Fellowship Year Curriculum

Fellowship Year Curriculum

Swedish Family Medicine – Advanced Training in Geriatrics
2012-13

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Summary of Clinical Rotations

  1. Outpatient care – fellows have three clinic sessions per week at Swedish Family Medicine: geriatric continuity clinic, family medicine continuity clinic, and geriatric consultation clinic. This is a longitudinal experience, and happens concurrently with other rotations.
  2. Acute Inpatient Care – fellows spend 6 months per year on the inpatient service, caring for our panel of geriatric patients and the patients of Providence ElderPlace. They provide geriatric teaching and supervision to the First Hill family medicine residents (Green Team), and are in turn supervised by our geriatric faculty. They also provide inpatient geriatric consultations. This is a longitudinal experience, and happens concurrently with other rotations.
  3. Long term and post-acute care – fellows see patients weekly in our two local nursing homes, Kline Galland and Washington Care Center, once a week. They have a busy panel of both long-term and sub-acute patients. This is a longitudinal experience, and happens concurrently with other rotations.
  4. Acute Rehabilitation – fellows spend one month on the Acute Rehabilitation Unit at Swedish-Cherry Hill, under the supervision of the Swedish physiatrists. This rotation includes both inpatient and outpatient experiences.
  5. Geropsychiatry – new this year, fellows work with the geropsychiatrist at Providence ElderPlace, Dr Sam Appel.
  6. Swedish Wound Clinic – fellows learn to care for chronic non-healing wounds under the direction of Dr Cynthia Campbell.
  7. Providence Hospice – new this year, fellows rotate with the home care RNs and therapists, as well as the director of Providence Hospice, Dr Wayne McCormick.
  8. Neurology – fellows work at the Movement Disorders Clinic at the Swedish Neuroscience Institute, under the direction of Dr Susie Ro and Dr Jennie Witt.
  9. Palliative Medicine – fellows spend a month as a member of the Swedish inpatient Palliative Care Consult team.
  10. Home visits – fellows conduct home visits on their patients in patient homes, adult family homes, and assisted living facilities. These visits occur under the supervision of our faculty as well as local geriatrician, Dr Kristin Anderson.
  11. Medical Director – fellows visit several facilities and attend meetings with local medical director Dr Eric Troyer.
  12. Residential Care Team – new this year, fellows each spend two months learning post-acute care on the Swedish RCT, under the direction of Dr Troyer. This will occur at Kline Galland Home and at Providence Mt St Vincent.

Summary of Faculty Development/ Leadership Training

  1. Fellows act as Preceptor in the family medicine clinic once per week. They are paired with a faculty supervisor.
  2. Fellows teach and supervise family medicine residents on the inpatient service throughout the year.
  3. Fellow deliver didactics presentations every three months to the residents of Swedish Family Medicine – First Hill and SFM – Cherry Hill.
  4. Fellows attend weekly Faculty Meetings at the residency, and are invited to all faculty-development sessions.
  5. Fellows produce an academic project during their fellowship: either a formal CME presentation, or a piece of academic writing, or both.
  6. Fellows attend monthly sessions at the VA with UW geriatrics and palliative medicine fellows, as part of the Professional Development Series conducted by Dr Elizabeth Vig.

Acute Inpatient Care
Rotation length: 6 months (longitudinal)
Location: Swedish Medical Center (First Hill)
Supervising Faculty: Haymon, Ainsworth, Babineau, Kazemi
Evaluation: direct observation and written competency-based evaluation.


Practical details:

Monday Tuesday Wednesday Thursday Friday
 AM FMS until 10AM FMS until 10AM FMS until 10AM FMS (rounds and teaching with team)  FMS until 10AM  FMS until 10AM
PM

  • Each month, one fellow is assigned to the Inpatient Geriatrics Service, a sub-set of the Family Medicine Service.
  • The fellow is responsible for rounding on the patients of the Geriatrics team who have been admitted (either from clinic or the nursing home) and the hospitalized patients of Providence-Elder Place.
  • The fellow provides geriatric teaching and supervision to the First Hill family medicine residents. The fellow also provides inpatient geriatric consultations, under the supervision of our geriatrics faculty.

Rotation Goals and Objectives:

Patient Care

  • Provide care to geriatric patients with common, acute conditions requiring hospitalization.
  • Manage transitions in care, from the inpatient setting to the outpatient and sub-acute setting.
  • Gain expertise in providing compassionate end-of-life care.

Medical knowledge

  • Improve knowledge of common geriatric conditions requiring hospitalization, such as infections, fractures, strokes, heart disease, and cancer.
  • Gain experience in the palliation of pain, dyspnea, nausea, constipation, and anxiety.

Practice-based learning and improvement

  • Improve skills in recognizing acuity as well as in prognostication.
  • Interpersonal and communication skills
  • Provide leadership on the resident team in the care of geriatric patients.
  • Become adept at collaborative decision making with patients and families, particularly as patients reach the end of life.

Professionalism

  • Interact professionally with members of the interdisciplinary care team, with residents, and with attending physicians.

Systems-based practice

  • Understand the role of hospital medicine, as well as its limitations, in the care of frail elderly patients


Geriatrics Outpatient Clinic
Rotation length: 12 months (longitudinal)
Location: Swedish Medical Center (First Hill)
Supervising Faculty: Ainsworth and Haymon
Evaluation: direct observation, chart review, and written competency-based evaluation.

Practical details:

Monday Tuesday Wednesday Thursday Friday
AM
PM Geriatric Fellow Clinic

    

  • Fellows have geriatric continuity clinic on Monday afternoons at Swedish Family Medicine.
  • There is a dedicated faculty preceptor for this clinic, who discusses all fellows’ patients, sees and examines patients as necessary, and reviews and co-signs all chart notes.

Rotation Goals and Objectives:

Patient Care

  • Improve diagnostic and therapeutic skills in a range of common geriatric medical conditions: heart disease, lung disease, neurologic disease, rheumatologic disease, cancer, infections, and dementia.
  • Recognize acuity in frail elders: determine appropriate follow-up, determine need for hospital admission.
  • Determine the appropriateness of labs and studies in the investigation of disease.

Medical knowledge

  • Gain expertise in the geriatric syndromes: falls, dizziness, cognitive impairment, polypharmacy, urinary incontinence, vision loss, and hearing loss.
  • Learn to recognize caregiver strain, evaluate patient safety, and determine the need for a higher level of care.

Practice-based learning and improvement

  • Become proficient at using evidence to inform treatment decisions. Recognize the limits of evidence in the care of frail elderly.
  • Learn to use preventive care principles (such as screening) in a manner appropriate to life expectancy and disability.
  • Develop knowledge of community resources available to support this population.


Interpersonal and communication skills

  • Communicate sensitively with patients and families, both face-to-face, and by telephone.
  • Become expert in discussions of goals of care, including end of life care.
  • Professionalism
  • Establish the central role of the primary care physician/ geriatrician in the care of the elderly.
  • Communicate and coordinate with other specialists in the development of appropriate care plans; that account for patient preference, life expectancy, and disability.

Systems-based practice

  • Participate in the work of the multidisciplinary team (including nursing, therapy, and social work) to provide comprehensive care.
  • Recognize the importance of care transitions, and the role for assisted living, adult family homes, skilled nursing facilities, home care, and long term care.

Geriatric Assessment and Consultation Clinic
Rotation length: 12 months (longitudinal)
Location: Swedish Medical Center (First Hill)
Supervising Faculty: Haymon
Evaluation: direct observation, chart review, written competency-based evaluation.

Practical details:

Monday Tuesday Wednesday Thursday

Friday

   AM Geriatric Assessment Clinic
PM

 

  • Geriatric Assessment and Consultation clinic is held on Thursday mornings at Swedish Family Medicine.
  • The fellows’ own patients as well as patients of the residency clinic are seen for complete Geriatric Assessment.
  • The fellows also perform specialty Geriatric consultations for community physicians.
  • The clinic is precepted by the geriatrics faculty.

Rotation Goals and Objectives:

Patient Care

  • Learn to perform complete Geriatric Assessments, to include evaluation of nutrition, hearing loss, vision loss, fall risk, urinary incontinence, polypharmacy, depression, cognitive impairment, functional status, caregiver strain, and advanced care planning.
  • Become adept at providing specialist geriatric consultation to community physicians for a wide range of geriatric clinical questions.
  • Recognize when safety concerns require recommending that patients transition to a higher level of care, and know how to access available options.

Medical knowledge

  • Develop expertise in functional and cognitive assessment, particularly in the diagnosis and management of dementia.
  • Identify common geriatric problems that are often missed in primary care, and develop specific treatment recommendations.

Practice-based learning and improvement

  • Understand the appropriate use of screening tools, and the evidence behind them, in the assessment of geriatric patients.

Interpersonal and communication skills

  • Communicate sensitively and accurately with patients, caregivers, and families regarding the diagnosis of, natural history of, and treatment options for dementia.
  • Become expert in discussions of goals of care, including end of life care.
  • Provide succinct and expert written communication to referring physicians; provide appropriate follow-up plans.

Professionalism

  • Interact professionally with referring physicians, acting as a community resource.
  • Establish the role of the consultative geriatrician in the care of the elderly.
  • Work closely and collaboratively with the multidisciplinary team, including nursing, behavioral health, social work, and rehabilitation therapy.

Systems-based practice

  • Understand the available community resources for patients with cognitive impairment.
  • Develop knowledge of medico-legal issues relevant to geriatric medical care, including Durable Power of Attorney, Health Care Directives, and Guardianship.


Family Medicine Outpatient Clinic
Rotation length: 12 months (longitudinal)
Location: Swedish Medical Center (First Hill)
Supervising Faculty: Swedish Family Medicine faculty
Evaluation: direct observation, chart review.

Monday Tuesday Wednesday Thursday Friday
AM Family med clinic Family med clinic
PM

  • Fellows have family medicine clinic on either Tuesday or Friday mornings at Swedish Family Medicine.
  • Precepting is done by the regular faculty preceptor of the morning, who discusses and examines patients as necessary, and reviews and co-signs all chart notes. Fellows are supervised at the same level as senior residents.

Rotation Goals and Objectives:
Patient Care:

Fellows maintain and develop skills in general outpatient family medicine, including pediatrics and obstetrics.

Long-Term Care
Rotation length: 12 months (longitudinal)
Location: Caroline Kline Galland Home; Washington Care Center for Comprehensive Rehab
Supervising Faculty: Haymon, Ainsworth, Babineau
Evaluation: direct observation, chart review, written competency-based evaluation.

Practical details:

Monday Tuesday Wednesday Thursday Friday
AM
PM Kline Galland Wash Care Center

    

  • Fellows spend one half-day per week at Kline Galland, and one half-day per week at WCC. 
  • Attending supervision is provided by our geriatrics faculty.

Rotation Goals and Objectives:
Patient Care

  • Provide longitudinal care to a panel of frail, institutionalized elderly with a wide range of medical and social issues.

Medical knowledge

  • Develop expertise in the common medical conditions of the long term care setting, including infections, dementia and behavioral disturbances, pressure ulcers, falls, polypharmacy, and pain management.
  • Recognize acuity in the LTC patient; know when and how to recommend hospitalization.
  • Become expert in palliation and in providing comfort care, including care at the end of life.

Practice based learning and improvement

  • Provide supervision and teaching to resident physicians in the care of nursing home patients.

Interpersonal and communication skills

  • Communicate sensitively and accurately with patients and families regarding prognosis and appropriateness of aggressive medical care.
  • Gain expertise in running family meetings
  • Respond appropriately to the concerns of nursing staff.

Professionalism

  • Interact closely and professionally with nursing home staff to provide excellent multi-disciplinary care.

Systems-based practice

  • Understand available practice models for the provision of long-term care.
  • Supervise mid-level providers, and educate them in the practice of long term care.


Post-Acute Care
Rotation length: two month block rotation (RCT) and 12 months (longitudinal) (WCC)
Location: Washington Care Center for Comprehensive Rehab
Supervising Faculty: Haymon, Babineau, Troyer
Evaluation: direct observation, chart review, written competency-based evaluation.

Practical details:

Monday Tuesday  Wednesday  Thursday  Friday
AM MSV 
PM  MSV Wash Care Center

 

  • Fellows spend one half-day per week at WCC throughout the year, providing both post-acute and long-term care. Attending supervision is provided by our geriatrics faculty.
  • At Mt St Vincent, fellows participate in post-acute care as members of the Swedish Residential Care Team. They are supervised by the director of Swedish RCT, Dr Eric Troyer. This happens every Tuesday for two months.

Rotation Goals and Objectives:
Patient Care

  • Provide post-acute care to patients recently discharged from the hospital.
  • Learn to appropriately monitor patients without the “luxury” of daily rounding.
  • Recognize acuity and the need for hospital re-admission.

Medical knowledge

  • Gain knowledge in rehabilitation therapies (especially physical and occupational therapies) and learn their appropriate use in the post-acute-care patient.
  • Understand discharge options from the skilled nursing facility, and the criteria used to determine a safe discharge.
  • Become expert in palliation and in providing comfort care, including care at the end of life.

Practice-based learning and improvement

  • Learn which medical treatments can be appropriately provided in the sub-acute setting.
  • Assist in the supervision and teaching of resident physicians in the care of post-acute patients.

Interpersonal and communication skills

  • Communicate sensitively and accurately with patients and families regarding prognosis and treatment options.
  • Gain expertise in running family meetings
  • Respond appropriately to the concerns of nursing staff.

Professionalism

  • Interact closely and professionally with skilled nursing facility care team to provide excellent multi-disciplinary care.

Systems-based practice

  • Understand the growing role of post-acute care in the health care system, and new models of care.
  • Develop appropriate systems for safe patient hand-offs between the hospital, the SNF, and the community.

Geropsychiatry@Elderplace
Rotation length: 1 month
Location: Providence ElderPlace
Supervising Faculty: Samuel Appel, MD
Evaluation: written competency-based evaluation.

Practical Details:

Monday  Tuesday  Wednesday Thursday  Friday
AM Geropsych
PM Geropsych

  • Fellows join Dr Appel on Tuesdays at PEP for mental health evaluation of complex geriatrics outpatients.

Rotation Goals and Objectives:

Patient Care

  • Become proficient in the inpatient and outpatient management of common psychiatric problems of the elderly, including dementia, depression and delirium.
  • Learn the appropriate criteria for inpatient geropsychiatry admission.

Medical knowledge

  • Develop expertise in the diagnostic criteria for dementia; understand the most common types, and how to differentiate them.
  • Understand the available nonpharmacologic and pharmacologic treatments for dementia and depression, and the evidence behind them.
  • Recognize the appropriate use and indications for neuropsychological testing.

Practice-based learning and improvement

  • Recognize the criteria for referral to a geropsychiatry clinic.

Interpersonal and communication skills

  • Work within the multidisciplinary care team (therapy, social work, nursing, and neuropsych), and communicate professionally with the care team.

Systems-based practice

  • Understand the role of the attending geropsychiatrist in the health care system, and how to use him/her appropriately as a consultant.
  • Gain knowledge of appropriate long-term placement for patients with dementia within our community.


Wound Clinic
Rotation length: 1 month
Location: Swedish Wound Care Center – Cherry Hill
Supervising Faculty: Cynthia Campbell, MD
Evaluation: written competency-based evaluation.

Practical Details:

Monday  Tuesday  Wednesday  Thursday Friday
AM
PM Wound clinic Wound clinic

Rotation Goals and Objectives:

Patient Care

  • Assist the multidisciplinary team in outpatient management of complex non-healing wounds.

Medical knowledge

  • Learn basic principles of wound care.
  • Develop familiarity with common dressings and wound care materials.
  • Understand the utility of and indication for negative pressure wound therapy (“wound vac”).

Practice-based learning and improvement

  • Develop knowledge and skills to allow the practice of wound care in the fellow’s own long term and subacute patient panel.

Professionalism

  • Interact professionally with the multidisciplinary wound care team.


Systems-based practice

  • Understand the role of the outpatient wound clinic in the health care system


Acute Rehabilitation
Rotation length: 1 month
Location: Swedish Medical Center – Cherry Hill
Supervising Faculty: David R Clawson, MD
Evaluation: written competency-based evaluation.

Practical Details:

Monday Tuesday Wednesday Thursday Friday
AM  Rehab Rehab Rehab Rehab
PM

  • Fellows participate in the care of patients on the Acute Rehabilitation Unit at Swedish, under the direction of the medical director of the ARU.
  • Fellows also attend clinic with the staff physiatrists.

Rotation Goals and Objectives:
Patient Care

  • Admit and follow patients admitted to the Acute Rehabilitation service, under the supervision of the attending physiatrist.
  • Participate in outpatient clinic with attending physiatrists.
  • Observe the assessments performed by physical, occupational, and speech therapists.

Medical knowledge

  • Increase knowledge of common conditions requiring rehabilitation: cerebrovascular disease, neuromuscular disorders, multiple sclerosis, and spinal cord injury.
  • Recognize the natural history and treatment course of patients requiring rehab after stroke.

Practice-based learning and improvement

  • Learn the criteria for referral to acute rehabilitation.
  • Recognize the important role of physical, occupational, and speech therapists in rehabilitation.


Interpersonal and communication skills

  • Communicate sensitively and professionally with patients, families, and staff.

Professionalism

  • Interact professionally with the multidisciplinary care team.

Systems-based practice

  • Understand the principles of discharge planning and determining an appropriate level of care.
  • Recognize the distinction between Acute and Sub-Acute Rehabilitation


Providence Hospice
Rotation length: 1 month
Location: Providence Hospice
Supervising Faculty: Wayne McCormick MD
Evaluation: written competency-based evaluation.

Practical Details:

Monday Tuesday Wednesday Thursday  Friday
AM Hospice Hospice
PM

 

Rotation Goals and Objectives:
Patient Care

  • Improve skills in providing home-based palliative and end-of-life care, by working directly with hospice physicians, nurses and other providers.

Professionalism

  • Interact professionally with the leadership of the hospice, with a view to building ongoing relationships between the Swedish Geriatrics team and Prov hospice.

Systems-based practice

  • Learn the basics of funding, certification, and documentation requirements for home health and hospice services, with a view to bringing expertise to the fellow’s own practice.
  • Observe the function of the multidisciplinary hospice and home-health care team.


Medical Director
Rotation length: 1 month
Location: Swedish Medical Center – First Hill
Supervising Faculty: Eric Troyer, MD
Evaluation: written competency-based evaluation.

Practical Details:

Monday  Tuesday Wednesday Thursday Friday
AM Medical
Director
Medical
Director
PM Medical
Director 
Medical
Director

Rotation Goals and Objectives:
Professionalism

  • Observe the role and duties of a medical director of a long term care facility.
  • Participate in meetings with the Swedish Residential Care Team.

Systems-based practice

  • Understand the role and duties of a Certified Medical Director in the context of the healthcare system.



Academic Project
Rotation length: 1 month + longitudinal
Location: Swedish Medical Center – First Hill
Supervising Faculty: Carroll Haymon, M.D.
Evaluation: review of final project by faculty, approval for publication or presentation.

Practical Details:

Monday Tuesday Wednesday Thursday Friday
AM Academic Projects Academic Projects Academic Projects Academic Projects
PM

   

Rotation Goals and Objectives:
Goal:
Produce a piece of academic writing, or an academic presentation, or both.

Medical knowledge

  • Obtain expertise in an arena of geriatric medicine.

Professionalism

  • Develop skills in critical review of the medical literature.
  • Improve presentation skills, including use of audio-visual aids.
  • Work with faculty and editors to produce a paper for publication.

Neurology – Movement Disorders
Rotation length: 1 month
Location: Swedish Neuroscience Institute – Cherry Hill
Supervising Faculty: Jennifer Witt, MD
Evaluation: written competency-based evaluation

Practical details:

Monday Tuesday Wednesday Thursday Friday
AM
PM Neurology Neurology


Rotation Goals and Objectives:
Patient Care

  • Become proficient at the diagnosis of common movement disorders
  • Learn about available treatment options for movement disorders

Medical knowledge

  • Understand the signs and symptoms of Parkinson’s disease
  • Master a directed neurologic exam for movement disorders.
  • Develop expertise in the initial prescribing of dopaminergic medications.


Practice-based learning and improvement

  • Learn the prevalence of common movement disorders in the geriatric population.
  • Recognize the criteria for referral to a movement disorders clinic.

Systems-based practice

  • Understand the role of a specialized movement disorders clinic within the medical community.


Palliative Care Consult Team
Rotation length: 1 month
Location: Swedish Medical Center – First Hill
Supervising Faculty: Janice Connolly, M.D.
Evaluation: written competency-based evaluation.

Practical Details:

Monday Tuesday Wednesday Thursday Friday
AM Pall Care Pall Care Pall Care Pall Care
PM Pall Care Pall Care

Rotation Goals and Objectives:
Patient Care

  • Participate in consultations and care conferences with the Swedish Palliative Care team.

Medical knowledge

  • Acquire knowledge and tools for end of life prognostication.
  • Develop skills in symptom management for palliation.

Practice-based learning and improvement

  • Learn how an inpatient palliative care team can contribute to the care of a hospitalized patient.
  • Recognize patients appropriate for referral to Palliative Care.

Interpersonal and communication skills

  • Communicate sensitively and professionally with patients, families, and the interdisciplinary care team.

Systems-based practice

  • Recognize the essential role of spiritual care, behavioral health, and social work in the care of the dying patient.

Home Visits
Rotation length: 1 month + longitudinal
Location: various adult family homes, assisted living facilities, and patient homes
Supervising Faculty: Carroll Haymon, M.D. and Kristin Anderson, M.D.
Evaluation: written competency-based evaluation.

Practical Details:

Monday Tuesday Wednesday Thursday Friday
AM

Home Visits

Home Visits

PM


Rotation Goals and Objectives:

Patient Care

  • Provide continuity care to a panel of frail, home-bound elderly.
  • Manage acute and chronic conditions in private homes, assisted living facilities, and adult family homes.

Medical knowledge

  • Improve history and physical exam skills in a setting where diagnostic testing is not readily available.
  • Recognize when patient condition should prompt transport to a higher-acuity setting.

Practice-based learning and improvement

  • Learn appropriate documentation and billing practices for home-based care.

Interpersonal and communication skills

  • Develop effective communication systems with caregivers, nurses, and family members for home-bound patients.
  • Communicate sensitively with patients and family members regarding advanced directives and goals of care.

Systems-based practice

  • Recognize the potential for home-based practice within the larger health-care system.