Download Indiana University Combined Geriatric/Oncology

Indiana University Combined
Geriatric/Oncology/Hematology Fellowship
Curriculum
July 2009 through June 2010
Overall Learning Objectives
At the end of training (36 months for combined Medical Oncology and Geriatric Medicine or
combined Hematology and Geriatric Medicine; 48 months for Hematology, Medical Oncology,
and Geriatric Medicine), the fellow will be able to do the following:
1) Provide competent, compassionate care to adults age 65 and over across the continuum
of care while also appropriately caring for their malignancy or hematological disorder
2) Evaluate and treat older adults who have chronic illnesses, including geriatric
syndromes, with the overarching goal of preserving function and quality of life
3) Demonstrate effective communication with patients and families, interacting with them in
a respectful manner
4) Interact effectively and respectfully with other disciplines who provide care to older
adults, especially Geriatric interdisciplinary teams
5) Teach medical students, residents and other professionals key concepts and principles
of geriatric medicine
6) Demonstrate scholarly activity in the field of Geriatric Medicine and Hematology or
Oncology
American Board of Internal Medicine Policy for Combined Training
Fellows enrolled in combined Geriatric Medicine and either Hematology or Medical Oncology
must complete the following to be considered board-eligible in both subspecialties:
 Eleven months of block clinical training in Hematology or Medical Oncology
 Seven months of block clinical training in Geriatric Medicine
 One month of end-of-life block experience counting for both disciplines
 ½ day per week for 22 months of continuity clinic in either Hematology or Medical
Oncology
 ½ day per week for 33 months of continuity clinic in Geriatric Medicine
 Fourteen months of combined training in research
 Three months of vacation or other leave
Fellows enrolled in combined Geriatric Medicine, Hematology and Medical Oncology must
complete the following to be considered board-eligible in all three subspecialties:
 Eleven months of block clinical training in Medical Oncology/Hematological malignancy
 Six months of block clinical training in non-malignant Hematology
 Seven months of block clinical training in Geriatric Medicine
 One month of end-of-life block experience counting for all disciplines
 ½ day per week for 33 months of continuity clinic in hematology/medical oncology
 ½ day per week for 44 months of continuity clinic in Geriatric Medicine
 Nineteen months of combined training in research
 Four months of vacation or other leave
Indiana University Hospital Acute Care for Elders Rotation
Learning Objectives
At the end of this rotation, the fellow will be able to do the following:
1)
Evaluate older adults and detect common geriatric syndromes (dementia, depression,
deconditioning, pressure sores, incontinence, sleep disorders, failure to
thrive/malnutrition, osteoporosis, elder mistreatment, and drug-induced illness);
2)
Describe iatrogenic complications with strategies to prevent them (including
deconditioning, adverse drug reactions, polypharmacy, malnutrition, delirium, and
pressure ulcers);
3)
Describe common atypical presentations of disease in older patients;
4)
Describe the presentation, differential diagnosis, etiology, work up and common
management strategies for older adults who have delirium;
5)
List community resources that would be helpful for older adults discharged from the
inpatient setting;
6)
Describe patients who are appropriate for subacute rehabilitation;
7)
Describe patients who are appropriate for institutional long term care placement and
describe community-based alternatives to institutional long term care;
8)
Describe patients who are appropriate for hospice care;
9)
Describe key principles of pain management in older inpatients;
10) Demonstrate respect for and understanding of the role of each interdisciplinary team
member;
11) Assess older adults’ cognitive, psychiatric, and psychosocial status, gaining
awareness about their decision-making capacity;
12) Participate in resident and medical student teaching.
Background
ACE is a model combining geriatric assessment and improvement of quality using patientcentered care, interdisciplinary team rounds and planning for home, and medical care review by
the ACE team.
Quality improvement
Randomized clinical trials in general medical patients have shown ACE to improve functional
status, lower risk of nursing home placement, and improve both patient and provider satisfaction
with care without an increase in costs of patient care to the healthcare system. In a study of
older adults with cancer admitted to an ACE unit, cognitive impairment (dementia and/or
delirium), depression, weight loss, and use of high-risk medications were commonly found.
Fellow Duties and Responsibilities
ACE at IU focuses on older adult patients on the hematology, oncology, and hospitalist services,
though consults may come from any service in the hospital as long as the patient is age 65 or
older.
1. The faculty geriatrician is notified when there is an ACE consult. As instructed by the
faculty, the fellow should review the patient’s current medical chart for pertinent
information and also the electronic medical record for further history. The fellow should
then see the patient, verify the history (with a family member/caregiver if necessary),
assess ADLs and IADLs, perform geriatric review of systems, and perform a focused
physical exam. The fellow should then formulate a problem list and a plan for
addressing each issue. Fellows should use the ACE form as a worksheet for recording
this data.
2. After seeing the patient, the fellow should then page the faculty geriatrician and meet her
for staffing rounds. On a case by case basis, these rounds may include conferring with
the patient’s primary medical team, social worker, case manager, pharmacist, nurse, or
physical therapist to determine how to best meet the patient’s needs.
3. After staffing rounds, the fellow should dictate the consultation note into the Clarian
Health Dictation system or type it into Cerner for documentation in the electronic medical
record.
4. Fellows should also see any patients that ACE is following, write a progress note that
focuses on the geriatric issues, and staff with the faculty geriatrician during rounds.
5. When residents or students are assigned to ACE at IU as part of their Geriatrics rotation,
fellows will assist the faculty geriatrician in teaching the learners about geriatric
assessment, geriatric syndromes, and the ACE concept of care.
Educational Techniques
The fellow will work closely with the geriatrician as well as the interdisciplinary team. The
faculty will provide one-on-one teaching and supervision of case-based learning. The fellow will
participate in teaching rotating residents in specific geriatrics topics.
Billing
The faculty geriatrician bills for all visits, both new and follow-up. To help prepare the fellow for
his/her career after fellowship, the faculty will provide education on the use of consultation
codes, subsequent visit codes, and diagnoses’ ICD-9 codes during the rotation.
Assigned Readings
Schubert CC, Gross C, Hurria A. Functional assessment of the older patient with cancer.
Oncology 2008. 22:916-922.
Flood KL, Carroll MB, Le CV, Ball L, Esker DA, Carr DB. Geriatric syndromes in elderly patients
admitted to an oncology-Acute Care for Elders unit. Journal of Clinical Oncology 2006.
24: 2298-2303.
Extermann M and Hurria A. Comprehensive geriatric assessment for older patients with cancer.
Journal of Clinical Oncology 2007. 25: 1824-1831.
Terret C, Zulian GB, Naiem A, Albrand G. Multidisciplinary approach to the geriatric oncology
patient. Journal of Clinical Oncology 2007. 25: 1876-1881.
Evaluation
Faculty evaluation
Key Competencies This Rotation
Patient care, Medical knowledge, Systems based practice, Interpersonal and Communication
Skills, Professionalism
Geriatric Psychiatry (VA)
Learning Objectives
At the end of this rotation, the fellow will be able to do the following:
1) Conduct a basic geriatric psychiatric assessment;
2) Evaluate and manage common geriatric psychiatric syndromes, including depression,
psychosis, anxiety, and behavioral problems associated with dementia;
3) Prescribe and manage psychotropic medications, including antipsychotics,
antidepressants, and anxiolytics appropriately and safely in an outpatient setting;
4) Describe common side effects of psychiatric medications in the elderly;
5) Describe the basic differential diagnosis of psychosis in the elderly;
6) Describe common issues in the treatment of substance abuse in older adults;
7) Describe the impact and management of personality disorders, somatoform disorders,
and mental retardation in the elderly;
8) Describe the basic assessment for decision making capacity and relate that to
competency;
9) List community based resources for older patients with psychiatric and/or substance
abuse problems
Education Techniques
The fellow will work in collaboration with the Geriatric Psychiatrist in clinic at the VA. There will
be individual didactic sessions and case-based learning with direct, one-on-one teaching and
feedback.
Assigned Readings
Hazzard’s Geriatric Medicine & Gerontology, 6th ed, Jeffrey Halter, Chapters 70, 71, 72, 73.
Evaluation
 Faculty evaluation
Key Competencies This Rotation
 Patient care
 Medical knowledge
 Systems based practice
 Interpersonal and Communication Skills
 Professionalism
Palliative Care Rotation
Learning Objectives
At the end of this rotation, the fellow will be able to do the following:
1) Competently share bad news with patients, being aware of cultural, personality, and
coping strategies of the individual patient;
2) Discuss the importance of establishing goals of care in patients near the end of life;
3) Facilitate family meetings, assist patient and their families in moving toward consensus
and acceptance of the grieving process;
4) Function effectively as a member of a palliative care interdisciplinary team;
5) Manage pain in palliative care patients, including identifying complex pain syndromes,
dosing opioids, listing advantages and disadvantages of specific opioids, and using
other pharmacologic agents;
6) Manage side effects of opioids, including constipation, nausea, pruritis, fatigue, and
myoclonus;
7) Describe the management of delirium in end of life care;
8) Discuss common psychological syndromes and their management in end of life care,
including depression and anxiety;
9) Describe the Medicare hospice benefit, different models of end of life care, and
challenges in the structure and funding of end of life care in the US;
10) Describe the management of common GI side effects in end of life care, including
nausea and vomiting, partial or complete bowel obstruction, and constipation;
11) Discuss the management of dyspnea in end of life care;
12) Recognize a patient who is close to death, describe, and manage common symptoms in
the last 48 hours;
13) Discuss the physician’s role in addressing spiritual concerns of patients near the end of
life;
14) Discuss appropriate and inappropriate approaches to tube feeding and hydration in end
of life care;
15) Recognize the spectrum of options available for end of life care;
16) Discuss common ethical dilemmas and their management in end of life care.
Education Techniques
 Case-based Learning – The fellow will work collaboratively with the interdisciplinary
palliative care team seeing patients in the Wishard and Visiting Nurse Health Systems.
 Individual Didactics (Attending will discuss patients with the fellow and provide direct,
one-one-one teaching and feedback.)
 Palliative care conference.
Assigned Readings
Hazzard’s Geriatric Medicine & Gerontology, 6th ed, Jeffrey Halter, Ch. 30, Pain Management,
Ch. 31, Palliative Care, Ch. 34, Ethical Issues.
Evaluations
 Faculty evaluation
Key Competencies This Rotation
 Patient care
 Medical knowledge
 Interpersonal and communication skills
 Professionalism
Physical Medicine and Rehabilitation
Learning Objectives
At the end of this rotation, the fellow will be able to do the following:
1) List the criteria for admission and discharge to acute rehab;
2) Describe the indications and appropriate usage of common assistive devices,
including walkers, front wheeled walkers, canes, and wheelchairs;
3) Describe how to use a cane when ascending and descending stairs;
4) Incorporate exercise strategies into rehabilitation plans for older adults;
5) Describe processes associated with amputation rehabilitation, include indications
and contraindications to prosthetics, fittings, and common problems associated with
prosthetics;
6) Demonstrate respect for the expertise of PT, OT, and speech therapy in caring for
frail older adults;
7) Describe at least three common post-CVA syndromes, including language disorders,
aphasia, dysphasia, and pain syndromes;
8) Describe the use of common rehabilitation assessment instruments including the
Barthel Index;
9) Incorporate exercise strategies into rehabilitation plans for older adults;
10) Become knowledgeable in energy-saving techniques to address fatigue, particularly
in older adults with cancer;
Educational Techniques
The fellow will evaluate patients in collaboration with faculty and other members of the
rehabilitation staff.
Assigned Readings
Hazzards’ Geriatric Medicine & Gerontology, 6th ed, William Hazzard, Ch. 29, Rehabilitation.
Evaluations
 Faculty Evaluation
Key Competencies This Rotation
 Patient care
 Medical knowledge
 Systems based practice
 Professionalism
Subspecialty Clinic Rotation (Continence Center for Women, Neurology,
Dermatology, Healthy Aging Brain Center [HABC], Physical Therapy Wound
Management, Podiatry, Additional Electives)
Learning Objectives
The fellow will rotate to a variety of outpatient clinics during the rotation. Objectives for each
site are listed below. In each clinical site, fellows are expected to participate actively in direct
patient care under the supervision of and as direct by their faculty attending.
Continence Center for Women:
1)
Identify types of urinary incontinence and management strategies;
2)
Recognize the role of urology, gynecology and nurse practitioners in the treatment of
urinary incontinence;
3)
Establish when referral for management of urinary incontinence is appropriate;
Neurology:
1) Describe the clinical features of early and late Parkinson’s disease;
2) List other disorders that may mimic Parkinson’s disease;
3) Describe management strategies in early and late Parkinson’s disease and other
movement disorders;
Dermatology:
1) Identify common skin disorders in older adults;
2) Differentiate benign from malignant skin disorders in older adults;
3) Recognize when to refer an older adult with a skin disorder to dermatology.
Healthy Aging Brain Center (HABC)
1) Distinguish the pathophysiology and natural history of different types of dementias;
2) Describe the diagnostic criteria for different types of dementia;
3) Order appropriate testing and interpret results when evaluating a patient with suspected
dementia, including direct interpretation of neuropsychological testing results and of
brain imaging studies;
4) Explain appropriate pharmacologic treatment options for cognitive, behavioral, and
psychological symptoms of dementia;
5) Discuss the definition and implications of diagnosis of Mild Cognitive Impairment;
6) Exhibit basic familiarity with the management of non-dementia illnesses in the patient
with dementia;
7) Work effectively within a multidisciplinary team, making appropriate use of the expertise
of non-physician members of the team;
Physical Therapy Wound Management
1) Understand sterile vs. clean technique;
2) Recall all components of a complete wound assessment;
3) Identifiy viable vs. non-viable tissue;
4) Recall commonly used wound related terminology and descriptive terms;
5) Understand the most current pressure ulcer staging system as defined by the National
Pressure Ulcer Advisory Panel;
6) Recognize different commonly used wound care products and recall the appropriate
application of these products;
7) Recall available wound treatment modalities for the management of acute and chronic
wounds (i.e. pulsed lavage, low-frequency ultrasound, High-Voltage Pulsed Current,
Negative Pressure Wound Therapy);
8) Understand why “Normal Saline Wet to Dry” dressings are no longer considered
standard of care;
9) Recognize the importance of edema control in wound management and recall the
appropriate amount of compression, given patient condition, when prescribing
compression stockings;
10) Recognize when it is appropriate to refer a patient with a wound to Physical Therapy
Wound Management;
Podiatry Clinic
1) Identify soft tissue and bony foot problems and their conservative and surgical treatment
options;
2) Evaluate the diabetic foot with and without neuropathy;
3) Describe treatment options for diabetic foot ulcers;
4) Evaluate the vascularly compromised foot and when to refer for surgical intervention;
5) Perform routine foot care;
6) Evaluate and treat foot injuries and know when to refer and who to refer them to;
Bone Clinic
1) Understand the pathogenesis of common disorders of the skeleton and of mineral
homeostasis in older adults;
2) Understand the biochemical and imaging tests needed to diagnose and manage
common disorders of the skeleton and of mineral homeostasis in older adults;
3) Understand the current therapies available to manage common disorders of the skeleton
and of mineral homeostasis in older adults;
General Subspecialties
NOTE – The fellow may elect a clinic in addition to those above. He/she must have specific
written goals and objectives for the clinic experience.
Educational Techniques
Case-based Learning will allow the fellow to work in collaboration with subspecialty attendings
who deliver care to older adults.
Assigned Readings
Hazzard’s Geriatric Medicine & Gerontology, 6th ed, Jeffrey Halter, Part III “Geriatric
Syndromes”, Chapters 51-60.
Evaluation
 Faculty evaluation
Key Competencies This Rotation
 Patient care
 Medical knowledge
 Professionalism
 Systems base practice
Longitudinal Rotations
Geriatric Medicine Continuity Clinic Rotation (1/2 day per week. 33 months for
Geriatric/Hematology or Geriatric/Oncology Fellows and 44 months for
Geriatric/Hematology/Oncology Fellows)
Learning Objectives
By the end of their clinical fellowship training, each combined geriatric/oncology-hematology
fellow will have achieved the following objectives:
1)
2)
3)
4)
5)
6)
7)
Identify the indications for comprehensive geriatric assessment in older adults with
malignancy and when referral to a geriatrician from the oncologist/hematologist is
appropriate;
Identify the indications for involvement of social work, physical therapy, occupational
therapy, speech therapy, dieticians, psychiatry, and others in the management of older
adults with malignancy;
Demonstrate respect for the role of different disciplines in the outpatient care of older
adults;
Recognize the indications for admission to the hospital of an older adult with
malignancy;
Use community resources to provide patient and caregiver resources;
Recognize when institutionalization is necessary for the benefit and safety of the
patient;
Perform history and physical examinations on older adults with malignancy and with
multiple illnesses and disabilities, with careful attention to the special adjustments that
need to be made, identifying all relevant problems, and outlining management plans;
8)
9)
10)
11)
12)
Communicate effectively with the referring physician, recognizing the optimum way to
deliver recommendations;
Demonstrate effective participation and leadership in interdisciplinary team care;
Recognize, evaluate, and manage patients with geriatric syndromes (dementia,
depression, urinary incontinence, social isolation and psychosocial dysfunction,
polypharmacy, falls and decline in functional ability, constipation, osteoporosis,
malnutrition, sensory, vision and hearing impairment);
Define the indications for various types of long-term care such as skilled nursing,
residential care and their relative costs;
Recognize when referral to additional subspecialists is appropriate.
Background
Due to the effects of aging and accumulation of chronic diseases over time, a population of
older adults will exhibit great variability in their degree of health, function, and frailty at the time
of diagnosis with malignancy. Older adults have unique and important medical and
psychosocial needs that may not be easily detected or addressed in the typical
hematology/oncology practice. Unfortunately, if these issues are not addressed, the patient is
at higher risk for functional decline and lack of tolerance of treatment for malignancy. To assist
in the care of older adults with malignancy, comprehensive geriatric assessments are performed
where geriatric syndromes are identified. The geriatric interdisciplinary team then assists with
implementation of the care plan to manage the syndromes while the patient undergoes
treatment of the malignancy.
Quality
Interdisciplinary team care of older adults has been shown to improve health outcomes and
quality of care for older adults while increasing patient, caregiver, and provider satisfaction.
Duties and Responsibilities
The combined geriatric-oncology/hematology fellow will be assigned a half-day session each
week in the consultation clinic. The fellow will work with the interdisciplinary team to evaluate
new consults and also to see patients in follow-up at the faculty’s discretion. The fellow’s
responsibilities during the session include each of the following:
1. Evaluate each patient independently and participate in interdisciplinary team rounds to
formulate a management plan. This evaluation should address not only medical issues
but also include assessment of functional status and screening for geriatric syndromes.
2. Complete the physician section of the new patient assessment form or dictate a
progress note for patients being seen in follow-up and discuss the case with the
interdisciplinary team members.
3. Staff each patient with the faculty geriatrician present in the clinic.
4. Write any orders (medications, home health orders, etc.) and facilitate implementation of
the care plan as advised by the staff geriatrician.
5. Dictate the comprehensive geriatric assessment on any new consults seen in clinic that
day. After the dictation is typed, the fellow should proofread and sign the dictation in
Fastscribe and then notify the faculty that the dictation is complete and ready for final
signature.
Billing
After the fellow staffs with the faculty geriatrician, the faculty will complete a bill for submission
to the billing department. Throughout the year during the clinic, the faculty will teach the fellow
about documentation, visit levels, ICD-9 codes, etc to prepare the fellow for his/her professional
career.
Educational Techniques
Case-based Learning
Supervised consultative medical care delivery
Individual Didactics (Preceptors will discuss patients with the fellows and provide direct, oneone-one teaching and feedback.)
Fellows’ Core Conference
Assigned Readings
Principles of Geriatric Medicine & Gerontology, 5th ed, William Hazzard, Part II “Principles of
Geriatric Care, pp 95-144.
Schubert CC, Gross C, Hurria A. Functional assessment of the older patient with cancer.
Oncology 2008. 22:916-922.
Extermann M and Hurria A. Comprehensive geriatric assessment for older patients with cancer.
Journal of Clinical Oncology 2007. 25: 1824-1831.
Terret C, Zulian GB, Naiem A, Albrand G. Multidisciplinary approach to the geriatric oncology
patient. Journal of Clinical Oncology 2007. 25: 1876-1881.
Evaluation
Faculty Evaluation biannually
Key Competencies for this Rotation: Patient care, Medical knowledge, Systems based practice,
Professionalism