to the COPT.
Advanced Placement
3.3
Top of the Document
Promotion Criteria
The fellow must demonstrate their ability to perform the following requirements in order to
receive a certificate of completion from VCOM for the fellowship program:
Patient Care:
1) Prioritizes a patient’s problem
2) Prioritizes a day of work
3) Monitors and follows up patients appropriately
4) Demonstrates caring and respectful behaviors with patients and families
5) Gathers essential/accurate information via interviews and physical exams and
reviews other data
6) Provides services aimed at preventing or maintaining health
7) Works with all health care professionals to provide patient-focused care
8) Knows indications, contraindications, and risks of invasive procedures
9) Competently performs invasive procedures
10) Understands and weighs alternatives for diagnosis and treatment
11) Uses diagnostic procedures and therapies appropriately
12) Elicits subtle findings on physical examination
13) Obtains a precise, logical and efficient history
14) Interprets results of procedures properly
15) Is able to manage multiple problems at once
16) Makes informed decisions about diagnosis and therapy after analyzing clinical data
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 27
Geriatric Fellowship Manual
17) Develops and carries out management plans
18) Considers patient preferences when making medical decisions
19) Triages patients to appropriate location
20) Spends time appropriate to the complexity of the problem
Medical Knowledge:
1) Uses written and electronic reference and literature sources to learn about patients’
diseases
2) Demonstrates knowledge of basic and clinical sciences
3) Applies knowledge to therapy
4) Is aware of indications, contraindications and risks of commonly used medications
and procedures
5) Demonstrates knowledge of epidemiological and social-behavioral sciences
6) Demonstrates an investigatory and analytic approach to clinical situations
Practice-Based Learning Improvement:
1) Understands his/her limitations of knowledge
2) Asks for help when needed
3) Is self motivated to acquire knowledge
4) Uses PowerPoint, Word, Internet and other computerized sources of results and
information; such as, “Up-to-Date” to enhance patient care
5) Accepts feedback and develops self-improvement plans
6) Undertakes self-evaluation with insight and initiative
7) Facilitates the learning of students and other health care professionals
8) Analyzes personal practice patterns systematically, and looks to improve
9) Compares personal practice patterns to larger populations
10) Locates, appraises and assimilates scientific literature appropriate to specialty
11) Applies knowledge of study design and statistics
Interpersonal and Communication Skills:
1) Writes pertinent and organized notes
2) Has timely and legible medical records
3) Uses effective listening, narrative and non-verbal skills to elicit and provide
information
4) Works effectively as a member of the health care team
5) Creates and sustains therapeutic and ethically sound relationships with patients and
families
6) Provides education and counseling to patients, families and colleagues
7) Is able to discuss end of life care with patient/families
8) Works effectively as a member or leader of the health care team
9) Works effectively as a leader of the health care team
Professionalism:
1) Establishes trust with patients and staff
2) Does not refuse to treat patients
3) Is honest, reliable, cooperative and accepts responsibility
4) Shows regard for opinions and skills of colleagues
5) Is free from substance abuse or satisfactorily undergoing rehabilitation
6) Demonstrates respect, compassion and integrity
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 28
Geriatric Fellowship Manual
7) Is responsive to the needs of patients and society, which supersedes self-interest
8) Displays initiative and leadership
9) Is able to delegate responsibility to others
10) Demonstrates commitment to on-going professional development
11) Demonstrates commitment to ethical principles pertaining to the provision or
withholding of care, patient confidentiality, informed consent and business practices
12) Demonstrates sensitivity to patient culture, gender, age, preferences and disabilities
13) Acknowledges errors and works to minimize them
14) Is effective as a consultant
Systems-Based Practice:
1) Is a patient advocate
2) Makes constructive comments
3) Advocates for high quality patient care and assists patients in dealing with system
complexity
4) Applies knowledge of how to partner with health care providers to assess, coordinate
and improve patient care
5) Uses systematic approaches to reduce errors
6) Participates in developing ways to improve systems of practice and health
management
7) Demonstrates ability to adapt to change
8) Provides cost effective care
9) Understands how individual practices affect other health care professionals,
organizations and society
10) Demonstrates knowledge of types of medical practice and delivery systems
11) Practices effective allocation of health care resources that does not compromise the
quality of care
Promotion Criteria
3.4
Top of the Document
Fellow Qualifications
(Reference AOA-Basic Standards for Fellowship Training in Geriatrics)
All fellows shall be graduates of an approved college of osteopathic medicine and have
completed an osteopathic family practice residency program. Fellows must be members
of the American Osteopathic Association (AOA) and their appropriate specialty college,
and maintain membership throughout fellowship.
The fellowship training program in Geriatrics is at least twelve (12) months in duration.
The Fellow in Geriatrics must:
a) Be a graduate from an AOA accredited College of Osteopathic Medicine.
b) Have successfully completed an AOA approved fellowship program in Family
Medicine.
c) Have AOA certification or be board eligible in Family Medicine.
d) Be a licensed physician to practice medicine in the state where the institution that
sponsors the program is located.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 29
Geriatric Fellowship Manual
1. The Fellow will adhere to a workload and call schedule that will allow him/her to
fully utilize his/her educational experiences without counterproductive fatigue,
depression, or burnout.
2. The Fellow will share outpatient call with his/her fellow colleagues. This call will
extend for one-week duration and will rotate weekly between program fellows. The
Program director and associate directors will provide back up at all times to the
fellow.
3. The fellow will complete all portions of the educational program listed in Program
Curriculum.
Top of the Document
3.5
Terms of Service
Geriatric Fellowship training is twelve (12) months. The contract will be issued for a
period of one year.
Under qualifying circumstances, the fellowship may be extended through the FMLA. All
leaves must be reported to the Program Director and the Director of Medical Education,
the Graduate Medical Education Committee, Human Resources and the subcommittee on
Fellowship Training of the American Osteopathic Association. All additional time taken
off during fellowship must be made up at the end of the contract year.
Top of the Document
Return to the beginning of document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 30
Geriatric Fellowship Manual
4
EMPLOYMENT POLICIES
4.1
Status
You are an employee of the institution. As a fellow employee, you are responsible to the
Board of Trustees through the Director of Medical Education. The institution is liable for
your acts. You will not be covered by malpractice insurance unless you are on an
approved rotation. Under no circumstances may the fellow engage in moonlighting, i.e.
employment outside of the hospital without prior written approval from the Program
Director and Director of Medical Education.
4.2
Educational Stipend
Each fellow will be allocated a specific dollar amount as outlined in the letter of
appointment to be used for educational expenses during each year of training. These
dollars will not carrier over into the next academic year. Funds will be available July 1 st
of each academic year. The following is a list of acceptable items that can be counted
toward these educational dollars:
Will be Approved:
Will NOT be Approved:
Medical Textbooks
Digital Camera
Medical Journal Subscriptions
CD Burner
Computer
Office Supplies
PDA (Palm Pilot)
Lab coat altering/dry cleaning
Medical computer software
Flash drives
Computer printer
Computer/Palm batteries
Computer scanner
Medical conference registration
*Airfare, hotel, meals (medical conference
related)
State licensing fees
Board application fees
AOA/AMDA dues
Board review audio/video tapes
Gas mileage (rotations, meetings)
*****Educational stipends may be subject to applicable taxation*****
*All conferences must be approved in advance by the Director of Medical Education and
all travel arrangements must be made by the GME Office after approval is obtained. If
the fellow is unsure whether an expense can be counted toward these educational dollars,
they are responsible for speaking with the Administrative Director or Director of Medical
Education prior to the purchase of such item.
To be reimbursed for educational expenses, the fellow must complete an “Employee
Expense Form”, sign and attach the original receipt(s). Return completed form and
receipts to the Administrative Director for further processing and tracking of educational
expenses. Note: Educational stipends may be subject to applicable taxation.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 31
Geriatric Fellowship Manual
Return to the beginning of document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 32
Geriatric Fellowship Manual
5
TIME-OFF BENEFITS
5.1
Time Away
Fellows are allocated days off for personal reasons during each academic year of training
as outlined in the fellow’s contract. The following is a list of acceptable personal days:
To be used for:
Vacation/Personal Days/Illness
Medical conferences
Do not need to be use for:
Holidays – when on call
Boards – preceptor excused – exam days
only
Interviews

All requests for time off must be submitted two weeks prior to the requested time
off or within 24 hours of returning from a sick day. Failure to comply will result
in these days being made up during the weekend. All notification of time away
must be communicated in writing.

If you request time off on a day when you are scheduled for call – you are NOT
excused from call. You must find someone to take your call and make that day
up at another time. TIME AWAY DOES NOT EXCUSE YOU FROM CALL.

You may not take more than one week vacation at a time.

You may not take time off after June 15th of each academic year, unless prior
arrangements are made with the Program Director.

If a fellow is assigned an outpatient clinic, notification of time off must be
reported to the Clinic one (1) month prior to the requested leave.
Top of the Document
5.2
Absences
The fellow will not be permitted to leave the Geriatrics Clinic other than during off-duty
hours without the permission of the Program Director, Director or Administrative
Director of Medical Education or Administration.
If it becomes necessary for a fellow to leave the premises during duty hours, permission
must be first obtained as stated above. The fellow must arrange for another physician to
cover the service.
Upon returning to assigned duties, the fellow is to notify the switchboard, the Department
of Medical Education and the nursing station, that you are back on duty.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 33
Geriatric Fellowship Manual
5.3
Illness
If a fellow is unable to report to duty due to illness, he/she is to notify the Program
Director, Department of Medical Education, the attending physician that the fellow is
rotating with and the switchboard. The fellow may be required to go to the Emergency
Room for an examination.
5.4
Unauthorized Absence
An unauthorized absence from duty will result in disciplinary action. Any unauthorized
absence of three or more consecutive business days will constitute a voluntary resignation
from the program.
5.5
Revocation of Off-Duty Hours
In the case of delinquent medical records, or other incomplete work, the fellow may be
assigned extra call by the Program Director, Director of Medical Education or the
Medical Education Committee Chairman, pending the completion of work.
Return to top
Return to the beginning of document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 34
Geriatric Fellowship Manual
6
PROGRAM CURRICULUM
The curriculum of the Geriatric Fellowship Training Program includes both didactic and
clinical components, delivered in both longitudinal learning experiences as well as
concentrated subspecialty fellowship rotations.
Geriatric medicine is the prevention, diagnosis, care and treatment of illness and
disability in older adults. Health care for older adults is most effective in an
interdisciplinary setting that considers the interaction of diseases, age, medication
regimens, and functional, person, environmental and social factors specific to groups of
elders as well as to individuals. Health care professionals in geriatrics acknowledge that
there are positive aspects to the aging process and that physical and mental deterioration
are not necessary consequences of growing older. Geriatrics exists to:





6.1
Maximize the independence of the individual patient
Ensure physical and emotional comfort
Optimize quality of life and a sense of well-being
Prevent premature or untimely death
Provide high-quality, efficient and cost-effective care
Osteopathic Philosophy & OMM
The specialty of Geriatrics consists of the prevention, diagnosis and management of
medical illnesses and injuries related to the geriatric patient. The major goal of the
osteopathic geriatrics program is to achieve mastery of the following Core competencies:
1. Osteopathic Philosophy and Osteopathic Manipulative Medicine
a. Integrate osteopathic principles into the diagnosis and management of
patients.
b. Apply osteopathic manipulative therapy to patient management where
applicable.
2. Medical Knowledge
a. Demonstrate competency in the understanding and application of clinical
medicine as it relates to patient care.
i. Demonstrate a thorough knowledge of the complex differential
diagnoses and treatment options of the Geriatrics patient.
b. Understand and apply the foundations of behavioral medicine as it relates
to Geriatrics.
i. Demonstrate an ability to provide end of life care.
ii. Identify and address the socioeconomic, ethnic, religious, and
cultural aspects of illness and their impact on a patient’s clinical
presentation and subsequent management.
3. Patient Care
a. Demonstrate an ability to rapidly evaluate, initiate and provide
appropriate treatment for patients who are critically ill.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 35
Geriatric Fellowship Manual
b. Demonstrate an ability to thoroughly evaluate, initiate treatment and
provide appropriate long-term therapeutic recommendations to patients
with chronic medical problems in both hospital and ambulatory settings.
c. Demonstrate an ability to make appropriate recommendations to promote
health maintenance and disease prevention.
d. Demonstrate an ability to gather appropriate essential medical
information from patient interviews, relevant medical records,
examinations and testing.
4. Interpersonal and Communication Skills
a. Exercise effective patient interview skills
b. Demonstrate appropriate verbal communication with clarity, sensitivity,
and respect,
c. Create well organized, clear, succinct but thorough and legible medical
records.
d. Demonstrate an ability to interact with support staff in the hospital and
ambulatory settings in a constructive, positive and effective manner.
e. Identify methods to communicate with non-English speaking patients,
and with those having sensory deficits (verbal, visual, and auditory).
5. Professionalism
a. Identify the role of Geriatrics as it relates to other medical disciplines.
b. Develop the principles of appropriate ethical conduct and integrity in
dealing with patients and the medical community.
i. Identify potential areas of conflict of interest inherent in medical
practice.
ii. Demonstrate appropriate, judicious and efficient utilization of
medical therapies, procedures, and testing without consideration
of personal gain.
iii. Demonstrate understanding of the implicit position of trust and
authority into which patients often place the physician; recognize
the ethical requirement to avoid exploitation of this trust either
intentionally or unintentionally.
c. Complete training in personal health information protection policies, and
recognize their application in daily medical practice.
d. Recognize the elements of religion, race, ethnicity, or cultural
background in individual patients, and address them properly.
e. Recognize the need for continuous quality of care in all patient
populations, and demonstrate lack of discrimination.
f. Provide medical care to those seeking it regardless of age, race, physical
handicap or religious affiliation.
6. Practice-Based Learning and Improvement
a. Develop professional leadership and practice management skills.
b. Evaluate the progress of the training of the fellow by using continuous
assessment tools.
i. Utilize systematic evaluation to include self study and
assessment, individual trainee assessment, and outcomes
analysis.
ii. Participate in quality improvement programs and assessment
activities in the hospital and ambulatory setting.
c. Expose the fellow to research methodology in Geriatrics.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 36
Geriatric Fellowship Manual
d. Identify information technology applicable to the practice of medicine
and research. Demonstrate the ability to effectively utilize such
technology.
e. Develop teaching skills in the Geriatrics fellow.
f. Promote the development of commitment to habits of lifelong learning
and scholarly pursuit in Geriatrics.
g. Prepare the fellow to meet the eligibility requirements of the AOA to
take the certification examination administered by the American
Osteopathic Academy of Geriatrics.
7. Systems-Based Practice
a. Develop in the fellow the skills needed to practice within a system-based
health care environment and to use the resources to deliver quality care.
b. Understand the national and local health care delivery systems and how
they impact on patient care and professional practice.
c. Develop and promote advocacy for quality patient centered health care in
complex systems.
Top of the Document
6.2
Continuity Clinic Experience
Location:
Duration:
Frequency:
Showalter Clinic
Entire Year
½ day each location
Overview:
The fellow will be responsible for elderly patients 62 years-of-age and older. Patients
will present with a wide-spectrum of illnesses and health for whom health maintenance
and prevention is the major goal, to the frail and disabled for whom comfort is often the
most important goal.
Educational Purpose:
To provide the fellow, through didactic and clinical experiences in inpatient settings, with
educational experiences that will enhance his/her knowledge and skills in diagnosing and
managing geriatric patients in a hospital setting.
The fellow will demonstrate competency in his/her ability to:




Effective 07/01/2010
Version 1
Learn comprehensive geriatric assessment, utilizing common standardized
assessment instruments for basic and instrumental activities of daily living,
cognitive screening, depression screening, social resources, and nutrition
screening.
Learn appropriate health maintenance/disease prevention measures for older
patients, following accepted clinical guidelines.
Acquire a function-oriented, rather than primarily a disease-oriented,
approach to the older patient.
Acquire expertise in communicating with older patients and their
families/caregivers.
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 37
Geriatric Fellowship Manual














Learn to integrate caregiver concerns and caregiver support into your care of
the dependent older patient; learn to treat the caregiver and patient as an
integral unit.
Acquire efficiency while retaining thoroughness in your primary care of the
frail elderly.
Acquire expertise in working with an interdisciplinary care team.
Acquire familiarity and expertise dealing with home health agencies.
Learn to perform geriatric consultation, particularly in the areas of preoperative assessment and dementia assessment.
Increase awareness and practice of cost-effective use of laboratory and
imaging services as well as subspecialty consultations.
Understand the provision of primary care by the Veterans Administration
Understand health-care financing of primary care for older Americans:
coverage and limitations, for Medicare parts A & B, major senior capitated
health plans in the Blacksburg area, Medi-Cal
Understand the importance of, and obtain experience in, assessing and
addressing cultural and ethnic biases, preferences, and attitudes towards
health care for the older person
Hone and expand primary-care family medicine skills through a panel of
primary-care, frail older patients followed for the entire duration of the
fellowship
Become aware of proper nutrition, exercise, screening and immunizations for
the elderly
Become aware of community resources to assist with these goals
Manage complex geriatric patients in an outpatient setting:
o Documentation
o Billing
o Health Care maintenance (routine/screening)
o Patient/caregiver education; discussing and setting goals of care
Learn to perform geriatric consultations in outpatient settings
o Communication with referring physicians
o Co-management with primary care physicians and/or other
specialists
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. The fellows work under supervision of a geriatric attending.
b. Patient care discussion during clinic with the attending geriatrician.
c. Every other week, individual meeting with clinic faculty supervisor.
d. Patient discussion is complemented by small, informal lectures on geriatrics
given by the faculty.
e. Reading assignments and literature searches are given to each and every house
officer in the team, and they are to be discussed after working rounds are done.
f. Time for lectures is always provided to the whole team, the fellow will make
him/herself available to the nurses for emergencies. Lectures by subspecialty
faculty are to stress critical aspects of their specialty – UNLESS, in the opinion
of the attending physician, there is a crisis in the department necessitating full
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 38
Geriatric Fellowship Manual
II)
III)
IV)
V)
coverage. (If this is the case, follow Lecture Attendance Protocol.)
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. IV placement
2. Venipuncture
b. Procedural Skills - The fellow will be evaluated on his/her ability to demonstrate
the following objectives
1. Joint aspirations and injections
2. Wound care
3. Dressing changes
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which
is identified and methods for avoiding such problems in the future.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 39
Geriatric Fellowship Manual
VI)
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Schwartz RS, Buchner DM. Exercise in the elderly: physiologic and
functional effects. In: Principles of Geriatric Medicine and Gerontology,
Fourth Edition, New York, McGraw-Hill, Inc., 1999, p. 143.
2. Hazzard WR. Preventive gerontology: a personalized, designed approach
to a life of maximum quality and quantity. In: Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 239.
3. Magenheim MJ. Preventive health maintenance. In: Duthie EH, Katz PR
(eds). Practice of Geriatrics, Third Edition, Philadelphia, WB Saunders
Company, 1998, p. 115.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Barratt AL, Les Irwig M, Glasziou PP, Salkeld GP, Houssami N.
Benefits, harms and costs of screening mammography in women 70
years and over: a systematic review. Med J Aust 2002 Mar 18;
176(6):266-71.
2. Nystrom L, Andersson I, Bjurstam N, Frisell J, Nordenskjold B, Rutqvist
LE. Long-term effects of mammography screening: updated overview of
the Swedish randomised trials. Lancet 2002 Mar 16; 359(9310):909-19.
3. Tune LE. Anticholinergic effects of medication in elderly patients. J Clin
Psychiatry 2001; 62 Suppl 21:11-4.
4. Hohl CM, Dankoff J, Colacone A, Afilalo M. Polypharmacy, adverse
drug-related events, and potential adverse drug interactions in elderly
patients presenting to an emergency department. Ann Emerg Med 2001
Dec; 38(6):666-71.
5. Veehof LJ, Stewart RE, Meyboom-de Jong B, Haaijer-Ruskamp FM.
Adverse drug reactions and polypharmacy in the elderly in general
practice. Eur J Clin Pharmacol 1999 Sep; 55(7):533-6.Veehof L, Stewart
R, Haaijer-Ruskamp F, Jong BM. The development of polypharmacy. A
longitudinal study. Fam Pract 2000 Jun; 17(3):261-7. Rajan S, Wallace
JI, Beresford SA, Brodkin KI, Allen RA, Stabler SP. Screening for
cobalamin deficiency in geriatric outpatients: prevalence and influence of
synthetic cobalamin intake. J Am Geriatr Soc 2002 Apr; 50(4):624-30.
6. Rush D. Nutrition screening in old people: its place in a coherent practice
of preventive health care. Annu Rev Nutr 1997; 17:101-25.
7. Chernoff R. Nutrition and health promotion in older adults. J Gerontol A
Biol Sci Med Sci 2001 Oct; 56 Spec No 2(2):47-53.
8. Shepherd J. Issues surrounding age: vascular disease in the elderly. Curr
Opin Lipidol 2001 Dec; 12(6):601-9.
9. Hall KM, Luepker RV. Is hypercholesterolemia a risk factor and should
it be treated in the elderly? Am J Health Promot 2000 Jul-Aug;
14(6):347-56.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 40
Geriatric Fellowship Manual
VII)
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.3
General Medicine and Geriatrics Consultation Service
Location:
Duration:
Frequency:
Montgomery Regional Hospital
Two-week block rotation
A minimum of two blocks
Overview:
The fellow will rotate on the service when there is a board-qualified geriatrician as the
attending physician. The fellow will see and examine all consultation patients > age 65,
plus patients < age 65 who have “geriatric” problems (e.g. pressure sores or delirium).
Although the fellow will be working with senior medical fellows, he or she is expected to
write at least one-third of the consultation notes for patients he/she evaluates. The fellow
will attend internal medicine morning report as a “geriatric expert” available to discuss
geriatric issues. The fellow will join the consultation fellows and medical students during
“work” rounds in order to point out and teach them about the relevant geriatric issues
with their patients. The fellow is expected to furnish the housestaff and students with
relevant geriatric articles.
Although the houseofficer or medical student will present most of the cases on rounds,
the effectiveness of the geriatric fellow will be measured by how accurately and
thoroughly the student or house officer raises the geriatric issues, and if he/she fails to,
whether the fellow brings them to the attention of the team. The fellow, as a boardeligible / certified family practitioner, will be expected to function as the first-line
consultant when the housestaff or students have internal medicine questions.
In addition to rounding with the General Medicine and Geriatrics housestaff, the fellow
will be available to provide formal and informal geriatric consultations on patients from
the medicine service. These cases will be presented to the geriatrics attending on
separate rounds. If a formal consultation is requested by the ward attending, the
geriatrics attending and the fellow each will leave a consultation note; otherwise, no note
will be left. Whether or not a formal consultation has been requested, following
presentation to and discussion with the attending, the fellow will contact the house officer
caring for the patient to relay suggestions for the assessment and management of the
geriatric issues.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 41
Geriatric Fellowship Manual
Educational Purpose:
To provide the fellow, through didactic and clinical experiences in inpatient settings, with
educational experiences that will enhance his/her knowledge and skills in diagnosing and
managing geriatric patients in a hospital setting.
The fellow will demonstrate competency in his/her ability to:








Acquire expertise performing inpatient consultations on geriatric patients
Hone and expand expertise communicating with the primary team requesting the
consultation
Acquire expertise preparing concise yet thorough consultation notes
Enhance teaching skills by being responsible for teaching housestaff and medical
students on the service about the geriatric issues raised during the consultations
Acquire clinical competence in the assessment, prevention, and management of
common complications experienced by the hospitalized elderly patient:
 Deconditioning and functional decline
 Delirium
 Pressure sores
Acquire competence in helping to plan for discharge and the coordination of
post-acute care
Acquire expertise in the peri-operative management of hospitalized older patients
Acquire expertise working with bedside nurses and floor charge nurses to
implement “non-medical” recommendations (e.g. nursing procedures to prevent
and manage delirium)
The fellows will obtain competency in all of the above goals by meeting the following criteria:
VIII)
IX)
Principal Teaching Methods
a. The fellows work under supervision of an geriatric attending.
b. Rounds typically begin in the conference room for a formal presentation of the
new admissions.
c. The team then makes rounds on all patients. Diagnostic and treatment strategies
are discussed at the bedside.
d. If time allows, patient discussion is complemented by small, informal lectures on
geriatrics given by the faculty.
e. Reading assignments and literature searches are given to each and every house
officer in the team, and they are to be discussed after working rounds are done.
f. Time for lectures is always provided to the whole team, the fellow will make
him/herself available to the nurses for emergencies. Lectures by subspecialty
faculty are to stress critical aspects of their specialty – UNLESS, in the opinion
of the attending physician, there is a crisis in the department necessitating full
coverage. (If this is the case, follow Lecture Attendance Protocol.)
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 42
Geriatric Fellowship Manual
X)
XI)
XII)
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. Understand blood gas results and respond appropriately.
2. Understand cardiovascular hemodynamics in a wide range of disease
states.
3. Management of congestive heart failure and cardiogenic shock.
4. Basics of conventional mechanical ventilation.
b. Procedural Skills - The fellow will be evaluated on his/her ability to demonstrate
the following objectives
1. Cardiopulmonary resuscitation
2. Endotracheal intubation
3. Central venous access
4. Hemodynamic monitoring (Pulmonary Artery Catheterization)
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which
is identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 43
Geriatric Fellowship Manual
XIII)
XIV)
1. Palmer RM, Acute care. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition. Philadelphia, WB Saunders Company, 1998, p.
65
2. Palmer RM. Acute care. In: Hazzard WM, Blass JP, Ettinger WH, Halter
JD, Ouslander JG. Principles of Geriatric Medicine and Gerontology,
Fourth Edition. New York: McGraw-Hill Inc., 1999, p. 483.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Palmer RM. Counsell S, Landefeld CS, Clinical intervention trials: the
ACE unit. Clin Geriatr Med 1998 Nov; 14(4):831-49.
2. Counsell SR, Holder CM, Liebenauer LL, Palmer RM, Fortinsky RH,
Kresevic DM, Quinn LM, Allen KR, Covinsky KE, Landefeld CS.
Effects of a multicomponent intervention on functional outcomes and
process of care in hospitalized older patients: A randomized controlled
trial of Acute Care for Elders (ACE) in a community hospital. J Am
Geriatr Soc 2000 Dec; 48(12):1572-81.
3. Palmer RM, Bolla L. When your patient is hospitalized: Tips for primary
care physicians. Geriatrics 1997 Sep; 52(9):36-42, 47.
4. Fortinsky RH, Covinsky KE, Palmer RM, Landefeld CS. Effects of
functional status changes before and during hospitalization on nursing
home admission of older adults. J Gerontol A Biol Sci Med Sci 1999
Oct; 54(10):M521-6.
5. Landefeld CS, Palmer RM, Kresevic DM, Fotinsky RH, Kowal J. A
randomized trial of care in a hospital medical unit especially designed to
improve the functional outcomes of acutely ill older patients. N Engl J
Med 1995 May; 18:332(20):1338-44.
6. Hirsch CH, Sommers L, Olsen A, Mullen L, Winograd CH. The natural
history of functional morbidity in hospitalized older patients. J Am
Geriatr Soc 1990; 38:1296-303.
7. Parkes J, Shepperd S. Discharge planning from hospital to home
(Cochrane Review). In: The Cochrane Library, Issue 2, 2002. Oxford:
Update Software.
8. Shepperd S, Iliffe S. Hospital at home versus in-patient hospital care
(Cochrane Review). In. The Cochrane Library. Issue 2, 2002. Oxford:
Update Software.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 44
Geriatric Fellowship Manual
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Academic Training
6.4
Top of the Document
Preventive Medicine
Location:
Duration:
Frequency:
VCOM Wellness Center
One ½ day per week
Duration of Training
Overview:
The geriatric fellow will have appropriate responsibilities related to preventive medicine
of the elderly patients to include proper nutrition, exercise prescription, counseling,
immunizations and chemoprophylaxis, in conjunction with the geriatric attending
physician.
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to care for people of advanced
years to help prevent functional decline. Spending time with the elderly patient in an
ambulatory setting provides an opportunity to observe and participate in the care of a
variety of patients while optimizing their function and wellness.
The fellow will demonstrate competency in his/her ability to:











Improve skills in performing a comprehensive musculoskeletal examination
Gait and balance evaluation/fall risk assessment
Assessment of strength and physical functioning
Knowledge of the application of physical treatment modalities – hear and cold,
hydrotherapy, electrical stimulation, traction, exercise, and biofeedback
Evaluation and management of pain (TENS, etc.)
General approaches to strengthening and reconditioning the elderly – PT, group
exercises
Principles of stroke rehabilitation
Non-operative management of degenerative and other arthritides
Prescription of walking aides and other assistive devices
Review medications to help reduce polypharmacy, reduce the risk of drug-drug
interaction and potential side effects
Provide a comprehensive history and physical exam on the elderly patient with
the goal being to increase independence and function ability
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 45
Geriatric Fellowship Manual
II)
III)
IV)
3. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
4. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows: Fellows are encouraged to teach nurses or other members of the
team special aspects of geriatric care. There may be additional learners,
(Medical, PA or NP students) on rotation simultaneously and fellows are
encouraged to provide relevant geriatric additional information as indicated.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts, private physicians,
family and/or caregivers is stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. Understand the importance of preventative care in the elderly
2. Demonstrate appropriate screenings for this age population
3. Perform review of medications to help reduce polypharmacy, reduce the
risk of drug-drug interaction and potential side effects
b. Procedural Skills - The fellow will be evaluated on his/her ability to demonstrate
the following objectives
1. Joint aspirations and injections
2. Wound care
3. Dressing changes
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 46
Geriatric Fellowship Manual
V)
VI)
VII)
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.5
Wound Care
Location:
Duration:
Frequency:
Carilion New River Valley Medical Center
Two-week block rotation
A minimum of two blocks
Overview:
The fellow will rotate with a wound care specialist where they will be exposed to all
types of wounds (pressure, post-op, etc.) where they will learn to classify, treat, and
prevent these wounds.
Educational Purpose:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 47
Geriatric Fellowship Manual
To provide the geriatric fellow with knowledge and skills to identify patients at risk for
development of wounds and wound complications; prescribe preventive measures to
promote skin integrity; and to treat wound problems once they develop.
The fellow will demonstrate competency in his/her ability to:











Identify and list indications for common skin hygiene products
Identify types of pressure induced skin injury
Identify types of vascular insufficiency induced skin injury
Describe the mechanism of vascular insufficiency and pressure induced skin
injury
Identify the risk factors for ulcer information
List and describe the stages of a pressure ulcer
List and describe various treatment modalities for pressure ulcers
Understand current ICD-9 and CPT coding of wounds
Demonstrate the ability to apply various modalities described above to wounds
Identify the indications for the various treatment modalities of pressure ulcers
Demonstrate selective debridement techniques
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
II)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
3. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
4. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows: Fellows are encouraged to teach nurses or other members of the
team special aspects of geriatric care. There may be additional learners,
(Medical, PA or NP students) on rotation simultaneously and fellows are
encouraged to provide relevant geriatric additional information as indicated.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient follow-
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 48
Geriatric Fellowship Manual
III)
IV)
V)
up, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. Understand the pathophysiology, risk factors, prevention, and
management of pressure ulcers, venous stasis ulcers, and ischemic
ulcers.
2. Venus insufficiency ulcers
3. Arterial insufficiency ulcers
4. Non-healing post surgical wounds
5. Traumatic skin lesions.
b. Procedural Skills - The fellow will be evaluated on his/her ability to demonstrate
the following objectives
1. Wound debridements – selective (sharp, surgical) and non-selective
2. Dressing changes
3. Wound V.A.C. Application
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Allman RM. Pressure ulcers. In: Hazzard WM, Blass JP, Ettinger WH,
Halter JB, Ouslander JG (eds.) Principles of Geriatric Medicine and
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 49
Geriatric Fellowship Manual
VI)
VII)
Gerontology, Fourth Edition. New York: McGraw-Hill, Inc., 1999, p.
1577.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Thomas DR, Kamel HK. Wound management in postacute care. Clin
Geriatr Med 2000 Nov; 16(4):783-804.
2. Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW. Beds, mattresses
and cushions for pressure sore prevention and treatment (Cochrane
Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update
Software.
3. Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on
chronic would healing: A meta-analysis. Wound Repair Regen 1999
Nov-Dec; 7(6):495-503.
4. Kunimoto BT. Management and prevention of venous leg ulcers: A
literature-guided approach. Ostomy Wound Manage 2001 Jun; 47(6):3642, 44-9.
5. Holloway GA Jr. Arterial ulcers: Assessment and diagnosis. Ostomy
Wound Manage 1996 Apr; 42(3):46-8, 50-1.
6. Paquette D & Falanga V. (2002). Leg ulcers. Clin Geriatr Med, 18(1), 788, vi.
d. Other
1. Treatment of pressure ulcers clinical practice guideline #15 U.S. Dept. of
Health and Human Services
2. Thomas DR. Prevention and treatment of Pessure Ulcers. JAMDA, Jan
2003 pp 46-59.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.6
Geriatric Psychiatry
Location:
Duration:
Frequency:
Effective 07/01/2010
Version 1
Salem VA
Two-week block rotation
A minimum of two blocks
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 50
Geriatric Fellowship Manual
Overview:
The physician with a Certificate of Added Qualifications in Geriatrics must be equipped
to care for people of advanced years with psychiatric illnesses and manifestations of
cognitive illnesses.
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to identify patients at risk for
development of psychiatric complications to be able to appropriately diagnose and treat
geriatric psych disorders.
The fellow will demonstrate competency in his/her ability to:












Perform a sensitive but comprehensive psychiatric history and mental status
evaluation
Be familiar with the diagnostic categories used in psychiatry (the “axes”) and
with the DSM-IV
Know the epidemiology and presentation of depression and anxiety in the elderly
Screen for and assess late-life depression and dysthymia, and will demonstrate
familiarity with common screening tools, such as the Geriatric Depression Scale
Demonstrate knowledge about the pharmacology, selection, dosing, duration of
treatment, and side-effects of medications for depression and anxiety in the
elderly
Demonstrate knowledge about the pharmacology, selection, dosing, and sideeffects of medications for paranoia and psychosis in the elderly
Demonstrate knowledge about pharmacologic and non-pharmacologic
interventions for behavioral disturbances complicating dementia
Demonstrate knowledge about the diagnosis and treatment of bipolar disorder in
the elderly
Know the role of ECT in the treatment of depression, its side-effects, efficacy,
and for whom to recommend it
Demonstrate sensitivity to the needs and burden of the caregivers of older
patients with psychiatric disorders
Increase their knowledge of community resources to evaluate and assist older
persons with nursing homes, state-run mental institutions, case management
services, and Adult Protective Services
Demonstrate knowledge of the financing and accessibility of psychiatric services
for the elderly
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 51
Geriatric Fellowship Manual
II)
III)
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows:
1. Fellows are encouraged to discuss and provide ‘mini lectures’ on medical
geriatric syndromes for psychiatry residents and students on this rotation.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. The underlying physiological “normal aging” changes in the various
body systems, including diminished homeostatic abilities, altered
metabolism and effects of drugs, and other changes that directly relate to
the assessment and treatment of elderly patients.
2. The normal psychological, social, and environmental changes of aging,
including reactions to common stresses and changes such as retirement,
bereavement, relocation, and ill health, and the changes in family
relationships that affect health care of the elderly.
3. The psychoactive medications, their utility and cautions in the geriatric
population.
4. The determination of capacity.
5. The indications and complications of ECT.
6. The atypical presentation of psychiatric disease in the elderly.
7. The financial aspects of the care of the elderly.
8. The psychological conditions which are either common in older patients.
i.
Alcoholism
ii.
Altered mental status
iii.
Dementia
iv.
Depression
v.
Sexual problems
b. Skills - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 52
Geriatric Fellowship Manual
IV)
V)
1. Obtain a comprehensive history and mental status examination, utilizing
available sources of information.
2. Set appropriate priorities for investigation and treatment.
3. Communicate with the patient and/or caregivers the proposed
investigation and treatment plan, involving them in such decisions.
4. Communicate hope and empathy, while balancing objectivity with
human involvement.
5. Counsel about psychologic, social, and physical stresses as well as the
likely changes of age and disease.
6. Coordinate the range of services with the patient’s support systems and
needs.
7. Integrate factors in the patient’s family, home and general lifestyle into
the diagnostic and therapeutic process.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Zarit SH, Zarit JM. Mental Disorders in Older Adults. New York, The
Guilford Press, 1998.
2. Jordan B, Cummings JL. Mental status and neurological examination in
the elderly. In: Hazzard WM, Blass JP, Ettinger WH, Halter JB,
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 53
Geriatric Fellowship Manual
Ouslander JG (eds). Principles of Geriatric Medicine and Gerontology,
Fourth Edition, New York, McGraw-Hill, Inc., 1999, p. 1209.
3. Blazer DG. Depression. In: Hazzard WM, Blass JP, Ettinger WH, Halter
JB, Ouslander JG (eds). Principles of Geriatric Medicine and
Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999, p.
1331.
4. Morris SK, Jeste DL. Schizophrenia and other psychotic disorders. In:
Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds).
Principles of Geriatric Medicine and Gerontology, Fourth Edition, New
York, McGraw-Hill, Inc., 1999, p. 1341.
5. Gambert SR. Aging of the chronically neuropsychologically impaired.
In: Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds).
Principles of Geriatric Medicine and Gerontology, Fourth Edition, New
York, McGraw-Hill, Inc., 1999, p. 1351.
6. Barry PP, Ackerman K. Chemical dependency in the elderly. In: Hazzard
WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds). Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 1357.
7. Rabins PV. Miscellaneous psychiatric disorders. In: Hazzard WM, Blass
JP, Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 1365.
8. Apfeldord W, Alexopoulos G. Psychopharmacology and psychotherapy.
In: Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds).
Principles of Geriatric Medicine and Gerontology, Fourth Edition, New
York, McGraw-Hill, Inc., 1999, p. 1369.
9. Cassel CK, et al eds. Geriatric Medicine, 3rd Ed. New York: Springer,
1997.
10. Adelman A & Daly M eds. Twenty Common Problems in Geriatrics.
New York: McGraw-Hill, 2000.
11. Ratnaike RN ed. Practice Guide to Geriatric Medicine. Sydney:
McGraw-Hill, 2002.
12. Cobbs EL, et al eds. Geriatric Review Syllabus American Geriatric
Society, 5th Ed. Kendall/Hunt, 2002.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Thomas DR, Kamel HK. Wound management in postacute care. Clin
Geriatr Med 2000 Nov; 16(4):783-804.
2. Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW. Beds, mattresses
and cushions for pressure sore prevention and treatment (Cochrane
Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update
Software.
3. Gardner SE, Frantz RA, Schmidt FL. Effect of electrical stimulation on
chronic would healing: A meta-analysis. Wound Repair Regen 1999
Nov-Dec; 7(6):495-503.
4. Kunimoto BT. Management and prevention of venous leg ulcers: A
literature-guided approach. Ostomy Wound Manage 2001 Jun; 47(6):3642, 44-9.
5. Holloway GA Jr. Arterial ulcers: Assessment and diagnosis. Ostomy
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 54
Geriatric Fellowship Manual
VI)
VII)
Wound Manage 1996 Apr; 42(3):46-8, 50-1.
6. Paquette D & Falanga V. (2002). Leg ulcers. Clin Geriatr Med, 18(1), 788, vi.
d. Other
1. Gareri P, De Fazio P, De Sarro G. Neuropharmacology of depression in
aging and age-related diseases. Ageing Res Rev 2002 Feb; 1(1):113-34.
2. Goldstein MZ. Depression and anxiety in older women. Prim Care. 2002
Mar; 29(1):69-80, vi.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.7
Geriatric Urology
Location:
Duration:
Frequency:
Urology Rotation
Two or four weeks
One block elective rotation
Overview:
The geriatrician must be able to care for patients with urologic disorders as there is such a
high incidence of them in the elderly population.
Educational Purpose:
 To provide the geriatric fellow with knowledge and skills to identify patients at
risk for urologic problems; such as incontinence, erectile dysfunction, recurrent
UTI’s and urinary retention
 To provide the geriatric fellow with knowledge and skills to prescribe preventive
measures to treat these and related disease processes
The fellow will demonstrate competency in his/her ability to:

Demonstrate knowledge in the pathophysiology of obstructive uropathy in older
men, as well as its diagnosis and treatment
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 55
Geriatric Fellowship Manual





Explain the pathophysiology of urinary incontinence in men and women, as well
as its diagnosis and management
Demonstrate their ability to perform a sensitive GU history in men and women,
using, when appropriate, standardized assessment questionnaires such as the
AUA symptom score for BPH
Demonstrate knowledge of the epidemiology and treatment of prostatic cancer
Interpret urodynamic pressure tracings and GU diagnostic imaging studies for
incontinence, as well as knowing when to order these studies
Demonstrate their ability to take a sensitive but thorough sexual history and
assess and manage sexual dysfunction in the older man
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
II)
III)
Principal Teaching Methods
a. By Faculty:
1. The fellow will work in the out-patient setting with a urologist.
2. The fellow will assist with in-patient urologic consults as indicated.
3. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
4. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
5. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows:
1. Fellows are required to teach members of the team special aspects of
geriatric care. There may be additional learners (medical, PA or NP
students) on rotation simultaneous and the fellow is encouraged to
provide relevant geriatric additional information to them.
2. Fellows may also be assigned topics for review and present to the
urology attending.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. Understand the pathophysiology, risk factors, prevention, and
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 56
Geriatric Fellowship Manual
IV)
V)
management of:
a) Erectile dysfunction
b) Overflow incontinence
c) Stress incontinence
d) Urge incontinence
e) Urinary retention
f) Recurrent UTI’s
2. Venus insufficiency ulcers
3. Arterial insufficiency ulcers
4. Non-healing post surgical wounds
5. Traumatic skin lesions.
b. Procedural Skills - The fellow will be evaluated on his/her ability to demonstrate
the following objectives
1. Outpatient procedures like an urogynecological exam, pessary fitting,
office cystourethroscopy, simple cystometry, foley catheter placement,
vaginal or vulvar biopsies, bladder instillations, suprapubic cathether
placement and care.
2. Observe urodynamic studies.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 57
Geriatric Fellowship Manual
VI)
VII)
VIII)
1. Ouslander JG, Johnson TM. Incontinence. In: Hazzard WM, Blass JP,
Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 1595.
2. Brandeis GH, Resnick NM. Urinary incontinence. In: Duthie EH, Katz
PR (eds). Practice of Geriatrics, Third Edition, Philadelphia, WB
Saunders Company, 1998, p. 189.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Burgio KL. Behavioral therapy: practical approach to urinary
incontinence. Contemporary Urology, 1994 Feb, 6(2):24, 29-36, 41.
2. Vapnek JM. Urinary incontinence. Screening and treatment of urinary
dysfunction. Geriatrics 2001 Oct; 56(10):25-9.
3. DuBeau CE. Urinary incontinence management: new questions from old
assumptions. J Am Geriatr Soc 2001 Jun; 49(6):829-30.
4. Hay-Smith EJC, Bø K, Berghmans LCM, Hendriks HJM, de Bie RA,
van Waalwijk van Doorn ESC. Pelvic floor muscle training for urinary
incontinence in women (Cochrane Review). In: The Cochrane Library,
Issue 2, 2002. Oxford: Update Software.
5. Goode PS, Burgio KL, Locher JL, Umlauf MG, Lloyd LK, Roth DL.
Urodynamic changes associated with behavioral and drug treatment of
urge incontinence in older women. J Am Geriatr Soc 2002 May;
50(5):808-16.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement are
suggested. A formal evaluation and verbal discussion with the fellow is to be done at
the end of the rotation.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.8
Older Women’s Health and Urological Gynecology
Location:
Effective 07/01/2010
Version 1
Carilion OB/GYN Blacksburg/Radford
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 58
Geriatric Fellowship Manual
Duration:
Frequency:
Two or four weeks
One block elective rotation
Overview:
The geriatric fellow must be equipped to care for people of advanced age in the care and
management of geriatric urological gynecology.
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to perform a complete
gynecologic history and exam on the elderly patient; and, diagnose and manage problems
related specifically to this population.
The fellow will demonstrate competency in his/her ability to:










Demonstrate their skill in performing a sensitive, thorough pelvic examination in
older women
Demonstrate knowledge of the epidemiology and risk factors for cervical,
uterine, and ovarian carcinoma.
Understand the pathophysiology and management of atrophic vaginitis and
urethritis in older women.
Demonstrate their ability to take a sensitive but thorough sexual history and
assess and manage sexual dysfunction in the older woman.
Demonstrate their ability to take a thorough history for the evaluation of urinary
incontinence and how (by history and physical exam) to assess the different types
of incontinence.
Develop a thorough knowledge of pelvic anatomy and the pathophysiology of
prolapse, including urethral prolapse, cystoceols, and rectoceols.
Demonstrate knowledge in the types of pessaries and the ability to select and fit
pessaries in straightforward cases.
Demonstrate knowledge of the pathophysiology and state-of-the-art medical
and/or surgical treatment options for the various types of urinary incontinence in
women (stress, detrussor hyperactivity, destrussor disinhibition, stress, overflow,
detrussor hyperactivity with incomplete contraction).
Demonstrate knowledge of the ancillary management of incontinence, including
the various types of diapers; scheduled and prompted voiding; and the role of
catheterization.
Demonstrate their ability to interpret urodynamic pressure tracings and GU
diagnostic imaging studies for incontinence, as well as knowing when to order
these studies.
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellow will evaluate patients in the gynecology office with the
supervision of the gynecologist.
2. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 59
Geriatric Fellowship Manual
II)
III)
IV)
3. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
4. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from patients and
their families and to do an effective physical examination in this milieu. Use of
information from old charts, private physicians, family and/or caregivers is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives
1. Understand the pathophysiology, risk factors, prevention, and
management of post menopausal changes in the elderly
2. Abnormal vaginal bleeding
3. Vaginal and pelvic exams in elderly
4. Atrophic vaginitis
5. Well exams, urinary incontinence.
b. Procedural Skills - The fellow will be evaluated on his/her ability to demonstrate
the following objectives
1. Pelvic/PAP
2. Breast examinations
3. Endometrial biopsies
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 60
Geriatric Fellowship Manual
V)
VI)
VII)
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Ouslander JG, Johnson TM. Incontinence. In: Hazzard WM, Blass JP,
Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 1595.
2. Brandeis GH, Resnick NM. Urinary incontinence. In: Duthie EH, Katz
PR (eds). Practice of Geriatrics, Third Edition, Philadelphia, WB
Saunders Company, 1998, p. 189.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Burgio KL. Behavioral therapy: practical approach to urinary
incontinence. Contemporary Urology, 1994 Feb, 6(2):24, 29-36, 41.
2. Vapnek JM. Urinary incontinence. Screening and treatment of urinary
dysfunction. Geriatrics 2001 Oct; 56(10):25-9.
3. DuBeau CE. Urinary incontinence management: new questions from old
assumptions. J Am Geriatr Soc 2001 Jun; 49(6):829-30.
4. Hay-Smith EJC, Bø K, Berghmans LCM, Hendriks HJM, de Bie RA,
van Waalwijk van Doorn ESC. Pelvic floor muscle training for urinary
incontinence in women (Cochrane Review). In: The Cochrane Library,
Issue 2, 2002. Oxford: Update Software.
5. Goode PS, Burgio KL, Locher JL, Umlauf MG, Lloyd LK, Roth DL.
Urodynamic changes associated with behavioral and drug treatment of
urge incontinence in older women. J Am Geriatr Soc 2002 May;
50(5):808-16.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 61
Geriatric Fellowship Manual
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.9
Long-Term Care
Location:
Duration:
Frequency:
Warm Hearth
Four-week block rotation
A minimum of three blocks
Overview:
The fellow must be equipped to care for people in long term care facilities. The fellow
who chooses to provide medical assistance to this population must be prepared to give
chronic, continuous and comprehensive care, while being aware of the psychosocial and
economic environment in which the person resides. The goals of care should start with
the maintenance or improvement of function and more through the steps necessary for the
provision of appropriate support, including comfort and terminal care, always delivered
with the highest ethical and humanitarian standards.
These residents have a series of chronic conditions, including diabetes mellitus, dementia,
depression, heart failure, osteoporosis, renal failure, chronic obstructive lung disease,
anemia, stroke, hypertension, urinary incontinence, constipation, arthritis, and others. The
fellow will also care for residents with subacute conditions such as hip fracture, and acute
problems of pneumonia, urinary tract infections, pressure ulcers, dehydration and
delirium.
The majority of patients on the nursing home service are long term residents of Warm
Hearth. Approximately 70% are women and 30% men. Most residents are Caucasians in
their 80s. Approximately 10% are receiving hospice/palliative care. The Fellows also
treat short-term residents receiving skilled nursing care and rehabilitation following
hospitalization. These short term residents may be patients initially seen in the Showalter
Clinic, Warm Harth Acute Inpatient Service or patients seen for Geriatrics Consultation
for private practice physicians.
Fellows will perform admission history and physical examinations and write orders for
new residents to the nursing home. They will perform regulatory visits in the nursing
home and see residents with acute medical problems. The fellows will serve as geriatric
consultants for residents receiving Medicare Skilled nursing care and rehabilitation.
Fellows learn about telephone triage through daily contacts from nursing home staff and
nighttime calls from the nursing home. These contacts are reviewed with the attending
physician and the fellow is provided direct verbal feedback.
Educational Purpose:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 62
Geriatric Fellowship Manual


To provide the geriatric fellow with knowledge and skills to provide quality care
to the complex long-term care patient
To learn ways to improve the elderly patients’ quality of life, through
comprehensive medical care
The fellow will demonstrate competency in his/her ability to:







Master knowledge & skills needed for performance of high quality medical care
in the Nursing Home
Acquire a working knowledge of the types of community-based resources for
older patients, how they are financed, their eligibility requirements, and how to
access them for your patients: Meals on Wheels, Adult Protective Services, Area
Agencies on Aging, Legal Aid Services for the Elderly, in-home supportive
services, adult day health care and respite-care services, senior centers, home
health care, hospice
Acquire an understanding of the long-term-care continuum and the core
regulations governing its components
Medicare-reimbursed home-health care, in-home supportive services, adult day
health care, community-based resources such as meals on wheels, assisted living
facilities/residential care, and intermediate and skilled nursing care facilities;
learn the role of the medical director in skilled nursing facilities.
The Minimum Data Set and its use in SNF’s.
The economic aspects of supportive services, including Title III of the Older
Americans Act, Medicare, Medicaid (Medi-Cal in California)
The role of transitional care for post-acute patient care; its relationship to
shortened lengths of stay under HCFA DRG’s; principles of cost-effective homehealth and nursing-home care.
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 63
Geriatric Fellowship Manual
II)
III)
b. By Fellows:
1. It is expected that geriatrics fellows on the nursing home rotation serve
as teachers and role models for more junior members of the team.
Fellows are expected to deliver at least one brief didactic talk on a
subject of interest, and to actively participate in bedside teaching during
work rounds. Fellows also serve as senior consultants to the students on
the team. Medical students, physician assistant students and nursing
students all rotate through the nursing home service. The teaching
provided by fellows is observed by the attending geriatricians and
critiqued.
2. Additional feedback is solicited from students on the team.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The underlying physiological “normal aging” changes in the various
body systems, including diminished homeostatic abilities, altered
metabolism and effects of drugs, and other changes that directly relate to
the assessment and treatment of elderly patients.
2. The normal psychological, social, and environmental changes of aging,
including reactions to common stresses and changes such as retirement,
bereavement, relocation, and ill heath, and the changes in family
relationships that affect health care of the elderly.
3. The unique modes of presentation of elderly patients for care, including
altered and nonspecific presentation of specific disease.
4. The tendency of elderly patients toward iatrogenic disease.
5. The consequences of immobilization and dependency.
6. The recommendations regarding prevention of illness and health
maintenance in the elderly.
7. The range of services available to promote rehabilitation or maintenance
of an independent lifestyle for the elderly, increasing their ability to
function as long as possible in as independent a setting as possible.
8. The characteristics of various types of long-term care facilities and
alternative housing available to the elderly.
9. The specific regulations for the care of patients in long-term care
facilities.
10. The pitfalls of geriatric care such as polypharmacy, iatrogenic illness,
over-dependency, inappropriate institutionalization, non-recognition of
treatable disease, overtreatment, etc.
11. The financial aspects of the care of the elderly.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 64
Geriatric Fellowship Manual
12. Means available to actively promote health in the elderly through
nutrition, exercise, and counseling.
13. The evaluation of the functional status of the elderly.
14. The conditions which are characteristic of older patients in long-term
care facilities:
a) Altered mental status
b) Anemia
c) Anorexia
d) Bacteruria
e) Completed stroke
f) Congestive heart failure
g) Constipation and fecal impaction
h) Degenerative joint disease
i) Dehydration
j) Dementia
k) Depression
l) Dizziness
m) Drug-induced illness
n) Elder abuse (physical, psychological, and financial)
o) Falls
p) Gait disorders
q) Hearing loss
r) Hypertension
s) Hypothyroidism
t) Incontinence
u) Malnutrition
v) Osteopenia/osteoporosis
w) Pain
x) Pneumonia
y) Postural hypotension
z) Pressure ulcers
aa) Palliative care
bb) Transient ischemic attacks
cc) Tremor/Parkinsonism
b. Skills – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. Obtain a comprehensive history and mental status examination, utilizing
available sources of information.
2. Comprehensively conduct an efficient physical examination in the
nursing home and home setting.
3. Select and interpret diagnostic procedures.
4. Set appropriate priorities for investigation and treatment
5. Communicate with the patient and/or caregivers the proposed
investigation and treatment plan, involving them in such decisions.
6. Communicate hope and empathy, while balancing objectivity with
human involvement
7. Counsel about psychologic, social, and physical stresses as well as the
likely changes of age and disease.
8. Coordinate the range of services with the patient’s support systems and
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 65
Geriatric Fellowship Manual
IV)
V)
needs.
9. Integrate factors in the patient’s family, home and general lifestyle into
the diagnostic and therapeutic process.
c. Procedures – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. IV’s
2. Veinipuncture
3. Joint Injection
4. Nail removal
5. I&D
6. Suturing
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Karuza J. Social support. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company, 1998, p.
23.
2. Besdine RW, Rubenstein LZ, Snyder L. Medical Care of the Nursing
Home Resident: What Physicians Need to Know. Philadelphia, American
College of Physicians, 1996.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 66
Geriatric Fellowship Manual
3. Katz PR. Nursing home care. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company, 1998,
p.73.
4. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics,
Fourth Edition, 1999. Chapter 15: Nursing home care, p. 452.
5. Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics,
Fourth Edition, 1999. Chapter 14: Health Services, p. 412.
6. Ouslander JG, Schnelle JF. Nursing home care. In: Hazzard WM, Blass
JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 509.
7. Messick CH. Subacute care. In: Hazzard WM, Blass JP, Ettinger WH,
Halter JB, Ouslander JG. Principles of Geriatric Medicine and
Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999, p.
493.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Hudson RB. Home and community-based care: recent accomplishments
and new challenges. J Aging Soc Policy 1996; 7(3-4):53-69.
2. Diwan S, Ivy C, Merino D, Brower T. Assessing need for intensive case
management in long-term care. Gerontologist 2001 Oct; 41(5):680-6.
3. Mottram P, Pitkala K, Lees C. Institutional versus at-home long term
care for functionally dependent older people. Cochrane Database Syst
Rev 2002;(1):CD003542.
4. Borgenicht K, Carty E, Feigenbaum LZ. Community resources for frail
older patients. West J Med 1997 Oct; 167(4):291-4.
5. Black DA. The modern geriatric day hospital. Hosp Med 2000 Aug;
61(8):539-43.
6. Krout JA. Senior centers and services for the frail elderly. J Aging Soc
Policy 1995; 7(2):59-76.
7. Hirsch CH. Epidemiology and demography of aging. Limited
distribution: Syllabus to EPM 421, UC Davis School of Medicine, 1998.
8. Leland JY, Schonwetter RS. Advances in hospice care. Clin Geriatr Med
1997 May; 13(2):381-401.
9. Miller SC, Mor VN. The role of hospice care in the nursing home
setting. J Palliat Med 2002 Apr; 5(2):271-7.
10. Hoyer T. Hospice and Future of End-of-Life Care: Approaches and
Funding Ideas. Journal of Palliat Med 2002; 5(2): 259-262.
11. Volicer L. Management of severe Alzheimer's disease and end-of-life
issues. Clin Geriatr Med 2001 May; 17(2):377-91.
12. Campbell I, Case C. Patient management in the subacute unit.
Lippincotts Prim Care Pract 1999 Mar-Apr; 3(2):231-41.
13. Evans JM, Chutka DS, Fleming KC, Tangalos EG, Vittone J, Heathman
JH. Medical care of nursing home residents. Mayo Clin Proc 1995 Jul;
70(7):694-702.
14. Ackermann RJ. Nursing home practice. Strategies to manage most acute
and chronic illnesses without hospitalization. Geriatrics 2001 May;
56(5):37, 40, 43-4 passim.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 67
Geriatric Fellowship Manual
VI)
VII)
15. Swagerty DL Jr, Rigler S. The physician's role in directing long-term
care. Understanding the rules is important for protecting your patients
and your practice. Postgrad Med 2000 Feb; 107(2):217-8, 221-2, 225-7.
16. Phillips-Harris C, Fanale JE. The acute and long-term care interface.
Integrating the continuum. Clin Geriatr Med 1995 Aug; 11(3):481-501.
17. Levenson SA. Subacute settings: making the most of a new model of
care. Geriatrics 1998 Jul; 53(7):69-74.
18. Kovach CR. Nursing home dementia care units. Providing a continuum
of care rather than aging in place. J Gerontol Nurs 1998 Apr; 24(4):306.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.10
Geriatric Dermatology
Location:
Duration:
Frequency:
Ambulatory office of Daniel Hurd, DO or LGH Out-Patient Clinic
Two or Four-week block rotation
One block elective rotation
Overview:
The geriatric fellow will have appropriate medical care responsibilities and work with the
dermatologist in the out-patient setting as well as any in-patient dermatology consults.
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to identify and appropriately
treat common skin disorders in the elderly patient.
The fellow will demonstrate competency in his/her ability to:

Effective 07/01/2010
Version 1
Conversant with age-related changes to the skin, hair, and nails, and the
resulting susceptibility to conditions such as xerosis, bruising, and pressure
sores
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 68
Geriatric Fellowship Manual




Learn the epidemiology and pathophysiology of common skin disorders in
the elderly, as well as common skin cancers and pre-cancerous lesions
(basal-cell and squamous-cell carcinomas, actinic keratoses)
Demonstrate the ability to perform a comprehensive skin examination and be
able to recognize common age-related cutaneous disorders and malignancies
Learn standard therapies for common skin disorders of the elderly, and will
learn the staging and treatments for skin cancers
Demonstrate the ability to perform a simple punch biopsy
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
II)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows:
1. It is expected that geriatrics fellows on the nursing home rotation serve
as teachers and role models for more junior members of the team.
Fellows are expected to deliver at least one brief didactic talk on a
subject of interest, and to actively participate in bedside teaching during
work rounds. Fellows also serve as senior consultants to the students on
the team. Medical students, physician assistant students and nursing
students all rotate through the nursing home service. The teaching
provided by fellows is observed by the attending geriatricians and
critiqued.
2. Additional feedback is solicited from students on the team.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient follow-
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 69
Geriatric Fellowship Manual
III)
IV)
V)
up, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The underlying physiological “normal aging” changes in the various
body systems, including diminished homeostatic abilities, altered
metabolism and effects of drugs, and other changes that directly relate to
the assessment and treatment of elderly patients.
2. The normal psychological, social, and environmental changes of aging,
including reactions to common stresses and changes such as retirement,
bereavement, relocation, and ill heath, and the changes in family
relationships that affect health care of the elderly.
3. The unique modes of presentation of elderly patients for care, including
altered and nonspecific presentation of specific disease.
b. Procedural – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. Obtain a comprehensive history and mental status examination, utilizing
available sources of information.
2. Comprehensively conduct an efficient physical examination in the
nursing home and home setting.
3. Select and interpret diagnostic procedures.
4. Set appropriate priorities for investigation and treatment
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 70
Geriatric Fellowship Manual
VI)
VII)
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Karuza J. Social support. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company, 1998, p.
23.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Hudson RB. Home and community-based care: recent accomplishments
and new challenges. J Aging Soc Policy 1996; 7(3-4):53-69.
2. Diwan S, Ivy C, Merino D, Brower T. Assessing need for intensive case
management in long-term care. Gerontologist 2001 Oct; 41(5):680-6.
3. Mottram P, Pitkala K, Lees C. Institutional versus at-home long term
care for functionally dependent older people. Cochrane Database Syst
Rev 2002;(1):CD003542.
4. Borgenicht K, Carty E, Feigenbaum LZ. Community resources for frail
older patients. West J Med 1997 Oct; 167(4):291-4.
5. Black DA. The modern geriatric day hospital. Hosp Med 2000 Aug;
61(8):539-43.
6. Krout JA. Senior centers and services for the frail elderly. J Aging Soc
Policy 1995; 7(2):59-76.
7. Hirsch CH. Epidemiology and demography of aging. Limited
distribution: Syllabus to EPM 421, UC Davis School of Medicine, 1998.
8. Leland JY, Schonwetter RS. Advances in hospice care. Clin Geriatr Med
1997 May; 13(2):381-401.
9. Miller SC, Mor VN. The role of hospice care in the nursing home setting.
J Palliat Med 2002 Apr; 5(2):271-7.
10. Hoyer T. Hospice and Future of End-of-Life Care: Approaches and
Funding Ideas. Journal of Palliat Med 2002; 5(2): 259-262.
11. Volicer L. Management of severe Alzheimer's disease and end-of-life
issues. Clin Geriatr Med 2001 May; 17(2):377-91.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 71
Geriatric Fellowship Manual
6.11
Musculoskeletal Disorders in the Elderly
Location:
Duration:
Frequency:
Rheumatology Rotation
Two or Four-week block rotation
One block elective rotation
Overview:
To ensure adequate teaching cases, Geriatric Clinic patients with hard-to-manage DJD
can be referred for an evaluation by the trainee and the attending rheumatologist. The
joint-replacement clinic compliments the rheumatology experience by exposing the
trainee to advanced DJD of the hip and knee.
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to identify patients at risk for
development of wounds and wound complications; prescribe preventive measures to
promote skin integrity; and to treat wound problems once they develop.
The fellow will demonstrate competency in his/her ability to:




The fellow will learn the epidemiology, pathophysiology, and state-of-the-art
management of major musculoskeletal conditions in the elderly:
o Osteoarthritis, especially of the knee, hip, and spine
o Late effects of rheumatoid arthritis
o Polymyalgia and temporal arteritis
o Gouty arthritis
o Rotator cuff disorders
The fellow will demonstrate the ability to perform thorough, targeted
musculoskeletal examinations, with commensurate demonstration of a
thorough knowledge of musculoskeletal anatomy.
The fellow will learn the role of selected strengthening exercises and other
physical and occupational therapies in the management of age-associated
osteoarthritis and shoulder problems.
Above and beyond the standard rheumatological and orthopedic evaluations
of the patients, the trainee will apply the knowledge and techniques gleaned
from the Pain Clinic rotation to assess the patient’s pain and propose
appropriate multi-modal pain-control regimens.
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 72
Geriatric Fellowship Manual
II)
III)
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows:
1. It is expected that geriatrics fellows on the nursing home rotation serve
as teachers and role models for more junior members of the team.
Fellows are expected to deliver at least one brief didactic talk on a
subject of interest, and to actively participate in bedside teaching during
work rounds. Fellows also serve as senior consultants to the students on
the team. Medical students, physician assistant students and nursing
students all rotate through the nursing home service. The teaching
provided by fellows is observed by the attending geriatricians and
critiqued.
2. Additional feedback is solicited from students on the team.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The underlying physiological “normal aging” changes in the various
body systems, including diminished homeostatic abilities, altered
metabolism and effects of drugs, and other changes that directly relate to
the assessment and treatment of elderly patients.
2. The normal psychological, social, and environmental changes of aging,
including reactions to common stresses and changes such as retirement,
bereavement, relocation, and ill heath, and the changes in family
relationships that affect health care of the elderly.
3. The unique modes of presentation of elderly patients for care, including
altered and nonspecific presentation of specific disease.
4. The tendency of elderly patients toward iatrogenic disease.
5. The consequences of immobilization and dependency.
6. The recommendations regarding prevention of illness and health
maintenance in the elderly.
b. Procedural – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. Obtain a comprehensive history and mental status examination, utilizing
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 73
Geriatric Fellowship Manual
IV)
V)
available sources of information.
2. Comprehensively conduct an efficient physical examination in the
nursing home and home setting.
3. Select and interpret diagnostic procedures.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Karuza J. Social support. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company, 1998, p.
23.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Hudson RB. Home and community-based care: recent accomplishments
and new challenges. J Aging Soc Policy 1996; 7(3-4):53-69.
2. Diwan S, Ivy C, Merino D, Brower T. Assessing need for intensive case
management in long-term care. Gerontologist 2001 Oct; 41(5):680-6.
3. Mottram P, Pitkala K, Lees C. Institutional versus at-home long term
care for functionally dependent older people. Cochrane Database Syst
Rev 2002;(1):CD003542.
4. Borgenicht K, Carty E, Feigenbaum LZ. Community resources for frail
older patients. West J Med 1997 Oct; 167(4):291-4.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 74
Geriatric Fellowship Manual
VI)
VII)
5. Black DA. The modern geriatric day hospital. Hosp Med 2000 Aug;
61(8):539-43.
6. Krout JA. Senior centers and services for the frail elderly. J Aging Soc
Policy 1995; 7(2):59-76.
7. Hirsch CH. Epidemiology and demography of aging. Limited
distribution: Syllabus to EPM 421, UC Davis School of Medicine, 1998.
8. Leland JY, Schonwetter RS. Advances in hospice care. Clin Geriatr Med
1997 May; 13(2):381-401.
9. Miller SC, Mor VN. The role of hospice care in the nursing home setting.
J Palliat Med 2002 Apr; 5(2):271-7.
10. Hoyer T. Hospice and Future of End-of-Life Care: Approaches and
Funding Ideas. Journal of Palliat Med 2002; 5(2): 259-262.
11. Volicer L. Management of severe Alzheimer's disease and end-of-life
issues. Clin Geriatr Med 2001 May; 17(2):377-91.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.12
Rehabilitation/Sub Acute Care
Location:
Duration:
Frequency:
Pulaski Health and Rehabilitation
Four-week block rotation
One block
Overview:
The geriatric fellow will have appropriate responsibilities related to the medical care of
elderly patients participating in skilled rehab, in conjunction with the geriatric attending
physician.
The fellow will have the opportunity to participate in team meetings and interact with the
rehab/therapy team to provide comprehensive care for their mutual patients.
Educational Purpose:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 75
Geriatric Fellowship Manual
To provide the geriatric fellow with knowledge and skills to care for people of advanced
years who present with functional decline either due to injury, disease or accident.
Spending time on an inpatient rehabilitation unit gives an opportunity to observe and
participate in the care of a variety of patients who require intense rehabilitation in order
to regain independence.
The fellow will demonstrate competency in his/her ability to:











Improve skills in performing a comprehensive musculoskeletal examination
Gait and balance evaluation/fall risk assessment
Assessment of strength and physical functioning
Knowledge of the application of physical treatment modalities – heat and cold,
hydrotherapy, electrical stimulation, traction, exercise, and biofeedback
Evaluation and management of pain (TENS, etc.)
General approaches to strengthening and reconditioning the elderly – PT, group
exercises
Principles of stroke rehabilitation
Non-operative management of the frozen shoulder/rotator cuff injuries
Non-operative management of degenerative and other arthritides
Prescription of walking aides and other assistive devices
Ability to effectively collaborate with and direct rehabilitation specialists (PT,
OT, Speech Therapists) in acute-care, nursing home, and home care
environments.
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows:
1. It is expected that geriatrics fellows on the nursing home rotation serve
as teachers and role models for more junior members of the team.
Fellows are expected to deliver at least one brief didactic talk on a
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 76
Geriatric Fellowship Manual
II)
III)
subject of interest, and to actively participate in bedside teaching during
work rounds. Fellows also serve as senior consultants to the students on
the team. Medical students, physician assistant students and nursing
students all rotate through the nursing home service. The teaching
provided by fellows is observed by the attending geriatricians and
critiqued.
2. Additional feedback is solicited from students on the team.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The underlying physiological “normal aging” changes in the various
body systems, including diminished homeostatic abilities, altered
metabolism and effects of drugs, and other changes that directly relate to
the assessment and treatment of elderly patients.
2. The normal psychological, social, and environmental changes of aging,
including reactions to common stresses and changes such as retirement,
bereavement, relocation, and ill health, and the changes in family
relationships that affect health care of the elderly.
3. The unique modes of presentation of elderly patients for care, including
altered and nonspecific presentation of specific disease.
4. The tendency of elderly patients toward iatrogenic disease.
5. The consequences of immobilization and dependency.
6. The range of services available to promote rehabilitation or maintenance
of an independent lifestyle for the elderly, increasing their ability to
function as long as possible in as independent a setting as possible.
7. The pitfalls of geriatric care such as polypharmacy, iatrogenic illness,
over-dependency, inappropriate institutionalization, non recognition of
treatable disease, overtreatment, etc.
8. The financial aspects of the care of the elderly.
9. The evaluation of the functional status of the elderly.
10. The conditions which often require admission to an inpatient rehab unit:
a) Completed stroke
b) Degenerative joint disease, s/p hip or knee replacement
c) Falls
d) Gait disorders
e) Osteopenia/osteoporosis
f) Pain parkinsonism
b. Skills – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 77
Geriatric Fellowship Manual
IV)
V)
1. Obtain a comprehensive history and mental status examination, utilizing
available sources of information.
2. Comprehensively conduct an efficient physical examination.
3. Select and interpret diagnostic procedures.
4. Set appropriate priorities for investigation and treatment
5. Communicate with the patient and/or caregivers the proposed
investigation and treatment plan, involving them in such decisions.
6. Communicate hope and empathy, while balancing objectivity with
human involvement
7. Coordinate the range of services with the patient’s support systems and
needs.
8. Integrate factors in the patient’s family, home and general lifestyle into
the diagnostic and therapeutic process.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Kemp B, Brummel-Smith K, Ramsdell JW. Geriatric Rehabilitation,
College Hill Press, 1990.
2. Studenski SA, Duncan P, Maino JH. Principles of rehabilitation in older
patients. In: Hazzard WM, Blass JP, Ettinger WH, Halter JB, Ouslander
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 78
Geriatric Fellowship Manual
VI)
VII)
JG. Principles of Geriatric Medicine and Gerontology, Fourth Edition,
New York, McGraw-Hill, Inc., 1999, p. 435.
3. Hoenig HM. Rehabilitation. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company, 1998, p.
159.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Cameron ID, Handoll HHG, Finnegan TP, Madhok R, Langhorne P. Coordinated multidisciplinary approaches for inpatient rehabilitation of
older patients with proximal femoral fractures (Cochrane Review). In:
The Cochrane Library, Issue 2, 2002. Oxford: Update Software.
2. Kwan J, Sandercock P. In-hospital care pathways for stroke (Cochran
Review). In: The Cochrane Library, Issue 2, 2002. Oxford: Update
Software.
3. Kramer AM, Coleman EA. Stroke rehabilitation in nursing homes: how
do we measure quality? Clin Geriatr Med 1999 Nov; 15(4):869-84.
4. Kane RL. Improving outcomes in rehabilitation. A call to arms (and
legs). Med Care 1997 Jun; 35(6 Suppl):JS21-7.
5. Miskelly FG. Assistive technology in elderly care. Age Ageing 2001 30:
455-458.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.13
Consult Service
Location:
Duration:
Frequency:
Montgomery Regional Hospital
Two or Four-week block rotation
One block elective rotation
Overview:
The geriatric fellow will need to be able to take a complete comprehensive and accurate
history of the elderly patient and perform a complete physical exam to assist and work
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 79
Geriatric Fellowship Manual
with the consulting physician by providing the expertise of the trained geriatrician to
assist in the best care for that individual patient.
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to perform complete geriatric
history and physicals, facilitate working with other physicians in caring for the same
patient, to improve communication between the primary care physician and specialist,
and to provide a comprehensive plan for the problem identified by the consulting
physician.
The fellow will demonstrate competency in his/her ability to:






The fellow will be able to identify pertinent medical, functional, and psychosocial factors that may affect peri-operative morbidity and mortality.
The fellow will demonstrate the ability to make appropriate
recommendations to prevent or reduce the likelihood of such morbidity.
The fellow will learn to perform pre-operative discharge planning – i.e.,
determining the likely short-term functional consequences of the planned
surgery, assessing the patient’s actual and potential caregiver support and
environment, and based on this evaluation, anticipating whether the patient
will be able to be discharged home without special services, home with home
care, or to a nursing home for transitional care.
The fellow will demonstrate the ability to dictate a thorough but concise
consultation report.
The fellow will learn to provide complete; yet concise recommendations
addressing the consulting physician’s concerns.
The fellow will learn to identify and manage patients at risk for geriatric
complications like delirium.
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 80
Geriatric Fellowship Manual
II)
III)
Lecture Attendance Protocol.)
b. By Fellows:
1. It is expected that geriatrics fellows on the nursing home rotation serve
as teachers and role models for more junior members of the team.
Fellows are expected to deliver at least one brief didactic talk on a
subject of interest, and to actively participate in bedside teaching during
work rounds. Fellows also serve as senior consultants to the students on
the team. Medical students, physician assistant students and nursing
students all rotate through the nursing home service. The teaching
provided by fellows is observed by the attending geriatricians and
critiqued.
2. Additional feedback is solicited from students on the team.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The underlying physiological “normal aging” changes in the various
body systems, including diminished homeostatic abilities, altered
metabolism and effects of drugs, and other changes that directly relate to
the assessment and treatment of elderly patients.
2. The normal psychological, social, and environmental changes of aging,
including reactions to common stresses and changes such as retirement,
bereavement, relocation, and ill heath, and the changes in family
relationships that affect health care of the elderly.
3. The unique modes of presentation of elderly patients for care, including
altered and nonspecific presentation of specific disease.
4. The tendency of elderly patients toward iatrogenic disease.
5. The consequences of immobilization and dependency.
6. The recommendations regarding prevention of illness and health
maintenance in the elderly.
b. Skills – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. Obtain a comprehensive history and mental status examination, utilizing
available sources of information.
2. Comprehensively conduct an efficient physical examination in the
nursing home and home setting.
3. Select and interpret diagnostic procedures.
4. Set appropriate priorities for investigation and treatment
5. Communicate with the patient and/or caregivers the proposed
investigation and treatment plan, involving them in such decisions.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 81
Geriatric Fellowship Manual
IV)
V)
6. Communicate hope and empathy, while balancing objectivity with
human involvement
7. Counsel about psychologic, social, and physical stresses as well as the
likely changes of age and disease.
8. Coordinate the range of services with the patient’s support systems and
needs.
9. Integrate factors in the patient’s family, home and general lifestyle into
the diagnostic and therapeutic process.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Francis J. Perioperative management of the older patient. In: Hazzard
WM, Blass JP, Ettinger WH, Halter JB, Ouslander JG. Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 377.
2. Roy RC. Anesthesia for older patients. In: Hazzard WM, Blass JP,
Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric Medicine
and Gerontology, Fourth Edition, New York, McGraw-Hill, Inc., 1999,
p. 391.
3. Bell R, Rosenthall RA. Surgery in the elderly. In: Hazzard WM, Blass
JP, Ettinger WH, Halter JB, Ouslander JG. Principles of Geriatric
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 82
Geriatric Fellowship Manual
VI)
VII)
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 413.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Hirsch CH. When your patient needs surgery: weighing risks versus
benefits. Geriatrics 1995 Jan; 50(1):26-31.
2. Hirsch CH. When your patient needs surgery: how planning can avoid
complications. Geriatrics 1995 Feb; 50(2):39-44.
3. Watters JM. Surgery in the elderly. Can J Surg 2002 Apr; 45(2):104-8.
4. Pasquali SK, Alexander KP, Peterson ED. Cardiac rehabilitation in the
elderly. Am Heart J 2001 Nov; 142(5):748-5.
5. Gloth, F. M., 3rd. (2001). Principles of perioperative pain management
in older adults. Clin Geriatr Med, 17(3), 553-573, vii-viii.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.14
Palliative Care
Location:
Duration:
Frequency:
Good Samaritan or Medi Hospice
Two or Four-week block rotation
One block rotation
Overview:
The fellow will attend the weekly interdisciplinary hospice team meeting and will make
home visits on selected hospice patients followed by Good Samaritan Hospice. Home
visits will be made with various members of the interdisciplinary team (nurse, social
work, chaplain). Fellows are encouraged to continue following their terminal hospice
primary-care patients until their demise; provision for house calls will be made in the
fellow’s schedule.
Educational Purpose:
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 83
Geriatric Fellowship Manual





To provide the geriatric fellow with knowledge and skills to care for terminally
ill patients
To provide appropriate pain management
To learn the benefits of hospice care for the patient, family, caregivers and
attending physician
To be familiar with hospice admission requirements and when a hospice referral
is appropriate
To learn how to have appropriate initial hospice conversations with patients and
their families
The fellow will demonstrate competency in his/her ability to:







Demonstrate an understanding of the range of services, funding, and eligibility
requirements for hospice.
Demonstrate the ability to interact effectively and professionally with members
of the hospice team.
Develop skill in sensitively assessing and addressing the patient’s and family’s
cultural and religious attitudes towards death and dying.
Demonstrate sensitive, effective communication with the patient and family
members concerning end-of-life care, and will demonstrate sensitive, effective
counseling about care issues.
Demonstrate knowledge of advance directives and California’s laws that govern
them.
Become familiar with the physiologic processes common to imminent death.
Acquire knowledge about pharmacologic and non-pharmacologic palliative
interventions, including the use of narcotic and non-narcotic pain medications.
(This objective is complimented by rotation # 13, Pain Clinic.)
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 84
Geriatric Fellowship Manual
II)
III)
IV)
Lecture Attendance Protocol.)
b. By Fellows:
1. As members of an interdisciplinary team, fellows are expected to share
their knowledge and expertise on end-of-life problems with the nurse
practitioner, social worker, therapists, nurses, dietitian, et al, and with
other students and trainees on the service.
2. The fellow is expected to present at least one 10-15 minute educational
presentation (on a palliative care topic) to the other trainees on the
service; in addition to informal bedside discussion and training.
3. Education of family members on health problems, prognosis and advance
planning is an important educational function for the fellow.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient followup, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. Didactics sessions covering symptom management, managing family
meetings/breaking bad news, pain management, and ethical issues
encountered in end-of-life.
2. Patient care rounds
3. Self-directed as fellow is expected to produce and present at least one
15-minute educational presentation during this rotation.
b. Procedural – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow will have many opportunities to work with patients,
caregivers and family members to identify primary goals of care,
perform advance care planning, counseling regarding treatment options,
discussion the hospice agencies regarding appropriateness and timeliness
of referrals.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
2. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
k) Be responsible for and punctual in covering the assigned shifts.
l) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
m) Attend all departmental conferences and meetings stipulated.
n) Complete all chart documentation and maintain daily logs.
o) Appropriate use of consultants and paramedical personnel.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 85
Geriatric Fellowship Manual
V)
VI)
p) Compassionate handling of families and development of rapport with
them.
q) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
r) The fellow must be responsible and reliable at all times.
s) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
t) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Karuza J. Social support. In: Duthie EH, Katz PR (eds). Practice of
Geriatrics, Third Edition, Philadelphia, WB Saunders Company, 1998, p.
23.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Hudson RB. Home and community-based care: recent accomplishments
and new challenges. J Aging Soc Policy 1996; 7(3-4):53-69.
2. Diwan S, Ivy C, Merino D, Brower T. Assessing need for intensive case
management in long-term care. Gerontologist 2001 Oct; 41(5):680-6.
3. Mottram P, Pitkala K, Lees C. Institutional versus at-home long term
care for functionally dependent older people. Cochrane Database Syst
Rev 2002;(1):CD003542.
4. Borgenicht K, Carty E, Feigenbaum LZ. Community resources for frail
older patients. West J Med 1997 Oct; 167(4):291-4.
5. Black DA. The modern geriatric day hospital. Hosp Med 2000 Aug;
61(8):539-43.
6. Krout JA. Senior centers and services for the frail elderly. J Aging Soc
Policy 1995; 7(2):59-76.
7. Hirsch CH. Epidemiology and demography of aging. Limited
distribution: Syllabus to EPM 421, UC Davis School of Medicine, 1998.
8. Leland JY, Schonwetter RS. Advances in hospice care. Clin Geriatr Med
1997 May; 13(2):381-401.
9. Miller SC, Mor VN. The role of hospice care in the nursing home setting.
J Palliat Med 2002 Apr; 5(2):271-7.
10. Hoyer T. Hospice and Future of End-of-Life Care: Approaches and
Funding Ideas. Journal of Palliat Med 2002; 5(2): 259-262.
11. Volicer L. Management of severe Alzheimer's disease and end-of-life
issues. Clin Geriatr Med 2001 May; 17(2):377-91.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 86
Geriatric Fellowship Manual
VII)
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
Top of the Document
6.15
Osteopathic Principles and Practice
1. Perform a comprehensive evaluation of the musculoskeletal system including the
osteopathic structural examination.
2. Be intimately familiar with osseous, muscular, ligamentous, tendicous, neurological,
and lymphatic anatomy.
3. Recognize common syndromes that present to the osteopathic specialist:
a. Psoas syndrome
b. Piriformis syndrome
c. Scoliosis
d. Costochondritis
e. Thoracic outlet syndrome
f. Carpal tunnel syndrome
g. Tension cephalgia
h. Low back pain
i. Reflex sympathetic dystrophy
j. Somatic dysfunctions of the axial skeleton
k. Somatic dysfunctions of the apprendicular skeleton
4. Be able to recognize the somatic dysfunctions associated with common sports
injuries.
5. Understand the effects of somatic dysfunction on athletic performance and properly
diagnose and treat these somatic dysfunctions.
6. Demonstrate skill in:
a. Prescribing appropriate bracing
b. Trigger point injections
c. Trigger point deactivation techniques
Top of the Document
6.16
Geriatric Neurology
Location:
Effective 07/01/2010
Version 1
Neurology Services of SW Virginia
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 87
Geriatric Fellowship Manual
Duration:
Frequency:
Two-week block rotation
A minimum of two blocks
Overview:
The fellows will see a full spectrum of neurologic diseases involving elderly, with
emphasis on cerebrovascular disease, movement disorders, seizures, cognitive disorders,
and various other degenerative conditions. Spending time in the ambulatory neurology
clinic and performing inpatient consultations with a neurologist affords an opportunity to
observe and participate in the care of a variety of patients who present with neurologic
conditions.
Educational Purpose:
To add to the fellow’s fund of knowledge and skills in the evaluation and management of
neurologic disease in the elderly
The fellow will demonstrate competency in his/her ability to:








Effective 07/01/2010
Version 1
Perform the evaluation and management of common neurological diseases
and/or syndromes in the elderly
Describe the:
o Normal physiologic changes in the aging nervous system
o Pathophysiology of common neurologic disease of the elderly
o Role of diagnostic tests in the evaluation of neurologic disease,
including laboratory tests, neuro imaging (e.g. CT, MRI),
electrophysiologic tests (e.g. EMG, EEG), and spinal fluid analysis
o Psychosocial aspects of Neurologic diseases in the elderly, including:
 Ethical/legal issues regarding neurologic problems (advance
directives, guardianship, DPOAHC)
 Health Economics (Medicare, Medicaid, etc.) of neurologic
problems.
Performance Expectations:
o Comprehensive screening neurologic exam
o Screening bedside mental status testing
o Symptom review of neuropsychiatric symptoms and functional status
o Demonstrate medical decision making and goal setting in the
treatment of neurologic disorders that incorporate the patient’s
values and preferences
o Order diagnostic tests and prescribe medications for patients with
neurologic diseases appropriately and safely.
Demonstrate the ability to perform a comprehensive, accurate neurological
examination
Demonstrate a knowledge of neuro anatomy appropriate to understand and
manage the conditions listed below
Demonstrate a basic knowledge of the neurological changes of normal aging
(cortical atrophy, slowing of conduction velocity in peripheral nerves, agerelated changes in gait and balance, etc.)
Demonstrate knowledge of autonomic changes seen in normal aging and in
disease
How to assess and manage peripheral neuropathies
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 88
Geriatric Fellowship Manual






Demonstrate the evaluation and diagnosis of gait disturbances in the elderly,
including the evaluation of falls.
Demonstrate knowledge of the pathophysiology, evaluation, and treatment
(pharmacologic and non-pharmacologic) of Parkinson’s disease and related
disorders
Perform an evaluation and management of “dizziness”
Obtain current (“state-of-the-art”) opinions regarding evaluation and
management of cerebrovascular disease, especially TIA’s
Assess deficits and rehabilitation needs in the patients with acute stroke, and
the prevention of stroke-related complications (e.g., seizure, contractures).
(This objective compliments #5-CREC and #9-PM&R.)
Evaluate and manage headaches in the older patient
The fellows will obtain competency in all of the above goals by meeting the following criteria:
I)
II)
Principal Teaching Methods
a. By Faculty:
1. The fellows work under supervision of a geriatric attending.
2. Rounds typically begin in the conference room for a formal presentation
of the new admissions.
3. The team then makes rounds on all patients. Diagnostic and treatment
strategies are discussed at the bedside.
4. If time allows, patient discussion is complemented by small, informal
lectures on geriatrics given by the faculty.
5. Reading assignments and literature searches are given to each and every
house officer in the team, and they are to be discussed after working
rounds are done.
6. Time for lectures is always provided to the whole team, the fellow will
make him/herself available to the nurses for emergencies. Lectures by
subspecialty faculty are to stress critical aspects of their specialty –
UNLESS, in the opinion of the attending physician, there is a crisis in
the department necessitating full coverage. (If this is the case, follow
Lecture Attendance Protocol.)
b. By Fellows:
1. Fellows round with the inpatient team which includes residents from
internal medicine and or family medicine and medical students. Fellows
are encouraged to teach members of the team special aspects of geriatric
inpatient care.
2. Fellows may also be assigned topics for review and presentation by the
neurology attending in both the inpatient and outpatient settings.
Core Competency 5: Patient Care
a. Trainees will learn to obtain a logical, chronological history from critically ill
patients and their families and to do an effective physical examination in this
challenging milieu. Use of information from old charts and private physicians is
stressed.
b. Fellows will learn to integrate physiological parameters and laboratory data with
the clinical history and physical exam to make clinical diagnostic and
management decisions.
c. Fellows will learn the appropriate use of daily progress notes in patient follow-
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 89
Geriatric Fellowship Manual
III)
IV)
up, and the need for frequent reevaluation of the unstable patient.
Core Competency 2: Medical Knowledge
a. Objectives – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The underlying physiological ‘normal aging” neurologic changes.
2. The unique modes of presentation of elderly patients for care, including
altered and nonspecific presentation of specific disease.
3. The conditions that commonly require the assistance of a neurologist,
including:
i.
Parkinson’s Disease
ii.
ALS
iii.
Azheimer’s Disease
iv.
Stroke
v.
Traumatic Brain injury
vi.
Epilepsy
2. The diagnostic entities available and their utility in selected clinical
scenarios.
3. The pitfalls of geriatric care such as polypharmacy, iatrogenic illness,
over-dependency, inappropriate institutionalization, non recognition of
treatable disease, overtreatment, etc.
4. The evaluation of the functional status of the elderly.
b. Skills – The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. Obtain a comprehensive history and mental status examination, utilizing
available sources of information.
2. Comprehensively conduct a complete neurological examination, basic
cognitive and affective evaluations.
3. Select and interpret diagnostic procedures.
4. Set appropriate priorities for investigation and treatment.
5. Communicate with the patient and/or caregivers the proposed
investigation and treatment plan, involving them in such decisions.
6. Communicate hope and empathy, while balancing objectivity with
human involvement.
7. Coordinate the range of services with the patient’s support systems and
needs.
8. Integrate factors in the patient’s family, home and general lifestyle into
the diagnostic and therapeutic process.
Core Competency 3: Professionalism
a. Objectives & Evaluation - The fellow will be evaluated on his/her ability to
demonstrate the following objectives:
1. The fellow should continue to develop his/her ethical behavior and the
humanistic qualities of respect, compassion, integrity, and honesty.
These goals are met in several ways:
a) Be responsible for and punctual in covering the assigned shifts.
b) Initiate medical therapy, treatment, and referral of assigned patient
after reviewing with the EM fellow and attending physician.
c) Attend all departmental conferences and meetings stipulated.
d) Complete all chart documentation and maintain daily logs.
e) Appropriate use of consultants and paramedical personnel.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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V)
VI)
f) Compassionate handling of families and development of rapport with
them.
g) The fellow must be willing to acknowledge errors and determine
how to avoid future similar mistakes.
h) The fellow must be responsible and reliable at all times.
i) The fellow must always consider the needs of patients, families,
colleagues, and support staff.
j) The fellow must maintain a professional appearance at all times.
Core Competency 6: System-Based Practice
a. Objectives - The fellow will be evaluated on his/her ability to demonstrate the
following objectives:
1. The fellow should improve in the utilization of and communication with
colleagues and other health professionals.
2. The fellow should improve in the use of cost effective medicine.
3. The fellow will assist in determining the root cause of any error, which is
identified and methods for avoiding such problems in the future.
4. The fellow will assist in development of systems’ improvement if
problems are identified.
b. Educational Materials - Mandatory Reading:
1. Rajput AH. Parkinson’s disease and related disorders. In: Hazzard WM,
Blass JP, Ettinger WH, Halter JB, Ouslander JG (eds). Principles of
Geriatric Medicine and Gerontology, Fourth Edition, New York,
McGraw-Hill, Inc., 1999, p. 1271.
2. Burke JR. Other neurodegenerative disorders. In: Hazzard WM, Blass
JP, Ettinger WH, Halter JB, Ouslander JG (eds). Principles of Geriatric
Medicine and Gerontology, Fourth Edition, New York, McGraw-Hill,
Inc., 1999, p. 1283.
c. Medical Literature - References of basic (classic and recent) articles in critical
care medicine are provided. These are to be read and discussed with the team.
1. Danisi F. Parkinson's disease. Therapeutic strategies to improve patient
function and quality of life. Geriatrics 2002 Mar; 57(3):46-50.
2. Marjama-Lyons JM, Koller WC. Parkinson's disease. Update in
diagnosis and symptom management. Geriatrics 2001 Aug; 56(8):24-5,
29-30, 33-5.
3. Sudarsky L. Neurologic disorders of gait. Curr Neurol Neurosci Rep
2001 Jul;1(4):350-6.
4. Fabbrini G, Barbanti P, Aurilia C. Tardive dyskinesias in the elderly. Int
J Geriatr Psychiatry 2001 Dec; 16 Suppl 1:S19-23.
5. Mahant PR, Stacy MA. Movement disorders and normal aging. Neurol
Clin 2001 Aug;19(3):553-63, vi.
6. Wolters EC, Berendse HW. Management of psychosis in Parkinson's
disease. Curr Opin Neurol 2001 Aug; 14(4):499-504.
7. Korczyn AD. Neuropsychiatric manifestations in Parkinson's disease.
Adv Neurol 2001; 86:395-8.
Core Competency 7: Practice Based Learning Improvement
a. Objectives
1. The fellow should use feedback and self-evaluation in order to improve
performance.
2. The fellow should read the required material and articles provided to
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
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current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
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Geriatric Fellowship Manual
VII)
enhance learning.
3. The fellow should use the medical literature search tools in the library to
find appropriate articles related to interesting cases.
Evaluation - Monthly evaluations by faculty of fellows and by fellows of faculty are
submitted. Fellow evaluations are written with input from the nursing staff, patients
or families as regards specific attitudes towards patients. Faculty supervises most of
the daytime procedures completed and will provide an evaluation and feedback here
is immediate and ongoing.
a. Feedback - At the midway point of the rotation, fellows are given feedback
(informally) on their performance to date. Areas and methods of improvement
are suggested. A formal evaluation and verbal discussion with the fellow is to be
done at the end of the rotation.
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Return to the beginning of the Manual
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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7
DIDACTIC PROGRAMS
7.1
Educational Experience
1. Journal Club will meet once monthly for one hour.
a. Two or three articles will be discussed.
b. A critical review of each article will be conducted.
c. Articles will be circulated for review one week ahead of scheduled
review time.
2. Geriatric Didactics
a. Didactic educational sessions will meet two hours weekly.
b. The subspecialty fellow will discuss fundamental geriatrics issues
with members of the faculty.
c. The longitudinal curriculum for study is listed in section c below.
3. Longitudinal educational core curriculum
a. Basic issues in geriatrics
1) The pre-participation examination
2) Fundamentals of being a team physician
3) Legal aspects of geriatrics
b. Medical topics in the elderly
1) Diabetes
2) Gastrointestinal problems
3) Genitourinary issues
4) Neurologic issues
5) Dermatologic problems
6) Issues in otolaryngology
7) Environmental issues
8) Hypertension
9) Cardiac rehabilitation
10) Cardiac arrhythmias
11) Infectious diseases
12) Anemia
c. Psychological and psychiatric issues
d. Musculoskeletal topics
Top of the Document
7.2
Meeting and Lecture Requirements
Fellows are required to attend a minimum of 90% of all meetings/lectures as directed by
the program director and participate in committee meetings in addition to participation in
institution’s student education programs.
An attendance record of 90% at all such programs is required for successful
completion of the Fellowship Program. Disciplinary action and/or additional training
may be required if fellows are found delinquent. Attendance is a requirement of your
employment. Failure to attend violates your contractual relationship with VCOM.
Effective 07/01/2010
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manual at any time without prior notice. It is the resident’s
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current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
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Geriatric Fellowship Manual
All fellows will attend the following didactic sessions:
Assigned committee meetings
Grand Rounds and Morning Lectures
Geriatric Weekly Didactic Lecture Series
CME Programs: Department Journal Club, Geriatric Book Club, On-service XRay Conference, General Medical Staff Meetings and Department Meetings.
Failure to comply may result in incomplete credit for the training year and failure to
receive a certificate. Fellows with less than 80% attendance at lectures will not be
allowed to do outside elective rotations.
Attendance will be recorded for the following lectures – all lectures will be held in the
Classroom unless otherwise noted on the Lecture Schedule.
 To be excused from required lectures, please leave a message for the Department
of Geriatrics.
 If you have an emergency and cannot attend a lecture, please notify the
Department of Geriatrics by noon for missed morning lectures and by 4 p.m. for
missed noon lectures.
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7.3
Top of the Document
Attendance Rosters
Attendance rosters will be prepared for each meeting, conference, and lecture, etc., which
the fellow is required to attend. These are specifically designed for the fellowshiptraining program. In order to document your training for the American Osteopathic
Association, it is mandatory that these rosters be completed and personally signed by
those fellows who are in attendance.
7.4
Journal Club
Journal Club is an integral element in any medical training center. It directs education to
fellows, as well as attending physicians and reviews current literature on specific medical
problems.
Fellows review journal articles recently released the month preceding the review. These
journals include JAMA, Gerontologist, Clinical Geriatric Medicine, Journal of American
Geriatric Society, and the New England Journal of Medicine. In addition, subspecialty
journals are reviewed by fellows and formally presented to the Director and invited
subspecialty physicians. Each fellow is assigned a journal to read and determine which articles
are pertinent to the program. This review is opened to the Geriatrics Department. In this
format, review articles are evaluated as well as original articles critiqued for their significance
in information, their type of set up for research, the number of people evaluated, and how well
their tables and graphs correlate to their conclusion. The article should be critiqued on its
content, as well as how information was gathered and techniques involved. The case presented
should be first discussed with the Journal Club coordinating physician.
Effective 07/01/2010
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may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
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Geriatric Fellowship Manual
Attendance sheets are to be signed and completed with date, time, topic, and presenter’s
name and then sent to the Department of Medical Education for CME credit.
Journal Club will meet once monthly for one hour.
a. Two or three articles will be discussed.
b. A critical review of each article will be conducted.
c. Articles will be circulated for review one week ahead of scheduled
review time.
7.5
Geriatric Weekly Didactic Lecture Series
1. The presenting fellow should choose a topic at least fourteen (14) days prior to the
scheduled presentation.
2. The topic should pertain to a recent case.
3. The topic should reflect that fellow’s clinical exposure.
4. The topic should be very narrow and precise.
5. Upon choosing a topic, prior to proceeding with preparation, it should be reviewed
and accepted by the Program Director.
6. Each accepted topic will then be given to the Medical Education Office for
announcement purposes at least five (5) days prior to the scheduled presentation.
7. The presenting fellow should have pertinent materials available on the day of the
lecture (projectors, x-rays, scans, etc.).
8. A written bibliography is to be distributed at the lecture.
7.6
OMM Lecture
Twice monthly, the Medical Education Department and Family Medicine Department
will provide formal lecture and hands-on laboratory to review basic and advanced
osteopathic techniques. All fellows are required to attend unless excused by the
Department.
Fellows will be asked to assist in the osteopathic medical student OMM labs and lectures
one-half day per week. Fellows will also participate in practicum testing as assigned.
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Top of the Document
Return to the beginning of the Manual
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
8
COMPORTMENT
8.1
Core Competencies
PATIENT CARE:
A) Patient Evaluation
1) History and Physical
2) Appropriate utilization of diagnostic studies
3) Interviewing skills
B) Integration of initial and follow-up assessments
1) Demonstration of effective and appropriate clinical problem solving skills
2) Inclusion of allied health assessments
3) Generation of differential diagnosis
4) Appropriate interpretation of diagnostic studies
5) Use of consultants and referral sources
C) Formulation of a patient management/treatment plan
1) Effective communication with interdisciplinary team
2) Inclusion of patient/family in treatment plan
3) Cost effective approach to management
D) Prescription, performance or interpretation of appropriate procedures and modalities
1) Specific therapy and modality prescription
2) Electrocardiographic studies
3) Therapeutic/diagnostic injections and aspirations
E) Assessment and provision of continuum of care needs
1) Effective communication with interdisciplinary team
2) Inclusion of patient/family in long term plan
3) Appropriate utilization of resources available
4) Provision of, or referral for primary medical care
F) Patient and family counseling/education
1) Assisting patient development of self-advocacy skills
2) Provision of education in injury/disease primary prevention
3) Provision of education in prevention of secondary complications
G) Knowledge and use of information technology-internet and computer application
H) Provision of care that is sensitive to the needs of those with cultural, ethnic, social, or
economic diversity.
MEDICAL KNOWLEDGE:
A) Basic Knowledge
1) Gross musculoskeletal anatomy and neuro anatomy
2) Body mechanics and gait analysis
3) Muscle and cardiovascular physiology
4) Prescription writing
5) Common physical therapy modalities
6) Geriatrics interventional techniques including joint aspiration, joint injections, and
peripheral injections
7) Roles of allied health professionals
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Geriatric Fellowship Manual
B) More specific knowledge of exercise prescription, pre-participation assessment, and
musculoskeletal medicine, is addressed in the Specific Goals and Objectives.
INTERPERSONAL AND COMMUNICATION SKILLS:
A) Communicate effectively with patients and families to create and sustain a professional
and therapeutic relationship
B) Communicate effectively with physicians, other health professionals, and health related
agencies
C) Work effectively with others as a member or leader of a health care team or other
professional group
D) Be able to act in a consultative role to other physicians and health professionals
E) Maintain comprehensive, timely, and legible medical records
PRACTICE-BASED LEARNING AND IMPROVEMENT:
A) Analyze practice experience in a systematic manner
1) Progress towards goals by completion of year of training
2) Progress towards goals by specific rotation
3) Extent of visits to therapies and participation in the application of therapy
modalities
4) Number of injections, aspirations
5) Review of critical incidents
B) Locate, appraise, and assimilate evidence from scientific studies related to their patients’
health problems
1) Use of medical libraries for text based information
2) Use of information technology such as drug databases or literature searches
3) Establishing goals for and monitoring progress toward independent reading
4) Establish goals for independent learning
C) Apply knowledge of study designs and statistical methods to the appraisal of clinical
studies and other information on diagnostic and therapeutic effectiveness
1) Critical appraisal of current literature in journal clubs, didactic sessions, or patient
care conference
2) Review of literature for research projects
D) Use of information technology to manage information, access on-line medical information
and support their own education
1) Use of hospital/clinic computer based information systems for daily patient care,
including charting, review of laboratory data, review of prior health care
2) Use of e-mail or web based discussion groups for didactic or clinical work
E) Facilitate the learning of students and other health care professionals.
1) Presentations/participation in team conferences
2) Participation in “in-service” teaching for allied health personnel
3) Teaching medical students in basic science courses or on clinical rotations
PROFESSIONALISM:
A) Demonstrate respect for and a responsiveness to the needs of patients and society
1) Accept responsibility for patient care including continuity of care
2) Demonstrate integrity, honesty, compassion, and empathy in the role of physician
3) Demonstrate dependability and commitment
B) Consistently demonstrate high standards of ethical behavior in clinical practice
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manual at any time without prior notice. It is the resident’s
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Geriatric Fellowship Manual
C) Demonstrate sensitivity to and respect for the dignity of patient and colleagues as persons
including their age, culture, disabilities, ethnicity, gender, and sexual orientation
SYSTEM-BASED PRACTICE:
A) Demonstrate knowledge of community systems of care and assist patients to access
appropriate levels of care
1) Demonstrate a knowledge of treatment settings including inpatient and outpatient
2) Demonstrates knowledge of the organization of care in each relevant delivery
setting
3) Demonstrate the ability to integrate care of patients across settings
B) Demonstrate the ability to work in various health care settings
1) Demonstrate the ability to partner with health care managers and providers to
assess, coordinate, and improve health care
2) Assess how activity in health care settings can affect system performance
C) Understand how patient care and professional practices affect other health care
professionals, health care organizations, and society as a whole
D) Practice cost effective health care and resource allocation that maximizes quality of care
E) Advocate for patients
1) Advocate for quality patient care
2) Assist patients and their families in dealing with system complexities
F) Promote health and function and the prevention of disease and injury
Top of the Document
8.2
Call Responsibility
Responsibilities:
 Weekday/night include: geriatric outpatients, long-term care patients and
consult patients
 Weekend includes: long-term care patients, geriatric inpatient service and
geriatric outpatients, and consult patients
1) Fellows will participate in calls via telephone conference when on the consult or inpatient service rotations and will not exceed AOA guidelines.
2) Fellows will participate in calls via telephone to cover the long-term care facility
throughout the year.
3) Fellows will do the initial evaluation and consult note on any geriatric consult
received between 7 a.m. and 5 p.m. on days they are taking call.
4) Attendings are to be second on call for all fellows.
5) Fellows call is between 5 p.m. – 7 a.m. on Monday through Friday and 7 a.m. – 7
a.m. on Saturday and Sunday. On designated holidays (i.e. 4th of July, Labor Day,
Thanksgiving, Christmas, New Years Day, and Memorial Day) call will be 7 a.m. – 7
a.m.
6) Fellows are not responsible for consultations (medical) at night (5 p.m. – 7 a.m.)
unless it is urgent.
7) Fellows are not responsible for participating in calls related to APCA.
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Effective 07/01/2010
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Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
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Geriatric Fellowship Manual
8.3
Procedures
Fellows are provided the opportunity to perform procedures as they arise. Fellows are
expected to become proficient in the following procedures:
1) Sufficient experience and training to ensure proficiency in the following procedures,
including indications, contraindications, complications, limitations and interpretation:
a. Peripheral venous line placement
b. IV line placement
c. Venipuncture
d. Osteopathic manipulative treatments
2) Sufficient experience and training to ensure proficiency in the interpretation of the
following procedures:
a. Arthrocentesis
b. Joint injection
c. Nail removal
d. I&D
e. Suturing
f. EKG interpretation
Formal lectures, hands-on labs and videotape procedure demonstrations are used to
introduce the procedure and review anatomy and indications/contraindications of the
procedure. Fellows are directly supervised by attending staff until proficiency develops.






All procedures are done under the supervision of an attending physician who is
responsible for the care of that patient. This supervision can be direct or indirect,
depending on the experience of the fellow.
Do not start any non-emergency procedure until you obtain permission from the
responsible attending physician.
Informed consent must be obtained before starting unless it is an emergency.
Procedure notes must be written immediately after the procedure.
Procedure logs must be completed by the fellow and signed by the supervising
fellow/attending.
Each time a procedure log is reviewed, the program director will assign a privilege
status as follows:
 Level I = Direct supervision only
 Level II = Perform and teach with indirect supervision
 Level III = Perform with indirect supervision; can teach and certify others
Fellows unable to master their skill level as indicated above will be assigned additional
procedure assignments until such time that the level is mastered. Individual adjustments
and accommodations are made on a case-by-case basis for those fellows unable to master
the skills as indicated above and additional training options are constantly evaluated.
1) Procedures in Geriatrics
(a) Treat minor lacerations.
(b) Recognize and reduce joint dislocation.
(c) Interpret and perform ECGs.
(d) Interpret and perform stress tests.
(e) Interpret and perform isokinetic dynamometer evaluations.
Effective 07/01/2010
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may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
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current copy of this manual is available in the VCOM Medical
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(f) Interpret pulmonary function studies.
(g) Perform:
(1) Intra articular injection
(2) Intra articular aspirations
(3) Trigger point injections
(h) Perform and interpret gait analysis.
(i) Screen for scoliosis.
(j) Measure and order appropriate orthotics.
(k) Provide advanced CPR.
2) ACLS
(a) Successfully complete ACLS training.
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8.4
Moonlighting
Fellows may Moonlight provided they have obtained a full, unrestricted medical license and
DEA number and only with the expressed, written consent of their Program Director provided
such activities do not interfere with their training obligations. Fellows who moonlight are
responsible for their own medical malpractice insurance coverage while engaged in
moonlighting activities.
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8.5
Evaluation
The Geriatrics Fellow will be evaluated throughout the year by means of a number of formal
and informal evaluation processes. These evaluations will test the fellow’s medical knowledge
base, clinical care, clinical skill performance, professional development and the ability to work
with colleagues.
A) Evaluation methodologies will include:
1) Written evaluations every 3 months by the supervising faculty.
2) Periodic skill competency evaluation, including examination skills, radiographic
interpretation, and procedural and OMT skills.
3) Regular professional critique by faculty with regard to oral presentations.
4) Regular professional critique by faculty with regard to teaching effectiveness of
trainers, medical students, and fellows.
5) Regular professional critique administered by faculty as to collegial relationships
and professional development.
8.6
Fellow Evaluation of Faculty/Program
A) Evaluation of faculty
1) Fellows will be informed in writing when any disciplinary measures are taken.
2) Fellows will evaluate core faculty at 3-month intervals.
3) The fellow will utilize these evaluations to conduct a yearly evaluation of each
faculty member.
Effective 07/01/2010
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manual at any time without prior notice. It is the resident’s
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Geriatric Fellowship Manual
B) Evaluation of the Program
1) The Division of Geriatrics will meet monthly and will provide minutes to the
office of the Dean.
2) The subspecialty fellow will evaluate the program on a 6-month basis in order to
assess compliance with teaching objectives and goals
3) The program director shall complete a yearly self-study in order to assure
program efficiency and excellence.
8.7
Research Responsibility
Overview:
The fellows will be required to prepare a research project or publishable paper by the end
of their fellowship training. This project will be discussed with the program director in
July of each academic year.
Goals:
Upon completion of the geriatric fellowship, the fellow will:
1. Develop familiarity with well-known statistical software and interpret computer output.
2. Evaluate study protocols and articles submitted for publication and actively participate in
clinical research.
3. Critically evaluate the clinical literature, understanding potential errors and fallacies, and
apply the results of medical studies to patient care.
4. Develop sound judgment about data applicable to clinical care.
Objectives:
The fellow will attain/achieve the above goals by meeting the following:
1.
2.
3.
4.
5.
Conduct a comprehensive literature review of a proposed area of study.
Design a protocol appropriate to their research question including a power analysis.
Write a protocol in NIH format and submit to the IRB.
Gather clinical data, and summarize the data and interpret.
Prepare project for presentation and/or publication
Educational Purpose:
To provide the geriatric fellow with knowledge and skills to identify patients at risk for
development of wounds and wound complications; prescribe preventive measures to
promote skin integrity; and to treat wound problems once they develop.
The fellow will demonstrate competency in his/her ability to:



Learn the principles of research design and clinical epidemiology
Become an effective teacher of geriatric medicine (via patient consultations,
teaching of houseofficers, and didactic lectures)
Become familiar with the activities of organized geriatric medicine and
gerontology by attending at least one national meeting of the American
Geriatrics Society or the Gerontological Society of America
Effective 07/01/2010
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may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
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Geriatric Fellowship Manual



Maintain current with mainstream geriatrics literature; all fellows are expected to
subscribe to and read the Journal of the American Geriatrics Society (JAGS), and
are encouraged to at least peruse the Gerontologist and the Journal of
Gerontology on a regular basis
Become proficient in performing literature searches using PubMed or a similar
database
Develop (if not already acquired) basic proficiency with computer-based word
processing, spreadsheet use, and slide making
The fellows will obtain competency in all of the above goals by meeting the following criteria:
1. Original research, accepted for publication by peer review journal – meets all requirements
2. Original Research, accepted and presented at Local, Regional or National Convention
(poster presentation) – meets all requirements
3. Participation in Journal Club, inclusive of obtaining, assigning and presenting articles with
written critique of articles submitted for review by program director twice annually.
Fellow participation in Journal Club will be review and evaluated twice annually by the
program director
4. Participation in Review of Medical Literature Didactics, in conjunction with VCOM,
offered twice annually
5. Participation in and submittal of written reports reviewing the medical literature for Peer
Review Activities in compliance with policies and procedures of the Department of
Geriatrics
6. Participation in and submittal of written reports, inclusive of medical literature review, in
conjunction with the Quality Improvement Initiatives of Edward Via Virginia College of
Osteopathic Medicine.
7. Presentation of four (4) lectures annually inclusive of medical literature review and
evaluation by member of the Geriatric Faculty of the presentation at either Formal
Didactics, Local, Regional or National Conference, or Medical Staff/Departmental
Meeting
a) Research and Scholarly Activity
1) The fellow will work with the Director of Research to develop a
research project of interest that will add to the body of scholarly
knowledge, with an emphasis on clinical research and outcome based
studies in the field of geriatrics.
2) The subspecialty fellow will have a working knowledge of:
i.
Research methodologies
ii.
Types of research projects
iii.
Critical analysis of existing research
iv.
Statistical analysis of data
3) The fellow will present scholarly material at one or more of the
following meetings. The lectures, posters and seminars at these
meetings are meant to present current research and reviews of
pertinent non-musculoskeletal, musculoskeletal as well as other
exercise related issues to athletes.
i.
Geriatrics Conference
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manual at any time without prior notice. It is the resident’s
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ii.
Manuscript submitted to a peer reviewed journal
8. Reading:
a) Designing clinical research: an epidemiologic approach, by Stephen B.
Hulley ... [et al.]. 2nd ed. Philadelphia: Lippincott Williams & Wilkins,
c2001.
b) How to read a paper. This series of eleven articles was published in the
BMJ and is also available as a book from BMJ Publications.
c) The Medline Database (BMJ 19th July 1997).
d) Getting your bearings (deciding what the paper is about). BMJ 26th
July 1997.
e) Assessing the methodological quality of published papers. BMJ 2nd
August 1997.
f) Statistics for the non-statistician Part I. BMJ 9th August 1997. And Part
II. BMJ 16th August 1997.
g) Papers that report drug trials (includes a checklist for getting good value
out of “drug reps” or detailmen. BMJ 23rd August 1997.
h) Papers that report diagnostic or screening tests. BMJ 30th August 1997.
i) Papers that tell you what things cost (economic analyses). BMJ 6th
September 1997.
j) Papers that summarize other pages (systematic reviews and metaanalyses). BMJ 13th September 1997.
k) Papers that go beyond numbers (qualitative research). BMJ 20th
September 1997.
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Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
9
CONTINUITY CLINIC
Goals: To create a Geriatrics Clinic experience designed to prepare Geriatrics Fellows for
Ambulatory Geriatrics. The Clinic will facilitate the diagnostic and therapeutic skills of
physicians in training utilizing patients representing the full spectrum of Geriatrics. To
provide primary and consultative Geriatrics Services within the MRH Clinics.
9.1
Overview
Geriatrics Fellows are required to attend continuity clinic forty-four (44) weeks per
academic year. The fellows will be supervised by an attending physician. Cases will be
discussed and all charts will be reviewed. The fellow will be exposed to a broad
spectrum of medical diagnoses and will be taught to apply the concepts of disease
prevention and health maintenance.
Fellows are required to maintain an ambulatory log that will be maintained in each
fellow’s personnel file. These logs must contain the patient’s medical record number,
diagnosis and the activity and/or procedure performed on each visit.
Fellows will maintain approximately fifty (50) patients per year in their patient panel.
Fellows will be evaluated on a semi-annual basis. Fellows will be evaluated by their
attending physician, clinic staff and their patients.
The fellow will be exposed to osteopathic concepts, behavioral and psycho-social aspects
of medical care, medical ethics, medical-legal implications and practice management
throughout the course of their training through lectures and discussions.
Fellow’s will be evaluated by the attending physician on their ability to perform a
comprehensive history and physical examination, including structural examination for
somatic dysfunction, pelvic exam, rectal exam, breast exam and male genital exam.
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9.2
Teaching Objectives
Fellows will learn skills required to:
1)
2)
3)
4)
5)
Effective 07/01/2010
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Provide Continuity Primary and Consultative Care
Office Procedural Skills
Understanding and Proficiency in proper Documentation
Understanding and Proficiency in Coding and Billing for services
Weekly Didactics with focus on General Ambulatory Geriatrics
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
9.3
Continuity Clinic Evaluation
Fellows will be evaluated quarterly with respect to participation in didactic sessions,
quality of charting, overall progress in clinic, attitude, professionalism and procedural
skills. The fellow will provide evaluations of preceptors and constructive feedback for
the preceptors and staff at this time as well.
The evaluation is conducted at least twice each year by the Geriatric Fellowship Clinic
trainer(s). The evaluation form is presented as a model, which utilizes the AOA core
competency requirements.
Trainer(s) should discuss the evaluation with the fellow, highlighting strengths and
weaknesses and pointing out areas that can be improved. The evaluation process should
be an opportunity for teaching by the trainers resulting in personal and professional
growth by the fellow. Serious deficiencies need to be documented along with a plan for
improvement.
A scoring grid is provided for those programs that have multiple trainers in their
ambulatory clinic who each fill out an evaluation. The grid serves to illustrate to the
fellow how their performance has been rated by several supervisors and adds some
validity to the evaluation when there is agreement in scores.
The AOA has adopted the six core competencies with an additional section for
Osteopathic Concepts. This evaluation, along with the Fellow Patient Evaluation, groups
the questions into categories based on these competencies. While there is considerable
overlap between the competencies, this format serves to illustrate how we are evaluating
these items while acting as a guideline for shaping our curriculum.
Medical knowledge and patient care issues are still paramount, but a successful physician
needs more than good knowledge. Assessment of professionalism and interpersonal
communication is often difficult, especially since the evaluating physician sees the fellow
in only one context.
The scoring grid may be used to compile the results of all the evaluations and will act as a
valuable resource to promote personal growth and change in our trainees. A discussion
between the clinic supervisor and the fellow concerning these results is an essential part
of this process.
9.4
Clinic Didactics
Teaching during clinic sessions occurs informally with discussion of various Geriatrics topics
as they pertain to the diagnoses of the patients seen in the clinic. Fellow notes are reviewed by
the supervising clinic attendings and teaching points are reviewed with the fellow.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
9.5
Charting
Charting will be in standard SOAP format, either dictated, neatly hand written or
standard forms.
Additionally, clinical trials/research will be conducted from the
Geriatrics Clinic with additional documentation requirements being requested of the
participating fellow/preceptor. All charting by fellows are reviewed and countersigned
by the fellow’s teaching attending and are completed during the assigned clinic. All
charting and fellow boxes will be completed prior to vacations or graduation.
Feedback regarding the fellow’s documentation will occur during the clinic session and a
compiled for inclusion in the fellow’s annual performance review will be made.
9.6
Clinic “After Hours”
After hours the Geriatrics Fellow in conjunction with the Clinic Director will arrange
coverage. Schedules will be created and distributed on a monthly basis. The hours of
Geriatrics Clinic Call are 5 p.m. – 9 a.m. Documentation of patient calls is mandatory.
Call Logs will be distributed to fellows for maintaining this documentation with copies
placed on the patient chart. Calls requiring more detailed documentation will be dictated
and a message left at the clinic indicating the patient name, phone number and direction
to the staff to obtain the dictated notation. If calling from your private phone, remember
to first dial *67 to block caller ID.
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9.7
Procedures
Fellows will develop proficiency in various procedures. The preceptor staffs all
procedures performed in Geriatrics Clinic. The fellow is responsible for staffing and
performing the procedure under the direct supervision of the attending physician,
notification of the attending 24 hours prior to the procedure and dictation of procedure
documentation.
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9.8
Vacation/Time Off from Clinic
All vacation requests will be filled in compliance with Medical Education Policies with a
copy being provided to the Geriatrics Clinic by the fellow at least 4 weeks prior to the
requested time. Any canceled clinic days require 2 weeks advanced notice and will be
made up by the fellow in discussion with the Clinic Director and staff. The only
exception is emergencies, which require immediate notification of the Clinic Director.
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Return to the beginning of the Manual
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 106
Geriatric Fellowship Manual
10
LOGS
Logging your activities is an essential part of any training program. Historically, it has
been a challenge for the fellows as well as trainers to have the paper work completed in a
timely manner. We all tend to procrastinate with paperwork. It is an essential part of
practice to adequately document your clinical work. It is a principal adopted by
Medicare, third party carriers, as well as the legal profession that “if it is not documented
– it did not happen”. To avoid frustration at the end of the year, and to enhance the
satisfaction within a training program, it is extremely important that timely logging of
clinical activities take place.
It is important to realize the essential nature of logging. The principal objectives for this
are:
1. Document to certifying agencies that you have accomplished a significant
amount of clinical exposure and expertise to have graduated or to be certified
and/or credentialed.
2. To document for the Department of Medical Education, the individual program
directors and trainers, that the education program is serving their individual
educational goals and providing the trainee with adequate opportunity to learn.
Outside accrediting inspection agencies do, in the normal course of their review
process, examine trainee logs.
3. To document your experience, for the purposes of applying for hospital
privileges in the future. This point is the most important and concrete for the
individual trainee. It is your personal future! Do not assume that by doing
rotations at any particular institution that privileges will automatically flow so
that logs need not be kept. Documentation is frequently important when
providing letter of reference for future training programs and/or when applying
for staff privileges. Frequently, individuals relocate on several occasions, and
each new institution requires documentation of prior experiences.
4. Logs are due at the completion of the rotation. Time logs are due on the 1st of
every month. Other logs and evaluations are due in within seven (7) days of
completing the rotation.
Appendices
10.1
Important Points to Remember
1. Responsibility of logs lies exclusively on the shoulders of the individual trainee, and
is an American Osteopathic Association requirement for graduation from the
program.
2. Log entries should be easily verifiable. It is a normal course of the hospital
inspection for an inspector to request records. Charts are pulled for verification that
the trainee participated in the care of a patient. Therefore, the logs should include
some evidence of the level of involvement in the case. The medical record as well
should reflect documentation of participation by the fellow. Therefore, if multiple
people are attending to a particular patient on a day that all parties contribute to the
care, it should be noted on the medical record (i.e., attending/fellow/MSIV).
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
3. The responsibility for archiving the logs falls primarily on the shoulders of the
trainee. The fact that the original copies are handed to the Medical Education Office,
should not give the trainee a false sense of security that the documentation is safely
stowed away. Record catastrophes do happen. It is; therefore, strongly emphasized
that all logs and records be copied and retained in the fellow’s personal possession.
Photocopies are your personal insurance policy. In accordance with AOA policy,
Edward Via Virginia College of Osteopathic Medicine is required to retain your logs
for only five years.
10.2
What to Log
1. Any continuity clinic encounter should be recorded. Include the patient’s name,
identification number, or other indicator as well as the diagnosis or multiple
diagnoses and level of involvement.
2. Procedures are particularly important. Institutions when credentialing frequently
request documentation of experiences. For this purpose, procedures are the most
critical activities to be logged.
3. Any outside educational experience including: Academy meetings, educational
seminars, and programs that are not held in-house or recorded in any other manner.
We do maintain records internally of lectures, presentations and meetings. All
activities out of the institutional walls would be lost unless included in your logs.
On-call experiences are often looked upon as secondary activities, but are still a part
of your net clinical experience. Therefore, they should be recorded as well.
10.3
How to Log
Be as specific as possible. Include name or initials, date, place, preceptor, and level of
involvement. This last item is most important for procedures that you may want
privileges for (i.e., observed 15 c-sections, participated or assisted in 20, did 2 under
observation). All entries supported by hospital medical record number, date, time,
location, preceptor, level of participation. You may want to mention complications or
other related specifics that you handled.
In short, logs help to aid the function of the program, but most directly benefit you. Keep
them current, and complete them in an organized manner. Do not procrastinate! The
Program Director may call for the logs at any time during the year for spot review. They
are your responsibility.
10.4
Policy Statement
The educational objective here exceeds assuring mechanical compliance with submitting
logs. It is designed to encourage a physician early in his career, the ability to follow
through with the medical record in a timely manner. This is a shared expectation of all
institutions that you will be involved with, so that it is appropriate to establish good
habits from the beginning.
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
1. Patient logs and preceptor evaluations are to be in the Medical Education
Department within seven (7) days of completion of a rotation.
2. Time log is due to the Medical Education Department immediately upon
completion of the rotation.
3. For longitudinal experiences that extend over the year period, it is expected that
they be evaluated on a quarterly basis.
4. If logs are not completed in this timely manner, suspension from the education
program may take place immediately upon direction of the Director of Medical
Education.
5. Any time lost from the educational program will then be made up with
compensatory time at the end of the educational program. A reminder –
suspension also means that time off is not compensated time. So, adjustments
will be made on the next pay check.
Exception to the rule:
1. Catastrophic illness where the fellow is not physically able to complete his/her
logs.
2. Catastrophic illness prohibits his/her preceptor from filling out the evaluation
form. Consideration will be given to late reports only if an explanation is
provided by the preceptor, in writing, and accompanies the log and evaluation.
Top of the Document
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
11
MEDICAL DOCUMENTATION
11.1
Medical Documentation
Formal communication in medicine is achieved by documentation in the medical record.
Since medical documentation is not often addressed in medical school, we will attempt to
provide general guidelines and rules to help maximize the quality of medical care as well
as minimizing liability.
It is essential to document all findings that are essential to the support of a diagnosis and
rationale for treatment plans. These findings may be positive or negative. All portions of
the record should be consistent. In the process of the physical examination, it should be
clear as to what was and was not examined. In the event an area was not included, it
should not be stated that it was “deferred”, but rather an explanation as to why the
examination was not performed should be made clear in the record. If a medical form is
being filled out, all areas of that respective form should be addressed in one way or
another. Continuing progress notes need not necessarily address processes that are
unchanged, but should detail an ongoing problem that is evolving. It is often better to
make a general statement than to attempt listing the entire possible alternative in a
situation because most often it will be incomplete. The generalized statement will suffice
for the documentation and not waste effort and time.
One will occasionally come across a difficult situation where an unusual happening or
adverse reaction has taken place. Avoid any commentary as to legal implications and
restrict your comments only to what is relevant to the patient care and patient’s condition
at the time. Keep the statement as factual as possible and do not attempt to misrepresent
them or color them either positively or negatively. If a patient or family make legal
threats, they may be noted, but in a purely objective way. Use purely professional style
in making your record entries. Never attempt to be joking, overly melodramatic,
blaming, or judgmental.
The medical record is strictly a forum to note the patient’s medical condition and
treatment. It is also not a location to “joust”, that is, to carry on a medical debate
between other health care practitioners who may also be writing notes on the document.
At all costs avoid any reference to blame, culpability, ability, or carelessness.
The credibility of your records is an important issue. First of all, they must always be
legible. A record that is unreadable does not exist. If you refer to other sources of
information that may not be reliable, the reasoning behind your doubts of reliability
should be included in the note. This again is where the professionalism and sincerity of
your entries are important. If there is ever the occasion to change a medical record, it
must be done carefully and in one of two potential ways:
1. It is to place a single line through the deleted material and initial, as well as
dating the change. Never, ever destroy, re-write, cross out, obliterate, or make
unrecognizable the original entry. The only acceptable motive for altering a
Effective 07/01/2010
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Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
medical document is for the protection and safety of the patient as well as
assuring the best medical care.
2. The second alternative in making a change in a medical record is to simply make
a new note referring to the prior comment and again – date, time and sign it.
If a patient has been injured or a medical complication has occurred, from an untoward
event, the appropriate mechanism of documenting that is in an incident report. This is
legally undiscoverable as long as it is not referred to in the original document. Therefore,
in the medical chart – do not state that a risk management activity or an incident report
has been filled out. Simply record the facts of the situation, as you know them. If the
incident involves any medical equipment, carefully preserve, but in no way alter or
destroy it. Sequester it and make it available to the Risk Management authorities.
In dealing with the patient in terms of complication, it is always imperative to show
concern for the welfare and comfort of the individual at hand. If no unusual event
transpires and there is no patient injury, do not volunteer any admission negligence and
avoid any statements that would imply that something has gone wrong until you have
notified and discussed the problem with the attending physician.
If an injury has occurred, never give false statements or misleading expressions. Again,
examine the patient and notify the attending physician. Although it is appropriate to
avoid being overly solicitous, it is equally appropriate to show a reasonable amount of
concern and empathy for the patient and family. Never ascribe blame to people, medical
equipment, or situations. Doing so is often a reflex response that is given without
objectivity and without the ability to consider all the influencing circumstances.
If a recognized potentially dangerous situation exists, take immediate action that would
be necessary to protect the patient from potential injury, harm or any adverse effect. It is
usually best to warn the attending physician. If you are aware of patient or family
dissatisfaction of the health care efforts, bring this to the attention of the attending
physician.
11.2
Medical Records
1) Always write with a black pen, as some other colored inks will not Xerox adequately
for insurance and legal purposes. Write legibly!
2) Physical workups must be done and dictated within 24 hours of assignment or prior
to surgery whichever comes first. Surgery workups should be written so that the
medical information is readily available.
3) When a physical workup is done, always write a progress note. It is to be written
immediately following the physical workup.
4) When responsible for interval progress notes, they should be written every working
day. If the condition of the patient changes during the day, extra progress notes are
to be written.
5) Everything you write on the chart must be signed.
a) When you write an order always include the name of the attending physician
first, (e.g., James Monroe, D.O./Peter Smith, D.O.)
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may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
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current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
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Geriatric Fellowship Manual
b) If done by an extern, or by an fellow, in communication with the attending
physician, always include the method of communication, preceded by his name,
(e.g., V.O. for “voice order” or “verbal order” and P.O. for “phone order”.)
6) All progress notes must be dated, timed and signed.
7) Medical records may be checked out of the Medical Record Department only for
their use in educational sessions.
CHARTING IS A HABIT – Good or bad it is up to you! If you are delinquent
repeatedly, disciplinary action will be taken.
11.3
Progress Notes
These must cover all significant physical changes, new signs and symptoms,
complications, consultations, and treatment given. They shall describe in proper
continuity the course, progress, treatment and disposition of the case. They shall include
significant results of tests or x-rays that influence the working diagnosis or therapy.
Progress notes are the one place on the chart where the physician’s philosophy of
management is displayed. Notes may have to be written several times a day, if the
patient’s changing condition warrants it, or once a day may suffice on assigned cases.
All progress notes shall be dated, timed and signed by the physician writing them.
Record your OMT on the progress notes. Include the biomechanical diagnosis for which
you are treating (e.g., “somatic dysfunction of _____ due to _____”). Date and time as
you do for all progress notes. Record the result. If it is a series of treatments, record
results after several treatments, but no less than every three days his note must briefly
state the chief complaint, the symptoms and physical finding that led to the working
diagnosis, the expected diagnostic regimen, therapy and possible consultations; also, the
prognosis as of that time.
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Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
12
ACKNOWLEDGMENT
I acknowledge that I have received a copy of the Edward Via Virginia College of
Osteopathic Medicine’s Geriatric Fellowship Manual, and I do commit to read and follow
these policies.
I am aware that if, at any time, I have questions regarding Edward Via Virginia College
of Osteopathic Medicine’s Geriatric Fellowship policies I should direct them to my
Program Director, Director of Medical Education or the Administrative Director of
Medical Education.
I know that Edward Via Virginia College of Osteopathic Medicine’s Geriatric Fellowship
policies and other related documents do not form a contract of employment and are not a
guarantee by Edward Via Virginia College of Osteopathic Medicine of the conditions and
benefits that are described within them. Nevertheless, the provisions of such Edward Via
Virginia College of Osteopathic Medicine policies are incorporated into the
acknowledgment, and I agree that I shall abide by its provisions.
I also am aware that Edward Via Virginia College of Osteopathic Medicine, at any time,
may on reasonable notice, change, add to, or delete from the provisions of the company
policies.
_____________________________
Fellow’s Printed Name
___________________________
OGY Level
_____________________________
Fellow’s Signature
___________________________
Date
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Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
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Geriatric Fellowship Manual
13
APPENDICES
13.1
13.2
13.3
13.4
13.5
13.6
13.7
13.8
13.9
13.10
13.11
Personal Information Sheet
Time Log
Fellow Continuity Patient Log
Attending Evaluation of Fellow Form
Fellow Evaluation of Faculty Form
Time Away Request Form
360° Evaluation Forms
Fellow End-of-Year Checklist
Employee Expense Reimbursement Form
Patient Evaluation of Fellow
Fellow Exit Questionnaire
Return to the beginning of the Manual
Effective 07/01/2010
Version 1
Edward Via Virginia College of Osteopathic Medicine at its option,
may change, delete, suspend or discontinue portions of this
manual at any time without prior notice. It is the resident’s
responsibility to obtain the most current version of this manual. A
current copy of this manual is available in the VCOM Medical
Education Department. Any changes in this manual shall apply to
existing as well as future residents.
Page 114