Residents
An Introduction to Managing Programmatic Growth and Development in Academic Geriatrics
Environmental Challenges
Programmatic Challenges
Common Themes
Environmental Challenges
Fewer physicians are being recruited into academic medicine in general and geriatrics in particular. The 2008 Institute of Medicine report, Retooling for an Aging America: Building the HealthCare Workforce, leaves no doubt about this challenge: "As of 2007, there were 7,128 physicians certified in geriatric medicine and 1,596 certified in geriatric psychiatry. According to one estimate, by 2030 these numbers will have increased by less than 10 percent; others predict a net loss of these physicians because of a decreased interest in geriatric fellowships and the decreasing number of physicians who choose to recertify in geriatrics. According to the Alliance for Aging Research, by 2030 the United States will need about 36,000 geriatricians."
Contributing factors are many. Low physician reimbursement by Medicare (on average 8 percent less than managed care reimbursement), and the additional time needed to provide care for frail elderly patients have resulted in low salaries and other factors that discourage physicians-in-training from pursuing careers in geriatric medicine.
For those hardy individuals who make it through to academic geriatrics, challenges related to variable funding streams from the National Institutes of Health (NIH) and other federal, local, and private sources mean that CoE directors must piece together funding for geriatrics fellowships and other activities from a variety of sources.
Programmatic Challenges
Leaders of CoEs are challenged to build the capacity of junior faculty to become the teachers and researchers of tomorrow, to address the shortage of senior faculty, and increasingly, to expand geriatrics expertise beyond academic geriatrics programs. As champions of geriatrics training and research, program directors are looking closely at how they can optimize resources and embed sound management practices. Many are working to develop internal marketing strategies, and some have increasingly explored fundraising strategies for local support and beyond.
Common Themes
A few common themes, or key points, emerged from interviews with CoE directors around the country:
CoEs are innovative. Leaders have incorporated a range of novel approaches that successfully address challenges related to expanding academic geriatrics programs, managing training and research activities, and training subspecialties physicians in geriatrics.
Leadership and management skills are not taught in medical school. Most CoE directors have had to learn management skills and business-oriented strategies primarily on the job. Many of those interviewed credited leadership training received after completing their medical training for strengthening their management skills and stimulating them to think in new ways. That additional training, advice from peers, plus experience, have taught them to think strategically, a critical component of smart growth for their programs.
Geriatrics is Collaborative. In order to address the complexities of caring for older patients, clinical geriatrics is by necessity collaborative and multidisciplinary. Academic geriatrics is also collaboratively oriented with regard to aging-related research and expanding geriatrics training into other subspecialties and disciplines. Long before the NIH formally recognized a new roadmap for collaboration and cross-specialty and cross-disciplinary engagement, geriatrics “got it.” Leaders interviewed in this report include some who have found ways to simultaneously strengthen geriatrics and build bridges with other disciplines to expand resources and develop new approaches.
The personal connection is powerful. CoE directors frequently emphasized the importance of the mentoring they received as they were forging their careers, the support and role modeling they received for building their programs via on-site consultations with senior leaders, and their own satisfaction in mentoring others. Many advocated for broader programs for mentoring and consultation. For programs to thrive, leaders stressed building strong relationships with senior management, including keeping deans and other administrators up-to-date about successes and goals, but also asking how geriatrics could be helpful to them and the institution.
Build a diversified portfolio. CoEs are expanding the number and type of funding sources to ensure longer-term stability and growth.
With CoEs, one size does not fit all. In terms of the management strategies described in this report, not all "best practices" are easily transferable from one setting to another. This is due to differences in the programmatic focus; maturity of the program; size and interests of faculty; sources, kinds, and depth of resources for geriatrics; and a variety of institutional characteristics. Nevertheless, it is hoped that the views and information shared here can stimulate discussions and opportunities.
Scholarly Projects for First-Year Internal Medicine Residents
at the University of Rochester School of Medicine
| SUMMARY |
| Target Audience Internal Medicine residents Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
Fostering academic development during residency training has been a successful means of recruiting academicians in other specialties. Early publications and scholarly work during residency may lay the foundation for future academic investigation and publications. According to a cohort study of neurology residents (see Available Materials), publishing before and during residency training were both associated with continued scholarly activity after residency.
To recruit residents to academic careers, each first-year Internal Medicine resident at the University of Rochester is required to undertake a project to gain experience in medical scholarship. Geriatrics faculty participate in this program in order to interest Internal Medicine residents in careers in academic geriatrics.
Program Operations
Each first-year resident chooses a research mentor from among 80-plus faculty volunteers, and spends two weeks developing her or his chosen scholarly activity. This might include designing a research project to be carried out over the remainder of the residency, preparing a case report, or performing a critical topic review based on the medical literature. Additional research experience is offered as an elective option in the second and third year of residency training. Several geriatrician faculty participate as volunteer research mentors, including those with careers as both researchers and clinician-educators.
The list of mentors is organized by the Department of Medicine/Internal Medicine Residency program. Additional information is available to residents on the URMC Internal Medicine Residency website (see Available Materials).
Staffing Requirements
Over 80 volunteer faculty serve as mentors to the residents. Internal Medicine Residency Program Directors and administrative staff in the Department of Internal Medicine oversee the program.
Program Costs and Funding Sources
The costs involved include faculty time to mentor and assist the residents in development and oversight of the scholarly project. All time is volunteered. Administrative costs are assumed by the Department of Internal Medicine.
In addition, if a resident’s work is accepted for presentation at the American College of Physicians annual meeting, the travel expenses are covered by the Residency Program. If the resident’s work is accepted for presentation at a subspecialty society national meeting, the travel expenses are covered by the sponsoring Division.
Process and Outcomes Data
Four residents who have completed their scholarly project in geriatrics have been recruited to geriatrics fellowships and have then remained in the geriatrics division in academic positions.
Residents have completed the following projects:
- Literature review on Healthy Aging
- Community Outreach Project entitled “Culturally Sensitive Exercise and Health Education in Latin American Elders." This project instituted an exercise and education program in diabetes, physical activity, and diet for attendees of a Hispanic day program in Rochester.
- Review article on Pain in the Minority Older Adult, published in a peer-reviewed journal
- Research project entitled "Glycopyrrolate for Urinary Incontinence in the Cognitively Impaired Elderly Patient"
Implementation Lessons
- It is important to introduce geriatrics as a research field to the residency program early on in training and to encourage interested residents to choose aging- related research projects.
- The web-based system has been very effective; some participants use it even before they arrive to start their residency.
Available Materials
Tools/Resources
Website
- The Internal Medicine Residency Research homepage, containing information on the research areas and application process: www.urmc.rochester.edu/smd/gme/prospective/
medicine/research_faculty/research_overview.cfm
Publication
- Dorsey, ER, Raphael, BA, Balcer, LJ, Galetta, SL
Predictors of future publication record and academic rank in a cohort of neurology residents
Neurology 2006;67:1335-1337
For More Information
Annette Medina-Walpole, MD
Associate Professor of Medicine
University of Rochester Medical Center
Medical Director, The Living Center
The Highlands at Pittsford
500 Hahnemann Trail
Pittsford, NY 14534
(585) 389-0988, x262
annette_medinawalpole@urmc.rochester.edu
Year-long Master Clinician Educator Program
at Mount Sinai School of Medicine
| SUMMARY |
| Target Audience Geriatrics fellows, chief residents, and junior faculty Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
In order to assure the highest quality of teaching in geriatrics among physician-training programs across the country, clinician-educators must possess significant pedagogic skills and a mastery of relevant content. The goal of the annual Master Clinician-Educator Program in Geriatrics is to produce expert geriatrics educators within geriatric medicine as well as within other disciplines.
In 2005, its pilot year, the program was offered exclusively to fellows enrolled in Mount Sinai’s geriatrics fellowship program. Starting in the 2005-06 academic year, the program was expanded to include selected Mount Sinai nongeriatrician chief residents and/or junior faculty in addition to geriatrics fellows.
The Master Clinician-Educator Program focuses on fundamental teaching principles, clinical teaching in sites specific to geriatrics, education research skills, and evaluation/assessment techniques that address issues fundamental to the care of older adults.
The specific learning objectives are for participants to:
- become familiar with classic teaching principles
- become aware of venue-specific skills necessary for teaching geriatrics
- acquire skills in curricular development
- design learner- and topic-specific curricula in geriatrics content
- communicate his/her curricular design effectively
Upon satisfactory completion of the program, scholars receive a Certificate in Geriatrics Medical Education from the Department of Geriatrics.
Program Operations
The Master Clinician-Educator Program is offered during the second year of the geriatrics fellowship, during the final year of chief resident training, or over a one-year period for selected junior faculty from other disciplines. Up to four geriatrics fellows and three junior faculty or chief residents are enrolled in the program annually. Chief residents or junior faculty are chosen by a competitive application process that favors those planning to
relocate and practice academic medicine at another institution within the next three to five years. To encourage those who are not geriatrics fellows to participate, the Department of Geriatrics provides mentorship to enable trainees to develop expertise and visibility as geriatrics-oriented educators within their disciplines.
The program consists of a weekly two-hour seminar. Additional hours of independent study and scholarly work are expected between sessions. Seminars include didactic sessions, experiential learning opportunities, other classroom sessions, and application-based work and workshops. The workshops consist of work in progress reports on goals, objectives, curricula, and evaluations based on the scholars’ own work. Scholars are also able to watch others teach in the medical school and reflect on the process and content of that teaching. Four sessions result in educational tools produced by the scholars that can be added to their portfolio of portable, ready-to-use geriatrics training materials.
Program trainees also teach in different clinical arenas where they are observed and receive feedback from faculty. Because of the interdisciplinary nature of the Clinician-Educator Program, all scholars learn how to work with a variety of other specialists in order to integrate geriatrics curriculum, content, and teaching throughout institutions and across the continuum of care.
Participants are also required to complete a scholarly project and a publication timeline during their training year. They also develop a mentored career plan to enable them to become faculty who promote and teach geriatrics at other institutions.
Staffing Requirements
Three geriatrics faculty members (one at 20% and two at 10%) and one part-time administrative assistant who serves as program coordinator (at 20%) are needed to staff the program.
Program Costs and Funding Sources
The total annual budget of approximately $150,600 covers staffing costs, fellows’ salaries, food, books, and office expenses.
The program development was funded by the Donald W. Reynolds Foundation via its Consortium for Faculty Development to Advance Geriatric Education (FD~AGE) grants; its ongoing operation is supplemented by funds from the John A. Hartford Foundation Center of Excellence and the Brookdale Department of Geriatrics and Adult Development.
Process and Outcomes Data
44 Scholars have graduated from the program since 2005.
Pre- and post-survey program evaluations are conducted. Prior to the course, 85% of the scholars wanted a career in academics, 5% stated they had experience with curricular development, and 1% reported that they had formal training. After the course was completed, 85% of the scholars felt more comfortable in starting curricular projects.
10% of the participants have presented their work at national meetings and are currently working on their manuscripts.
32% of the scholars are faculty members in geriatrics/palliative care at Mount Sinai, 59% are in geriatrics/palliative care or geriatrics/internal medicine at other institutions, and 9% are faculty in other subspecialties with geriatrics interest.
Implementation Lessons
- This is a developmental process for the scholars, which requires a time commitment from them to work outside the classroom, as well as a time commitment from the teaching faculty to hold individual mentoring meetings.
- An evaluator should be part of the development team.
Available Materials
Tools/Resources
Publications
- Learning in Adulthood
Merriam, SB, Caffarella, RS
Jossey-Bass. San Francisco 1999 - Curriculum Development for Medical Education
Kern, DE
The John Hopkins Press. Baltimore 1998 - ABC of teaching and learning
Kern DE, Thomas PA, Howard DM, et al
BMJ series: 2003;326
For More Information
Helen Fernandez, MD
Mount Sinai School of Medicine
Brookdale Department of Geriatrics and Adult Development
10th Floor, Annenberg Building
One Gustave L. Levy Place
Box 1070
New York, NY 10029-6574
(212) 241-5561
Helen.Fernandez@mssm.edu
Manual Three: Managing Programmatic Growth and Development in Academic Geriatrics
Chapter I: Expanding Academic Geriatrics Programs
1. Internal Marketing to Institutional Stakeholders
2. Building Clinical Revenue
3. Fundraising Strategies
4. Using Consultants
5. Big Picture Perspectives on Expanding Geriatrics Programs
Chapter II: Managing Training and Research Activities
1. Build an Administrative Infrastructure
2. Centralize Grants Management: A Closer Look
3. Pool Resources to Fund Fellows and Junior Faculty
4. Develop a Strong Mentoring Program
5. Expand Opportunities through Interdisciplinary Research
6. Build Collaborative Programs
Chapter III: Training Subspecialty Physicians in Geriatrics
1. Joint Fellowships and Junior Faculty Support
2. Mini-fellowships in Geriatrics
3. Training Hospitalists in the Care of Older Adults
Chapter IV: Selected Profiles of CoE Directors and the Programs They Lead
1. Boston University Medical Center
2. Emory University/University of Alabama at Birmingham
3. Indiana University
Establishing an American Geriatrics Society Resident Chapter
| SUMMARY |
| Target Audience Physicians-in-training at the resident level Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
The American Geriatrics Society (AGS) Resident Chapter network was established to interest physicians-in-training in the field of geriatrics, enhance the visibility of geriatric medicine at the resident level, and provide educational programs on geriatric medicine. CoEs and other geriatrics programs are encouraged to develop an AGS Resident Chapter as a means to recruit trainees into geriatrics fellowships and academic careers.
The AGS Resident Chapter network began in 2007. Chapters are organized by medical school geriatrics programs under the leadership of a faculty advisor. The AGS website contains an updated list of current chapters (see Available Materials).
Resident Chapter goals are:
- to encourage interest in geriatrics among faculty and residents in the various disciplines concerned with the care of older adults
- to encourage curriculum developers to include geriatrics in the general curriculum as well as in elective course offerings and multidisciplinary programs
- to develop educational programs in geriatrics open to the medical school faculty as well as to local health care professionals
- to promote educational activities within community facilities, such as nursing homes and senior centers.
Program Operations
To establish and maintain an AGS resident chapter, interested groups must fill out an application form, which is available on the AGS website (see Available Materials). The AGS Education Committee reviews applications upon receiving them.
Resident Chapters are expected to submit an annual report on their activities, membership, planned future goals, and the overall progress toward initial stated goals. The AGS provides progress report forms.
Resident Chapters are responsible for notifying the AGS of any change in faculty advisors or resident officers. This can be done annually, when the progress report is submitted.
Staffing Requirements
A geriatrics department/division faculty member must be selected to serve as the Chapter advisor. This provides continuity to the Chapters. The advisor must be an AGS member (if the Chapter has more than one advisor, at least one must be a member).
Program Costs and Funding Sources
Program costs are dependent upon the activities the Chapter undertakes, and can include: faculty advisor and administrative staff time, social events, educational materials, and visiting faculty and lecturers.
The AGS provides $200 to each Resident Chapter annually for program support.
Process and Outcomes Data
Current AGS Resident Chapters have developed a variety of activities, including case-based geriatrics morning reports; resident board review sessions; and journal clubs focused on geriatrics topics.
The Boston University Medical Center chapter hosted a geriatrics career night dinner at which approximately 20 Internal Medicine and Family Medicine residents, 3 Geriatrics fellows, and 10 faculty members from the section of Geriatrics came together to learn about geriatrics fellowship, research, and career opportunities. A similar event was held for at the Tufts-New England Medical Center, attended by 11 residents and Internal Medicine faculty members.
Implementation Lessons
- Residents are busy and hungry. Host dinners in the early evening so residents can attend them on their way home from work. Having the dinner at the institution, rather than at a restaurant, may increase attendance.
- It is helpful to get chief residents involved—they are in charge of morning reports and special intern conferences.
Available Materials
Tools/Resources
- AGS Resident Chapter guidelines and application form: americangeriatrics.org/education/residents/establishing_chapter.shtml
- List of current AGS Resident Chapters and contacts: americangeriatrics.org/education/residents/current_resident_chapters.shtml
For More Information
Joe Douglas
Coordinator for Professional Education and Special Projects
American Geriatrics Society
350 Fifth Avenue, Suite 801
New York, NY 10118
(212) 308-1414
jdouglas@americangeriatrics.org
Manual Two: Approaches to Recruitment to Advanced Fellowship Training and Faculty Positions in Academic Geriatrics
An Introduction to Academic Geriatrics Recruitment and Career Development
Pre-Fellowship Decision Recruitment Strategies - Expose Residents to Geriatrics Fellowship and Career Opportunities
- Geriatrics Is Your Future: A Regional Resident Recruitment Program at Baylor College of Medicine
- Annual Resident Award Summit at the Southeast Center of Excellence in Geriatric Medicine (Emory University and the University of Alabama at Birmingham Schools of Medicine)
- Using Resident Applications to Identify and Engage Geriatrics Trainees at the University of Texas Health Science Center at San Antonio
Support Resident Research and Scholarly Projects in Geriatrics
- Scholarly Projects for First-Year Internal Medicine Residents at the University of Rochester School of Medicine
- Establishing an American Geriatrics Society Resident Chapter
Post-Fellowship Decision Recruitment Strategies - Provide Faculty and Peer Mentoring on Academic Careers
- Collaborative Grant Review and Mentoring for Clinician-Researcher and Clinician-Educator Trainees at Emory University/University of Alabama at Birmingham (Southeast Center of Excellence in Geriatric Medicine)
- Junior Faculty Mentoring in Aging Research at the Indiana University School of Medicine Center for Aging Research
- Aging-Related Research Career Development Core for Junior Investigators at the University of Michigan
Implement Programs that Promote Academic Career Preparedness
- One-day Career Development Retreat for First-year Medicine Subspecialty Fellows at the University of California, San Francisco School of Medicine
- Fellows’ One-Year Academic Career Development Course at the University of Rochester Medical Center
Approaches to Advancing Clinician-Educator Careers
- Academic Faculty Scholars Program in Geriatrics for Non-Geriatricians at Boston University
- Geriatrics Excellence in Teaching Series for Faculty and Fellows at Duke University School of Medicine
- Faculty Enrichment and Educational Development Program at the Indiana University School of Medicine
- Year-long Master Clinician-Educator Program in Geriatrics at Mount Sinai School of Medicine
- Area of Concentration for Clinician-Educators at the University of Chicago
- Knowledge and Skills in Cultural Competence and Minority Health Issues at the University of Pennsylvania
Approaches to Advancing Research Careers
- One-Year Course in Research Methods and Design for Geriatrics Fellows and Junior Faculty at Weill Medical College of Cornell University
- Grant Writing Seminar for Geriatrics Fellows and
Junior Faculty at Weill Medical College of Cornell University
- Advanced Aging Research Training Seminar Series at Harvard Medical School
- Clinical Investigator Training Enhancement Program at the Indiana University School of Medicine
- Scholarly Activities Clinic for Clinician-Educator Junior Faculty in Geriatrics at the Indiana University School of Medicine
- Interdisciplinary Academic Advancement Seminar for Junior Faculty Interested in Aging Research at the David Geffen School of Medicine at the University of California, Los Angeles
- Portfolio Structure for Fellows and Junior Faculty in the Academic Geriatrics Research Track at the University of Pittsburgh School of Medicine
Four-Week Elective in Geriatrics for Internal Medicine Residents
at the Yale School of Medicine
| SUMMARY |
| Target Audience All Internal Medicine residents who have completed the required four-week inpatient geriatrics rotation Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
All Internal Medicine (IM) residents at Yale School of Medicine complete a four-week rotation in an inpatient geriatric setting. Approximately one half are assigned to the Veteran’s Administration Medical Center and the other half to the Acute Care of the Elderly (ACE) Unit at Yale New Haven Hospital. During this required inpatient rotation, the residents are exposed to diagnostic and management issues involved in the care of hospitalized older patients.
The goal of the elective rotation in geriatrics, which complements the required inpatient rotation, is to expose IM residents to geriatrics and geropsychiatry in a variety of nonhospital care settings, including subscute, assisted living, nursing home, outpatient clinic, and home.
This program is designed to help residents:
- understand care delivery in a variety of settings including both the services available and the role of the physician
- appreciate the different ways that the goals of care can be met in these settings, and the unique opportunity that they afford to avoid hospitalization
- understand the role of geriatric syndromes in the quality-of-life of individuals in these settings, and gain skill in diagnosing and managing the patient’s illnesses, given their multifactorial nature
- have opportunities to further their skills in end-of-life and palliative care through interactions with the hospice, palliative care, and geropsychiatry teams
- appreciate the need for appropriate information transfer in transitions in care.
A 2005 geriatrics education needs assessment conducted with Yale medical students and Internal Medicine residents revealed that trainees experienced frustration with the traditional medical model of care (disease-focused, cure-oriented) in caring for older patients because of the multifactorial nature of many illness states, barriers to communication, and differences in goals for outcome in older adults. This residency rotation is designed to help the learner move from a disease-management model to a geriatric holistic model of care. Improving trainees’ geriatrics knowledge and skills can help change their attitudes toward, and skills in, caring for older people, and may help to encourage more trainees to pursue careers in geriatrics.
Program Operations
The rotation is tailored to the differing levels of the residents’ prior experiences and interests. Residents can choose either a two-week or four-week elective. Please see Available Materials for an example of a four-week schedule.
The two-week elective is an introduction to sites of care. Residents spend at least two full days on home care, and four full days in the nursing home setting, doing both admission evaluations and care plans for patients admitted for subacute medical care, and monthly reviews of longer-term residents. The residents spend two half days in the geriatric assessment and management consultation center learning geriatric assessment and interdisciplinary team skills. The other two days are tailored to the residents’ interests. Examples of activities chosen include a geriatric musculoskeletal clinic with a geriatric rheumatologist, a wound care specialty consultation, and an electroconvulsive therapy session with a geropsychiatrist.
In the four-week elective, the resident gradually takes on more responsibility. In the Extended Care (long-term) setting they see assigned patients once a week over the four weeks, including new, complex patients in subacute facilities and hospices. A preceptor initially accompanies residents to see patients in their homes and in assisted-living settings, but residents may make follow-up visits on their own. They spend one full day with the Agency on Aging and a half-day at an adult day care center.
The residents are encouraged to participate in the didactic activities of the geriatrics division, including geriatrics journal club, research in progress, and geriatrics grand rounds. (See Available Materials.)
Staffing Requirements
The education coordinator and an administrative assistant organize the program; the education coordinator is the main preceptor at the clinical sites. There is additional time required of the other geriatrics faculty who incorporate resident supervision and education into their clinical activities.
Program Costs and Funding Sources
There are minimal costs for occasional meetings and conferences. The time of the education coordinator and of the program assistant is covered by the geriatrics division’s endowment fund.
Process and Outcomes Data
Residents complete online evaluations. Data are still being collected for the two years of online evaluations.
Implementation Lessons
- The residents must have direct patient responsibilities and be held responsible for attendance.
- The residents should have at least one half day off (and sometimes two) to help them remain invested during their days at the facility.
- Avoid having residents visit two different sites in one day unless it is absolutely necessary, as residents find the travel time and switching gears very disruptive. Full-day blocks are better.
- Observation days should be limited to one day out of five.
Available Materials
Tools/Resources
- Rotation Schedule
- Schedule of Rotation Didactics, Grand Rounds, Journal Clubs, Seminars, and Workshops
Publications
- Perceived Needs for Geriatric Education by Medical Students, Internal Medicine Residents, and Faculty
Drickamer, MA, Levy, B, Irwin, K, Rohrbaugh, R
Journal of General Internal Medicine
2006;21(12):1230-4
For More Information
Margaret Drickamer, MD
Associate Professor and Associate Section Chief for Geriatrics Education
Section of Geriatrics
Yale Medical School
20 York Street, TMP 15
New Haven, CT 06504
(203) 688-9423
margaret.drickamer@yale.edu
Using Resident Applications to Identify and Engage Geriatrics Trainees
at the University of Texas Health Science Center at San Antonio
| SUMMARY |
| Target Audience Incoming Internal Medicine and Family and Community Medicine residents who are undecided about an area of specialization Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
The goal of this approach is to attract residents into geriatrics fellowship training slots at the University of Texas Health Science Center at San Antonio through mentoring by a geriatrician. Research indicates that forming a personal relationship with a role model or mentor in a given field is an effective recruitment strategy.
Second-year Internal Medicine and Family and Community Medicine residents who are undecided about an area of specialization or who have already expressed an interest in geriatrics fellowships are invited to participate in the program, which began in 1998 under the San Antonio Hartford Foundation Center of Excellence in Geriatric Medicine and Training.
Program Operations
Geriatrics faculty review all the annual applications, scores, and personal statements of trainees entering Family and Community Medicine (FCM) and Internal Medicine (IM) residencies. This includes 25 second-year IM residents and 12 second-year FCM residents (out of a total of 36 FCM residents who enter the program annually). They are triaged into three categories:
- residents who are unlikely to pursue geriatrics because they have already indicated another subspeciality interest
- residents who are undecided about a specialty
- residents who have already expressed an interest in geriatrics or an interest in an academic career in any field.
Family and Community Medicine
During the first year, geriatrics faculty establish informal relationships with the targeted residents. They begin their three-year continuity training at long-term care facilities with an orientation during the month of training. About eight times a year, at an assigned long-term care facility, residents spend a half day with a geriatrician.
Residents are invited to various didactic activities and social events during their second year, such as a welcoming dinner, where they meet fellows, former fellows, and other residents interested in geriatrics. This exposes them to the geriatrics community at San Antonio and enables them to get to know geriatricians better. Geriatricians are “pitched” as a select group of individuals pursuing a unique and challenging discipline.
Residents are also invited to attend the “Geriatrics is Your Future” resident recruitment weekend at Baylor College of Medicine and to lunch with a geriatrician who has completed a fellowship. Former geriatrics fellows are the most credible and effective recruiters. During this year, residents are approached about applying for the fellowship and told what it involves.
Third-year residents complete a two-month rotation in geriatrics. One month is spent at an inpatient facility, and one month at a nursing home. During the third year, the application process is facilitated for those residents who have chosen a geriatric fellowship.
Internal Medicine
The Extended Care Treatment Center at the VA hospital is one of the sites where second- year IM residents can be assigned for continuity training, and where they then receive mentoring. Assignment is based on an expressed interest in geriatrics. In addition, all second-year residents have a required rotation in geriatrics. These two clinical rotations give geriatricians a chance to serve
as mentors and to form relationships with potential fellowship candidates.
Staffing Requirements
There are no additional staffing requirements. Faculty and current and former fellows are asked to attend several social evenings each year to get to know the residents.
Program Costs and Funding Sources
There are modest costs for social events, covered by the Hartford Foundation Centers of Excellence budget.
Process and Outcomes Data
Since the start of the program nine years ago, 24 residents have been recruited: six former fellows are in academic slots at San Antonio; one is in an academic position at UAB; and two are associate faculty at the UT extension campus on the Texas-Mexico border.
During this time, the number and qualifications of fellowship program applicants has improved steadily.
Implementation Lessons
- Recruitment efforts should not be targeted at interns. Interns indicated that attempts to get them to commit to geriatrics during this overwhelming first year added too much pressure and thus were counterproductive.
- Recruitment messages have to be personalized and should be tailored to each individual as much as possible. Messages must address concerns that prevent trainees from pursuing geriatrics, such as how to fund research training and how to pay off student loans. Having current or recent fellows address solutions to these issues is most effective.
- It is important to emphasize the breadth and variety of possible career paths in geriatrics and to communicate information about salaries and career satisfaction in the field.
Available Materials
Tools/Resources
Website
- UTHSCSA CoE website: http://geriatrics.uthscsa.edu
For More Information
Cynthia L. Alford, MD
Associate Professor
Department of Family and Community Medicine
University of Texas Health Science Center
7703 Floyd Curl Drive, Mail Code 7794
San Antonio, Texas 78229-3900
(210) 358-3885
alford@uthscsa.edu
How to Use the Network Resource Center
One-month Rotation in Acute-care Geriatric Medicine for Senior Residents
at the David Geffen School of Medicine at the University of California, Los Angeles
| SUMMARY |
| Target Audience Internal Medicine Residents in their final year Purpose Program History Operating Costs Outcomes Available Materials For More Information |
Program Overview
The UCLA Division of Geriatrics provides training in Geriatric Medicine to three affiliated residency programs in internal medicine. Since 1997, this training has included a four-week acute-care inpatient rotation in geriatrics for senior residents in Internal Medicine and Family Practice. All patients admitted to this inpatient hospital service are ambulatory care or nursing home patients of the UCLA Geriatrics Practice physicians who staff the service.
The goals of the Geriatric Medicine residency rotation are to:
- demonstrate competence in the comprehensive care of hospitalized geriatric patients, concentrating on issues more specific to older adults
- recognize differences in disease presentation in the elderly population
- learn how to apply evidence-based, cost-conscious strategies to diagnosis and disease management in older patients
- understand functional status and how it relates to outpatient and inpatient geriatrics and discharge planning
- learn how to function as a member of an interdisciplinary team caring for geriatric patients in both inpatient and skilled nursing facility settings
- participate in family meetings and be an effective communicator
- understand utilization of resources and appropriate levels of care in geriatric patients
- learn how to address end-of-life issues with patients and family members
- understand the multiple factors involved in effective and successful discharge planning in geriatric patients
- gain experience in working in a community hospital environment and a skilled nursing facility
- learn how to manage medical problems over the phone
- recruit primary care residents to advanced geriatrics training and careers in Geriatric Medicine.
Training is conducted at the UCLA-Santa Monica Medical Center and Orthopedic Hospital.
Program Operations
In addition to the clinical teaching that occurs during inpatient rounds led by the geriatrics attending physicians, residents attend a 30-minute lecture/discussion five days per week on 20 clinical topics in geriatrics such as: orientation to the geriatrics service, functional assessment, delirium, rehabilitation services, malnutrition, and pain management. The rotating attending geriatrician usually leads the lectures.
One of the most notable learning activities is the residents’ participation in the daily 30-minute geriatrics interdisciplinary team meetings. The team consists of the primary nurses; staff from physical therapy, occupational therapy, and speech therapy; a dietitian; a social worker; a discharge planner; and physicians. The medical residents lead the meetings, which provide unique opportunities for them to improve communication, clarify patient outcomes, and improve quality of patient care. The team reviews individual patient progress and does discharge planning. Moreover, there is continuous sharing of information and learning for all members of the team.
At the completion of the rotation, the residents are expected to:
- demonstrate baseline competency and improvement in medical interviewing and physical diagnosis
- formulate a differential diagnosis and plan for evaluating and managing patients admitted to his/her service
- recognize common geriatric syndromes and be able to manage them
- efficiently and effectively chart daily progress notes in the medical record
- effectively cross cover patients when other team members are not available
- demonstrate an understanding of appropriate utilization of consult services and diagnostic testing
- function effectively as a member of a multidisciplinary team to ensure proper care and welfare of patients
- participate in family meetings and communicate effectively to patients and their families
- determine appropriate level of care upon discharge
Rotating geriatric physicians receive standardized lecture materials, which include power point slides, handouts, and sample board review questions. Guest lecturers are provided with guidelines for their lecture content, with annual review and suggestions for improvement.
Staffing Requirements
Two full-time UCLA geriatrics faculty staff the rotations in one-week rotations. Outpatient clinic preceptors are provided largely by one or two of the geriatrics faculty in the geriatrics ambulatory care clinics.
Program Costs and Funding Sources
UCLA received a 1994 John A. Hartford Foundation grant to increase geriatrics content in primary care residency training. This funding provided leadership support and development for the curriculum and evaluation process. Today these ongoing and recurring costs are funded largely by the UCLA Department of Internal Medicine and the Division of Geriatrics. In addition, faculty contribute their time and effort to update and maintain educational activities, evaluation methods, and teaching skills.
Process and Outcomes Data
One of the most powerful outcomes of the program has been the opportunity to recruit geriatrics fellows from the primary care residents rotating on the inpatient geriatrics service. Since the rotations began in 1997,
17 fellows have been recruited from UCLA’s internal medicine residency programs and three fellows have been recruited from family practice residency programs. Some residents have also participated in research experiences with UCLA geriatrics faculty.
The Internal Medicine House Staff program conducts retreats and feedback sessions with the residents. These sessions are often attended and evaluated by members of the geriatrics faculty. Information from resident feedback is brought to the Geriatrics Division Executive Committee, where plans for improvement and updates in the program are discussed and implemented.
This activity is uniformly valued among the residents and they consistently report a high satisfaction with this activity on their evaluations.
Implementation Lessons
- The acute inpatient resident education program has been the most successful recruitment tool for new geriatrics fellows.
- A successful inpatient rotation for senior residents in internal medicine requires a balance of steady patient care responsibilities, learning opportunities, and inspiring role models.
- Advanced trainees require careful attention for "the teachable moment" and the opportunity to have a close working relationship with an experienced role model who can add value to their practice experience.
- The organization and function of the entire interdisciplinary team is important. Residents are most impressed by the team’s daily meetings, which result in timely and effective discharge placements as well as appropriate implementation of community-based resources.
Available Materials
Tools/Resources
- A list of topics covered in the 20 lectures given during the 4-week rotation
- A CD containing UCLA Geriatrics Division educational materials
For the materials CD, contact:
Ann Hu
UCLA Donald W. Reynolds Program Coordinator
David Geffen School of Medicine at UCLA
10945 Le Conte Avenue, Suite 2339
Los Angeles, CA 90095-1687
(310) 312-0531
achu@mednet.ucla.edu
For More Information
Bruce A. Ferrell, MD
Professor of Medicine and
Associate Chief of Education
Division of Geriatric Medicine
David Geffen School of Medicine at UCLA
10945 Le Conte Avenue, Suite 2339
Los Angeles, CA 90095-1687
(310) 825-8253
bferrell@mednet.ucla.edu
