MDC7140
Geriatrics Thread Rotation

Medical Student Syllabus

Course Director and Coordinator Contact Information

Course Director:
Senthil Meenrajan, MD, MBA
Associate Professor, Department of Medicine
Email
(352) 672-8401

Course Coordinator:
Jessica Highland
Academic Program Specialist I
College of Medicine
Email
352.273.5161 (O)

Clerkship Goals and Objectives
Welcome to Geriatrics; together with Palliative Care, this is a 4 credit thread rotation that spans the 3rd and 4th year of medical school. The aim of this clerkship is to provide 3rd and 4th year medical students with an in depth knowledge and clinical experience, to improve their understanding of geriatrics and help manage older patient’s acute and chronic problems better.

Clerkship Objectives
The expectations of your performance follow the College of Medicine’s competency based curriculum, as well as the Association of American Medical Colleges (AAMC) Core Entrustable Professional Activities for Entering Residency (EPAs).

There are several objectives, both general and specific. You will experience, be taught, and evaluated in the following competencies, identified as the Accreditation Council for Graduate Medical Education (ACGME) core competencies, which continue into residency:

• Patient care and procedural skills (PC)
• Medical knowledge (MK)
• Practice-Based Learning and improvement (PBL)
• Interpersonal and Communication skills (IC)
• Professionalism (P)
• Systems based practice (SBP)

You will be given the opportunity to demonstrate the following EPAs within these specified assignments and/or performance during these clinical periods:

1. Obtain History and Perform Physical Exam:
   • Students will evaluate patients in multiple clinical settings. During the MS3 year there will be multiple tools to complete, by obtaining accurate history and performing focused physical exam. During the 4th year, during the rehabilitation week, students will evaluate patients at the nursing home or assisted living.
2. Document Encounter:
   • Students will have an opportunity during the Geriatric rotation to document the clinical information. During the 3rd year, assessments are made using standardized tools and during the 4th year, capstone week, follow up evaluation of older adults occurs at the nursing homes and students will document all the information.
3. Formulate a Clinical Question and Retrieve Evidence:
   • Students will evaluate patients at nursing homes, identify key differences in the care provided at long term care (LTC) facilities vs hospital based care, identify clinical questions as it relates to care of the older patients at LTC facilities and retrieve information relating to the same.
4. Collaborate on an Interprofessional Team:
   • Students will be active participants on Interprofessional teams particularly during their rehab block where they will work directly with physical therapists, occupational therapists, speech language pathologists, MD/NP/PA, social work, and other interprofessional care team members.
   • Students will be participants on interdisciplinary teams during their palliative blocks where they will work directly with MD/NP/PAs as well as palliative social workers, chaplains, and other interprofessional care team members.

General Objectives:
Based on the AAMC Geriatric Competencies for Medical Students, the following domains are emphasized:

The Geriatric 5Ms

• Mind:
  Address cognitive, mood, and behavioral changes, such as delirium, dementia, and depression, using appropriate screening tools and differentiating between normal aging and illness.
• Mobility:
  Assess and manage fall risk, including gait and balance, identify underlying causes and implement preventive interventions
• Medications:
  Evaluate medication regimens for appropriateness in older adults, considering age-related changes in drug metabolism, and identify medications to avoid or use cautiously.
• Multicomplexity:
  Manage complex or chronic illnesses, in the context of long term care, and in the context of patients seeking care in clinic and the hospital setting.
• Matters Most:
  Engage older adults and their caregivers in patient-centered discussions to determine what matters most, aligning treatment plans with individual priorities, prognosis, and function.

To this end students will:

Incorporate a basic working knowledge of syndromes and diseases unique to or more common in older persons. (MK, PC)(MK.01, PC.01, PC.02)

Improve clinical skills of history taking and physical exams of older adults, especially in the context of long term care. (PC)(PC.01)

Develop an understanding of geriatric assessment of older patients including the use of screening instruments and an awareness of the importance of patient’s functional status in medical care. (MK, PC)(MK.01,PC.02)

Recognize the advantages of working collaboratively with an interdisciplinary health care team. (IC, P, SBP)(ICS.04, P.02, SBP.06)

Apply evidence based medicine to the care of the elderly. (PBL)(PBLI.01)

Specific Objectives

Demonstrate professionalism and a caring attitude in working with older adults and in particular, frail elderly in assisted living and long term care settings. (P)(P.01, P.06)

Gather historical information and conduct medication reviews, identify polypharmacy and inappropriate medications for the elderly based upon Beers criteria, and evaluate medication interactions and side effects. (MK, PBL)(MK.01,PBLI.01)

Describe geriatric syndromes, including but not limited to: falls, delirium, dementia, osteoporosis, failure to thrive, osteoarthritis, immobility and functional capacity. (MK)(MK.01)

Perform multiple geriatric assessments including cognitive assessments and mobility assessments using validated tools (MOCA, Timed Up and Go, Mini Nutritional Assessment) (MK, PC) (MK.02, PC.02)

Accurately identify clinical situations where life expectancy, functional status, patient preference or goals of care should override standard recommendations for screening tests or treatments in older adults. (PC, PBL) (PC.03, PBLI.01)

Recognize how a functional assessment with interdisciplinary team members, in conjunction with medical assessments and social assessments determine appropriate and safe discharge plans from institutional settings to home or across institutional settings (IC, SBP)(ICS.02, ICS.04,SBP.06)

Formulate a patient-centered, interprofessional and evidence-based management plan. (PC, PBL, SBP, IC)(PC.02, PBLI.02, SBP.04,ICS.02)

At the end of the clerkship students will be able to: (MK, SBP)(MK.02, SBP.01, SBP.04)

• Evaluate older patients using standardized tools
• Develop a better understanding of long term care of older patients
• Evaluate functional status of patients and formulate appropriate interventions
• Participate in developing a care plan to address physical, psychological, social, practical and spiritual needs.
• Address patient preferences in their own care and assist patients complete advance directives

Thread Rotation Format:

A. During MS3 year:

• Complete the following Clinical Skill Enhancement (CSE) Activities
  • MOCA/MMSE (1)
  • b. Mini-COG (3)
  • c. Geriatric Depression Scale (1)
  • d. CAM – Delirium (3)
  • e. Katz ADL assessment (3)
  • f. Lawton IADL assessment (3)
  • g. Get-up and go test (3)
  • h. Mini-Nutritional Assessment short-form (3)
  • i. Tinetti Gait Assessment (1)
  • j. Tinetti Balance Assessment (1)
  • k. Hearing Handicap Inventory for the Elderly (1)
  • l. Older People’s QoL Questionnaire (3)
  • m. Advance Directive Completion (3)
• Complete Aquifer modules
  During the thread rotation students will complete the following modules on Aquifer:
  • Dementia
  • b. Delirium
  • c. Decision Making Capacity
  • d. Fall assessment
  • e. Frailty
  • f. Transitions of care and discharge planning
  • g. Patient safety in Hospitalized Patient

B. During MS4 year:

Suggested weekly schedule during Rehab/LTC week:

• Day 1 – work with physical therapist
• Day 2 – work with occupational therapist
• Day 3 – work with Speech/swallow therapist
• Day 4 – evaluate 3 nursing home residents and write notes
• Day 5 – reflective writing

Daily Procedures on Geriatric Medicine Capstone Week

Specific to Rehabilitation/Long term care week:

1. The student will be part of the team evaluating frail elders in an acute-care rehabilitative, sub-acute rehabilitative or long-term care setting.
2. Students will learn how to function as part of an interdisciplinary health team.
3. Learn to assess and describe baseline and current functional abilities in an older patient by collecting historical data from multiple interdisciplinary sources, including physical therapist, occupational therapist and speech/swallow therapist.
4. Develop a preliminary management plan for patients with functional deficits, including adaptive interventions and involvement of interdisciplinary team members from appropriate disciplines, such as social work, nursing, rehabilitation, nutrition, and pharmacy.
5. Learn about the unique aspects of caring for older adults in the long term care setting, where dementia and behavioral symptoms of dementia is common.
   

** for details about the Palliative/Hospice Capstone week and SIM activity, refer to Palliative thread canvas page.

Assignments:

1) Clinical Skills Enhancement: Completed during the MS3 year. Students will use the validated tools during interactions with older patients in different clinical settings including ambulatory clinics, inpatient wards. Students will learn to incorporate these assessment methods during all clerkships, when they interact with older adults

2) Aquifer Modules: Completed during the MS3 year. Students will complete the case study on a number of high yield geriatric topics, that will enhance their understanding of geriatric syndromes, continuity and transition of care

3) Nursing home patient follow up: during the week at the nursing facility, students will evaluate 3 older residents there and write appropriate follow up notes

4) Attendance at NH: Students must obtain and daily attendance record from the NH administrative office. This must be submitted at the end of the week on canvas

5) Reflective Writing: Students will complete 2 write ups as noted.

• To better understand the complexities and unique aspects of caring for older adults at nursing homes, students will reflect on the patients they evaluated and write about 250-300 words on what they found challenging about the clinical care of elderly at nursing homes
• Do a short 250-300 word evidence based review of a topic that’s relevant to nursing home care e.g. polypharmacy, pharmacotherapy for management of behavioral symptoms, wound care, chronic pain

Course Resources and Reading Materials

Aquifer Geriatric Case-based reading is recommended for all. Other optional (but recommended) readings are available through Canvas.

Please login to the Canvas / e-Learning with your Gatorlink for the most up-to-date course information.

The following textbooks are recommended only for your reference:

• Geriatrics at Your Fingertips (available to borrow at orientation or online version available);
• Current Geriatric Diagnosis and Treatment;
• Geriatric Physical Therapy;
• Fast Facts and Concepts: Searchable database for evidence based practices for geriatric and palliative care syndromes.
  • http://www.mypcnow.org/#!fast-facts/c6xb
• The Palliative Response, Dr. F. Amos Bailey;
  • http://www.uab.edu/medicine/palliativecare/training/palliative-response
• Being Mortal by Atul Gawande
• Additional tools to use and study during Geriatric Medicine week
  • Guide to Geriatric Assessments pocket card

Student Attendance

In order to have an absence excused, you will need to complete the MedCat (https://medcat.medinfo.ufl.edu/)* for both planned and unexpected absences. Any email requests sent to the course director will be redirected to the online request form.

The following requests are typically excused:

• Personal illness
• Appointments related to health
• Unexpected family events that involve immediate family members (**We recognize that not everyone’s closest support person(s) fit the traditional definition of immediate family. If the request relates to someone who is the equivalent of immediate family, students are asked to provide a brief explanation so that can be factored in to the decision.)
• Wedding requests for immediate family and/or you are member of the wedding party that involve no more than one missed day of classes
• Religious holidays (we follow UF policy but still require submission of the request)

The following requests are typically unexcused:

• Planned requests submitted after the clerkship starts
• Unexpected requests submitted more than 24 hours after the missed session without a compelling reason for the delay
• Attendance at a meeting where you are not presenting
• Interviews during required clerkships (Students are explicitly advised to not schedule interviews during required clerkships. In the event of unexpected or unplanned single day interviews or second looks, consideration will be made for the request.)

For more information on the attendance policy for required educational activities, please visit:

• https://osa.med.ufl.edu/support/policies-procedures/attendance-policy-for-required-educational-activities/
• Attendance Policy for Required Educational Activities.
• Absence Request Process & Guidelines.

Make-up Guidelines
As for any unexpected absence, you must follow the unexpected absence policy. If you feel ill, please contact Jessica Highland/Dr. Meenrajan once you feel better for advice about making up your missed work.
Once you feel well enough to engage in make-up work, please follow up with the clerkship leadership for details about the make up sessions.

Any make-up work that needs to be completed after the capstone weeks, will result in a hold grade until the clerkship requirements are completed and you are able to receive your final grade.

Absences for Health Services
Students are encouraged to maintain their own personal health throughout medical school. This includes their dental, mental and/or physical health. Ideally, students will make every effort to schedule these appointments at dates/times that do not conflict with required educational activities. When this is not possible, students must submit their request for an excused absence to the Geriatrics Clerkship Director. Upon approval, the director will notify the student of makeup requirements and due date, if appropriate.

Clerkship Evaluation/ Grading Policies/ Student Performance Criteria
*For additional expectations and requirements, review the UF, College of Medicine Medical Education Program Policies and Procedures https://osa.med.ufl.edu/policies-procedures/.

• Clerkship Evaluation (feedback from students):
  We appreciate your feedback! The Course evaluation form can be accessed in New Innovations.
  
• Grading Policies and Student Performance Criteria
  Students will be evaluated based on completion of required activities, timeliness of submissions, completeness of nursing home patient assessments and the reflective writing assignment.

Mid-thread Feedback:
At the completion of the MS3 year, students will be given a progress report of whether they are on tract, with completion of the required Aquifer modules and CSE activities.

Grade Determination: This Clerkship is Pass/Fail

• Successful passing grade requires completion of all required activities laid out in the syllabus
  
• If all requirements are not met, and the determination is made for a failing the Geriatric Medicine Clerkship Committee will meet and determine if a failing grade is indeed appropriate or if in-course remediation can be first attempted. The remediation will be at the discretion of the clerkship committee, which includes the course director Dr. Senthil Meenrajan and palliative course director Dr. Paige Barker.
  
• If a failing grade is determined as the ultimate grade after the above procedures or if remediation is not successful as determined by the discretion of the course directors, the students will be referred to the College of Medicine Academic Status Committee and their grade will remain Incomplete (I) until action decided by the committee.
  
• Attendance is mandatory, and no unexcused absences are permitted including leaving early or not attending parts of the daily duties. If such absence is occurring, the clerkship committee will meet to determine if a failing grade is appropriate or follow the remediation procedures above. See earlier notes regarding attendance.

ALL components must be completed for a passing grade. In addition, the course director has jurisdiction over any attendance, professionalism, or educational concerns and may modify the final grade if necessary.

Grade Grievance Process
Medical students may appeal a final grade or evaluation based on concerns about discrimination or the process used to assign the grade. Further information about the process can be found https://osa.med.ufl.edu/policies-procedures/grade-grievance-process/.

UF Student Honesty Policy / Honor Code
UF students are bound by The Honor Pledge, which states, “We, the members of the UF community, pledge to hold ourselves and our peers to the highest standards of honor and integrity by abiding by the Honor Code. On all work submitted for credit by students at UF, the following pledge is either required or implied: “On my honor, I have neither given nor received unauthorized aid in doing this assignment.” The Conduct Code (http://www.dso.ufl.edu/sccr/process/student-conduct-honor-code/) specifies a number of behaviors that are in violation of this code and the possible sanctions. Furthermore, you are obligated to report any condition that facilitates academic misconduct to appropriate personnel. If you have any questions or concerns, please consult with the instructor of the class.

Americans with Disabilities Act (ADA) Accommodations
The University of Florida is committed to providing academic accommodations for students with disabilities.
Students requesting accommodations must first register with the Disability Resource Center (DRC) (352-392-8565) by providing appropriate documentation. Once registered, students should present their accommodation letter to the College of Medicine’s ADA Representative, Mr. Jim Gorske, who will distribute the accommodation letter to the clerkship. The University encourages students to register with the DRC as soon as they begin medical school or upon the verification of a disability.

Mistreatment Policy
The University of Florida College of Medicine is committed to treating all members of the college community fairly with regard to both personal and professional concerns. The student mistreatment policy ensures that concerns are promptly dealt with and resolutions reached in a fair and just manner. The college’s procedures enable students to bring problems to the attention of the COM administration in a timely manner. The college forbids any retaliatory action against students who present grievances in good faith. To review the entire policy and/or to enter a mistreatment report: https://osa.med.ufl.edu/policies-procedures/medical-student-mistreatment-policy/.

Contact Information for UF Student Counseling & Wellness Center
Contact information for the Counseling and Wellness Center: http://www.counseling.ufl.edu/cwc/, (352) 392-1575; and the University Police Department: 392-1111 or 9-1-1 for emergencies.