HURLEY MEDICAL CENTER
GERIATRIC FELLOWSHIP PROGRAM
GERIATRIC RESIDENCY SELECTION CRITERIA
POLICY:
Medical graduates appointed to the Geriatric Fellowship Program at Hurley Medical Center
must meet the following criteria.
1.
Candidates must submit a medical degree prior to the start of the residency program.
2.
Candidates must present documentation of graduation from an ACGME accredited Internal Medicine
residency program in good standing.
3.
Candidates must submit three letters of recommendation.
4.
Candidates must submit official medical school transcripts.
5.
Candidates must submit a personal statement and curriculum vitae.
6.
Where applicable, candidates must submit proof of a valid ECFMG certificate and a valid TOEFL
certificate.
7.
Where applicable, candidates must submit one of the following visas: J-1, Immigrant, or any other visa
deemed acceptable for residency training at Hurley Medical Center.
8.
Candidates must submit proof they have passed the USMLE examination parts 1, 2 and 3 with a score of
at least 78. Exceptions can be made for candidates whose school does not require passing USLME.
9.
Candidates must participate in interviews with appropriate residency training program faculty who will
assess professionalism, teamwork, clinical abilities, interpersonal skills, humanistic quality, academic
performance and communication skills.
10.
Candidates must meet all eligibility and selection criteria of resident’s guidelines established by the
Accreditation Council for Graduate Medical Education.
11.
Candidates must apply through ERAS.
I:IntMed\Geriatric Program\Resident Candidate Criteria
HURLEY MEDICAL CENTER
GERIATRIC FELLOWSHIP PROGRAM
ACUTE GERIATRICS TEACHING PROGRAM
A:
ACUTE GERIATRICS CURRICULUM
An acute geriatrics curriculum requires a different paradigm from the traditional teaching of ward
medicine. This paradigm recognizes that hospitalized elderly patients often present with unusual symptoms that
challenge normal diagnostic methods, experience a high rate of iatrogenic illness, and face serious risk of
functional decline and personal indignity while in the hospital. Primary teaching goals therefore, are to
understand the interaction of acute hospitalization with the physiologic changes of aging, to make accurate
diagnosis of atypical symptoms, and to implement care that prevents primary topics in an acute geriatrics
curriculum that are used to generate bedside and didactic teaching sessions.
Understand common physiologic changes of aging
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Diminished cognitive reserve
Immune system senescence
Decline in musculoskeletal and autonomic function
Reduction in pulmonary compliance and reserve
Diminished GI motility
Reduction in renal and hepatic pharmacodynamics capacity
Loss of skin function and integrity
Common sensory deficits (e.g. diminished hearing and vision)
Risks of bladder incontinence due to changes in prostate, pelvic muscle, and neurologic function
Understand the interaction of hospitalization with elderly persons
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Detrimental effects of immobilization on continence, skin integrity, and musculoskeletal functions
Understand the high risk for functional decline and institutionalization
Know the common causes of delirium, falls, and procedure complications
Risk assessment and prevention of polypharmacy and nosocomial infections
Recognize loss of personal dignity caused by hospital environment
Recognize indications for selection of nasogastric, gastroostomy, or jejunostomy tube feeding
Understand the risks and benefits of enteral feeding, including positive and negative effects on
aspiration risk and quality of life
Accurate diagnosis of atypical symptoms
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Raise awareness of subtle presentation of serious illness in the elderly (e.g., lower incidence of chest
pain in acute myocardial infarction, high prevalence and atypical symptoms of depression)
Know the common manifestations of drug toxicity in elderly patients (e.g., weakness, delirium, falls,
incontinence)
Maintain high suspicion for skin and soft tissue infections in bed-bound population
Recognize delirium as a presentation of systemic infection or hemodynamic compromise
Detect the functional decline caused by dehydration, malnutrition, and bed rest
Implementation of standards of care
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Preservation of functional independence with early mobility
Methods for risk assessment and treatment of delirium and pressure ulcers
Daily medication review for necessity and toxicity
Regular use of interdisciplinary team process to address all medical, social and functional issues needed
for successful discharge planning
Understand the proper use of alternatives to physical restraints
Prevention of iatrogenic illness from procedures, catheters, and foreign hospital environment
Develop skills at leading family conferences, particular in planning end-of-life care
Legal and ethical aspects of end-of-life decision-making, including substituted judgement, power of
attorney for health care and use of do-not-resuscitate, do-not-hospitalize, and hospice care orders.
KEY ELEMENTS OF AN ACUTE GERIATRICS TEACHING PROGAM
This section outlines the personnel and structural components of an acute geriatrics-teaching program.
This outline can be adapted to match the needs of the local residency environment.
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Faculty Supervision– The presence of a teaching physician with expertise in geriatrics is an essential
element. These supervisory physician acts as role models to underscore the risks of iatrogenic illness,
place high priority on patients’ functional status, and provide daily mentorship on managing the care of
frail persons with complicated medical and social problems.
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Interdisciplinary Team Experience– The residents should meet regularly (daily if possible) with a
team of PT/OT therapists, social worker, home care staff, and nursing staff to discuss the acute and postacute plan of care. Integration of an interdisciplinary approach into daily rounds helps residents gain
appreciation for the valuable role of every discipline in the successful care of elderly hospitalized
patients. This meeting allows team members to hear regularly about the needs of the elderly patients
and provides an invaluable team experience for the interns.
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Case-Based Teaching Rounds– On a daily basis, an attending physician and supervising medical
resident alternate in leading a 30-minuet case-based discussion on a topic of acute geriatrics care. This
prepared classroom session is held in the early morning before work rounds and is evidence-based
whenever possible. Topics for this teaching session are chosen from the curriculum described in section
A.
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Bedside Teaching Rounds– The teaching physician performs bedside rounds with housestaff daily.
These rounds usually last for two hours and focus on history and physical examination skills and on
practical advice for the management of frail elderly persons with acute illness. Bedside teaching
remains the cornerstone for the management of acute geriatric problems such as delirium, pressure
ulcers, functional decline, and pain management. It is preferable that the teaching physician also be the
physician of record, although this is not possible for all patients.
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Didactic Conferences– A weekly schedule of department-wide didactic sessions should include regular
leadership by physicians with expertise in geriatrics. Conferences at which geriatricians maintain a
strong presence include:
1)
2)
3)
Morning report – These weekly one-hour sessions are joined by geriatrics faculty and internal
medicine faculty and focus on recent geriatrics literature that pertain to the presented case.
Residents’ Noon Lectures – Each year, geriatrics faculty conduct four conferences that are
devoted to distinctive syndromes in geriatric medicine.
Department of Medicine Grand Rounds- Faculty from the division of geriatric medicine offer an
average of two clinical presentations per year. These are devoted to recent progress in the field
of geriatric medicine.
II
A.
POST-ACUTE/REHABILITATION TEACHING PROGRAM
Post-Acute/Rehabilitation Curriculum
A primary goal of a post-acute teaching program is to change residents’ thinking from a traditional diseasebased model of diagnosis and treatment to one that emphasizes functional recovery and the successful transition
of patients back into the community. To achieve this goal, curriculum topics for the didactic and bedside
teaching sessions are chosen from three categories of functional, social, and medical issues.
Functional Issues
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Understand common conditions in older people, which benefit from rehabilitation
Understand the community discharge options for people with functional impairment
Develop history and physical exam skills that focus on functional assessment
Understand the role of assistive devices and orthotics for various functional deficits
Gain an appreciation of function so that functional improvement becomes a major part of residents’
clinical decision making
Social Issues
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Appreciate the importance of patients’ home situation and caregivers in discharge planning
Learn to function as a physician leader on an interdisciplinary team and to value the role of all other
professional staff
Develop interviewing skills that thoroughly assess the social environment and all resources that are
available for a patient after discharge
Learn to construct social and medical systems that provide adequate safety and follow-up care
Medical Issues
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Understand the major categories of hip and knee orthopedic repairs and their implications for issues
such as total hip precautions and weight-bearing status
Know standard of care for DVT prophylaxis after orthopedic procedures
Demonstrate understanding of pharmacology appropriate for the elderly by prescribing simplified
medical regimens with minimal polypharmacy and toxicity
Recognize the etiology and presentation of major stroke syndromes, their etiology, and optimal
treatment
Refine residents’ neurologic and musculoskeletal physical diagnosis skills
Recognize and treat common post-acute complications such as nosocomial infections and procedural
complications
Understand the appropriate prevention and treatment of pressure ulcers
Learn to manage post-acute care of bladder/bowel dysfunction
Recognize multi-factorial causes and atypical nature of depression
Understand the strengths and weaknesses of a post-acute/rehabilitation setting in the continuum of care
for frail older patients.
B.
Key Elements of a Post-Acute/Rehabilitation Teaching Program
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Patients- Patients in the inpatient post-acute setting generally belong to three major categories: patients
with new neurologic deficits, patients with recent orthopedic procedures, and patients with general
deconditioning and loss of function due to a recent hospital admission. In addition to their rehabilitation
issues, these patients usually have numerous active medical issues such as bladder dysfunction, deep
venous thrombosis (DVT) prophylaxis, nosocomial infections, depression, delirium, and polypharmacy.
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Faculty Supervision- Residents work under the direct daily supervision of a physiatrist physician and
with physician with expertise in geriatric medicine that has clinical responsibility for the patients. This
allows residents to receive daily instruction on practical geriatric and rehabilitation issues from a
physician skilled in these areas.
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Interdisciplinary Team Experience- Residents participates in weekly meetings where they interact
with all disciplines of the professional staff involved in patients’ care. Such staff includes social work,
PT, OT, speech pathology, physiatry, psychology, nursing, and home care services. This
interdisciplinary experience is the central mechanism for learning the methods of functional recovery
and comprehensive discharge planning that are essential to successful care in the rehabilitative setting.
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Didactic Teaching Rounds- One-hour weekly sessions are devoted to case-based teaching rounds that
focus on post-acute issues. These talks provide residents with exposure to a core base of knowledge in
neurologic evaluation, common post-hospital syndromes (e.g. infections and procedure complications),
and in rehabilitative medicine.
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Bedside Rounds- The attending physician leads residents on bedside rounds 3-5 times per week. These
rounds allow residents to observe patients’ functional progress and to discuss newly admitted patients.
This process provides residents with an opportunity to directly implement tools of functional assessment
as the patients are undergoing their rehabilitation.
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Family Meetings- Residents participate as the primary physician during family meetings for each
patient on the rehabilitation unit. These meetings include the patient, family, and interdisciplinary staff
and focus on all issues that affect patients’ recovery and discharge plan. The meetings occur after 7-10
days on the unit, last for 30-45 minutes, and aim to improve communication between team members and
patients and their families.
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Didactic Conference- Two weekly seminars are devoted to discussing the clinical and scientific basis of
geriatric medicine and serve as an integral part of the post-acute/rehabilitation rotation. These
conferences review major topics in geriatric medicine and reinforce learning that occurs on the postacute unit.
III
“AMBULATORY” GERIATRICS TEACHING PROGRAM
A.
“Ambulatory Geriatrics Curriculum
The curriculum for an outpatient rotation in geriatrics will cover the following:
a)
Primary and Preventive Health Care
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Understand the proper use of immunizations in elderly patients
Environmental strategies for fall prevention
Risks and benefits of cancer screening in the aging population
Methods for prevention of drug toxicity
Establish clear advance directives
b)
Management of Common Outpatient Geriatric Problems
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Urinary incontinence- Understand the physiologic, behavioral, and pharmacologic causes of urinary
incontinence. Residents should become familiar with the wide range of treatment options available,
including pelvic muscle exercises, biofeedback, behavioral change, as well as drug and surgical
therapies.
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Dementia- Residents refine skills in neurologic and mental status evaluation and learn to distinguish
clinical features of various dementing diseases. They also learn to work within an interdisciplinary team
that provides the medical and social resources needed for the support of demented patients and their
families. This includes evaluation of elderly drivers.
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Osteoporosis- Residents learn to understand the risk factors, etiology, evaluation, and treatment options
for metabolic bone disease in the elderly. The focus is on methods of preventive care that can reduce the
burden of disability from osteoporosis.
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Rheumatologic Disease- Specific teaching goals include the assessment of function in patients with
musculoskeletal disorders, diagnosis and management of osteoarthritis, tendonitis, bursitis, crystalinduced joint disease, late-onset connective tissue disease, and the use of local and systemic therapies
for these conditions. Residents also gain experience in assessing and managing patients with
musculoskeletal pain, falls, and a need for joint replacement.
c)
Interdisciplinary approach
A primary teaching goal is for residents is to understand and appreciate the critical role of all team
members in the primary care of elderly patients. Residents learn to respect and work cooperatively with every
caregiver. This is accomplished by the following practices.
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B.
Coordination of home nursing and rehabilitative services with nurses and therapists
Establishment of social and personal care support via social work and community resources
Developing collegial working relationships with aides or family caregivers who provide the bulk of
patients’ personal care needs
Learning to involve pastoral care staff in stressful or end-of-life circumstances
Learning to manage patients with terminal illness from experience in a home hospice care team that
includes family caregivers, nurses, aides, and social work staff
Key Elements of an Ambulatory Geriatrics Teaching Program
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Primary Care Geriatrics Practice- The primary focus of this experience is on management of multiple
chronic illnesses, reducing polypharmacy, and the maintenance of independence. Residents work in an
outpatient clinic under supervision of physicians with expertise in primary care geriatric medicine.
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Urinary Continence Clinic- In this clinic, residents work with a clinical nurse specialist and physician
with expertise in bladder dysfunction. They perform new patient evaluations for the comprehensive
diagnosis and management of urinary incontinence. Teaching tools include a standard continence
interview form, bladder ultrasound testing, and specialized examination techniques to allow pelvic and
bladder function assessment.
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Geriatric Rheumatology Practice- In this specialty program, residents focuses on the diagnosis and
treatment of musculoskeletal disease with the goal of attaining maximal function with minimal drug
toxicity. Residents work directly under the supervision of a physician who has expertise in geriatric
medicine and musculoskeletal diseases of elderly patients.
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Physician Supervision- In each setting, residents see patients under the guidance of a physician with
expertise in geriatric medicine. This supervision is critical to developing strong role models who can
communicate enthusiasm and knowledge about the subject of geriatric medicine. In particular, residents
benefit greatly from exposure to physicians with experience in geriatric medicine and additional
expertise in Rheumatology, infectious diseases, home care, urinary continence, and osteoporosis.
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Weekly Didactic Sessions- Each week during the rotation, residents participate in a block of three 45minute small group seminars on an array of topics in geriatric medicine. These seminars are case-based
and re-emphasize the principles raised in residents’ clinical experiences in various geriatric ambulatory
clinics
H:geriatric.fellowship.curriculum
HURLEY MEDICAL CENTER
GERIATRIC FELLOWSHIP PROGRAM
CURRICULUM INFORMATION
Elective (3 months)
Geriatric Outpatient Clinic (1 month)
Geriatric Inpatient Service (2 months)
Geropsychiatry (1 month)
Hospice Care (1 month)
PMR Inpatient (1 month)
PMR Consultative (1 month)
Sleep Disorder/Urology (2 months)