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CURRICULUM GUIDELINES FOR GERIATRICS
TRAINING IN INTERNAL MEDICINE
RESIDENCY PROGRAMS

The AGS Education Committee

*Last Updated January 22, 2004*

OVERVIEW

The internist of the future will be providing much of the medical care for older persons. Currently persons over 65, who are 13% of the population, account for 40% of visits to internists and this number is rising (1). A physician who cares for elderly patients must use diagnostic and therapeutic interventions appropriately while at the same time recognizing the variability in the health status, values and wishes of older persons. He or she must understand normal and abnormal aging, atypical presentation of illness, common geriatric syndromes and differences in the natural history and preferred management of specific diseases in older adults. In addition, the physician must have the necessary skills to manage patients in a wide array of health care settings, with acute and chronic conditions. Finally, the internist must be able to collaborate with other health care providers to achieve high quality health care for the older patient.

Training programs for internists should address the many age-related issues that are essential to good medical practice. Many national organizations, including the Institute of Medicine, have endorsed the need for enhanced residency training in geriatrics (2). This need has been recognized by the Association of Professors of Medicine: " . . . residency programs must teach mastery of the competencies of geriatric medicine. Chairs of departments of internal medicine must lead the way to make geriatric medicine a centerpiece of internal medicine training (3)." Similarly the American College of Physicians has strongly supported reorganization of the residency curriculum and changes in organizational affiliations to facilitate training in geriatrics (4).

Since 1989, the Residency Review Committee has listed specific requirement with regard to geriatric education in the medical residency. Current requirements are (5):

"Residents must have formal instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical experience should be directed by an ABMS - certified geriatrician. These experiences may occur at one or more specifically designated geriatric inpatient units, geriatric consultation services, long-term care facilities, geriatric ambulatory clinics, and/or in home care settings."

GUIDELINES

The purpose of these guidelines is to outline the attitudes, knowledge, and skills required for successful care of older people by internists. These guidelines can help program administrators to survey the adequacy of their current curriculum training objectives and educational experiences, and serve as a guide for programs that are developing such training. Medical residency training programs already prepare house officers to manage a wide range of medical conditions. The guidelines emphasize areas that need additional consideration when caring for older patients.

Attitudes

Specific attitudes are important for the internist who cares for older patients.

1. The training program must encourage respect for older persons and their wishes for autonomy. The training experience should promote compassionate care of the elderly patient. The internist should believe in the utility of high-quality medical care, including use of sophisticated and expensive technologies in appropriate circumstances, but must also be aware of the limits of medical intervention and of the physician's obligation to provide appropriate and humane care to the terminally ill.
   
   
2. The resident needs to appreciate the striking heterogeneity found among older persons with respect to physiologic function, health status, belief systems, values, and personal preferences.
   
   
3. The resident needs to be able to negotiate goals of care with the patient and family and take into consideration both the individual's values and preferences as well as the physician's professional judgment.
   
   
4. The resident must be willing to seek out and consider the observations and opinions of family and other concerned individuals in evaluating an older patient and bear in mind that the primary obligation is always to the patient.
   
   
5. The training experience should demonstrate the function and importance of a multidisciplinary approach to caring for older persons, including appropriate respect for other health professionals and paraprofessionals and their roles in the provision of services.
   
   
6. The resident must understand that maintenance of function and quality of life are more often goals of care than cures of disease.

Knowledge

The internal medicine resident should be able to demonstrate understanding of the following subjects:

1. Normal human aging, age-related changes in tissues, organs and physiologic function, and homeostasis.
   
   
2. Age-related changes in epidemiology of diseases, presentation of illnesses, response to therapy, pharmacokinetics and pharmacodynamics.
   
   
3. The adjustments necessary in history taking and physical examination.
   
   
4. Principles of biomedical ethics, including an understanding of decision-making capacity, competence, and autonomy.
   
   
5. Principles of fitness, exercise and rehabilitation as applied to older people.
   
   
6. The elements and conduct of Comprehensive Geriatric Assessment.
   
   
7. Nutritional needs of older persons, including recognition and treatment of malnutrition.
   
   
8. Health promotion and disease prevention strategies.
   
   
9. Risks and benefits of surgical interventions, pre-operative evaluations and post-operative care.
   
   
10. Organization and financing of health care for older persons.
    
    
11. Care at the end-of-life, including management of pain, dyspnea, and other symptoms.
    
    
12. Detections, evaluation and management of the following geriatric syndromes.
    
    
    1. Cognitive impairment/dementia
       
       
    2. Depression
       
       
    3. Incontinence (urinary and fecal)
       
       
    4. Gait and balance disorders
       
       
    5. Immobility
       
       
    6. Pressure ulcers
       
       
    7. Polypharmacy
       
       
    8. Sensory impairment
       
       
    9. Pain
       
       
    10. Falls
        
        
    11. Delirium
        
        
13. The difference in incidence, natural history, presentation management, and outcomes of medical problems when they occur in elderly persons (see Appendix A).

Skills

Medical Residents should acquire the following skills:

1. The resident should be able to perform screening assessments of basic and Instrumental Activities of Daily Living (ADL and IADL), cognitive function, and gait and mobility, as well as participate with the team in formulating an interdisciplinary care plan.
   
   
2. The ability to facilitate medical decision-making for elderly patients, incorporating medical assessment as well as patient values and preferences. The resident should display respect for elderly patients and effective communication skills.
   
   
3. The ability to diagnose and manage acute and chronic multiple illnesses in elderly patients.
   
   
4. The ability to coordinate care of patients between ambulatory settings and long-term care, including home care, nursing homes, and hospice care.
   
   
5. The ability to effectively conduct discussions regarding goals of care and end-of-life care.

Settings

Since health care for older patients is provided in a wide range of settings, the resident should receive training experiences in a variety of sites. Training experiences can be arranged with local visiting nurse organizations, hospice programs, day hospitals, home care programs, or rehabilitation facilities. Nursing homes provide an important location for educational activities. Ambulatory care settings should be included in the training program as well. Medicine residents should have an opportunity to function as a member of a geriatric consultation service or in-patient geriatric assessment unit. All of these settings lend themselves to interdisciplinary work and can provide the opportunity for residents to both observe and function in the role of team coordinator.

Resources

Critical resources in resident education in geriatric care include: 1) allocation of resident time, 2) availability of interested and trained faculty, and 3) access to populations of elderly patients. The current training curriculum for medical house officers is very demanding; successful training activity requires planning and collaboration with other educators. Geriatric education can be integrated into the existing curriculum with minimal disruption of other experiences. The training experience can be taken in a "block," such as during a one-month rotation that includes exposure to multiple geriatric care delivery settings. Alternatively, regularly scheduled clinical experiences in an outpatient and nursing home setting can consist of one-half or one day per week over an extended period of time. Some geriatric learning objectives can also be accomplished through the use of lectures and discussions which are incorporated into the existing conference schedule for the house officers. No single approach has been shown to be superior.

Having appropriately trained and interested faculty is essential. Many programs have experienced, fellowship-trained geriatricians who can serve as useful resources. Where geriatricians are not available, interested internists with additional training in geriatric care can develop the training components. Many geriatrics centers of excellence offer special faculty training experiences.

In many programs, geriatrics training experiences can be developed jointly with family medicine, palliative care, psychiatry, neurology and rehabilitation medicine.

Curriculum recommendations (6-9) and educational materials for teaching are available (10-11) for programs.

Barriers and Their Solutions

A number of barriers to program development exist and must be considered. Some are generic and affect most programs, while others are institution specific.

1. Resident time. Residents are busy; experiences must be high quality to merit the resident's time. In some programs, a full month's rotation may be possible. In others, the training can be combined with an ambulatory rotation experience.
   
   
2. Reimbursement. Reimbursement for geriatric clinical care by many payer sources is often inadequate, given the time requirements and complexity of management. Residency programs can develop contracts for providing care in nursing homes, rehabilitation or chronic care hospitals. Some of these sites can provide salary support for residents and/or faculty in return for having high-quality care and teaching in their facility.
   
   
3. Resident/faculty attitudes. Many physicians continue to believe that management of a geriatric patient is no different from that of other internal medicine patients. Further, many believe that medical efforts are not well spent in the care of the elderly since cure is rare. These attitudes are a critical barrier that must be resolved before trainees can believe in the utility of this training.
   
   Attention to other goals, such as improved function or preserved independence, may make geriatric care more fulfilling. Well-established geriatric programs have experienced sufficient success to demonstrate their clinical utility to trainees.
   
   
4. Administrative resistance. Development of special geriatric training may be seen as competitive with other administrative units. Geriatric training should be integrative and should enhance the care of elderly patients throughout the institution.
   
   These barriers are not insurmountable. High-quality programs can be developed within these constraints using creativity, available resources, and a commitment to preparing internists to better care for aged patients.
   
   Note: Developed by the AGS Education Committee and approved May 1990 by the AGS Board of Directors. Reviewed 1996 and 2003. The American Geriatrics Society, The Empire State Building, 350 Fifth Avenue, Suite 801, New York, NY 10118, 212-308-1414, Fax: 212-832-8646, info.amger@americangeriatrics.org.

Bibliography

1. International Longevity Center paper. Committee members RN Butler, J Estrine, M Honig, D Lifsey, C Muller, N O'Brien. A national crisis: the need for geriatric faculty training and development. Toward functional independence in old age. 2002.
   
   
2. Committee on Leadership for Academic Geriatric medicine. Report of the Institute of Medicine: academic geriatrics for the year 2000. J Am Geriatr Soc 1987;35:773-791.
   
   
3. Association of Professors of Medicine. Supply, demand, and the workforce of internal medicine. Am J Med 2001;110:745-749.
   
   
4. American College of Physicians, Health and Public policy Committee Issues Paper: "Geriatric Training and the Internal Medicine Residency" submitted for publication.
   
   
5. Accreditation Council for Graduate Medical Education, Residency Review Committee - Internal Medicine. Special Requirements for residency training programs, 1998. Also can use website: Program Requirements for Residency Education in Internal Medicine. Available from: ACGME website at www.acgme.org. Accessed 8/4/03.
   
   
6. D Thomas, E Callahan et al. Improving Geriatrics Training in Internal Medicine Residency Programs: Best Practices and Sustainable Solutions. Ann Intern Med, Oct 2003; 139: 628 - 634.
   
   
7. Counsell S, Sullivan G. Curriculum recommendations for resident training in nursing home care. J Am Geriatr Soc. 1994;42(11):1200-1.
   
   
8. Sullivan G, Boling P, Ritchie C, Levine S. Curriculum recommendations for resident training in home care. J Am Geriatr Soc. 1998;46:910-2.
   
   
9. Counsell S, Kennedy R, Szwabo P. Wadsworth N. Wohlgemuth C. Curriculum recommendations for resident training in geriatrics interdisciplinary team care. J Am Geriatr Soc. 1999;47(9):1145-8.
   
   
10. Stanford University/John A Hartford Foundation website for geriatrics educational materials - http://www.jhartfound.org/
    
    
11. Society of General Internal Medicine website for geriatrics educational materials for generalists - http://www.sgim.org/interestgroup.cfm

Appendix A

The following is a partial list of diseases that internal medicine residents are trained to diagnose and manage. Each has aspects of presentation, natural history or management that require special attention in older patients.

1. Cardiovascular. Hypertension (systolic and diastolic), arrhythmias, coronary artery disease, valvular heart disease, congestive heart failure, peripheral vascular disease.
   
   
2. Musculoskeletal. Osteoarthritis, osteoporosis, rheumatoid arthritis, spinal canal stenosis, polymyalgia rheumatica, Sjogren's syndrome, and common fractures, especially hip, spine and wrist.
   
   
3. Neurological. Delirium, stroke, epilepsy, Parkinson's disease, Alzheimer's disease and other causes of dementia, and peripheral neuropathy.
   
   
4. Gastrointestinal. Common pathologic oral conditions, upper and lower gastrointestinal disease (including bleeding, malignancy, and ischemia), Hepatobiliary disease, and colon disorders including cancer, diarrhea and constipation.
   
   
5. Infections. Pneumonia, urinary tract infection, bladder catheter managment, cellulitis.
   
   
6. Prevention.