A PDF document containing this Orientation Information can be found here.
Geriatric Medicine at St. Joseph’s Hospital: Orientation
Site Coordinators: Dr. Heather McLeod
Ms. Niki Ropert (ropertn@stjosham.on.ca)
If you haven't done so already, please contact Ms. Ropert PRIOR to the start of your rotation to advise her of the following information:
Your academic and/or clinic half days away from the rotation
Any post-call days
Any previously approved holidays or professional leave.
Please also confirm whether you have completed Dovetale (EPIC) training.
OVERVIEW OF THE SERVICE
Inpatient Consultation:
The main activity of the geriatrics service at SJH is inpatient consultation. Requests for consultation are received from many different services and areas of the hospital, but the majority of our referrals come from Internal Medicine and Orthopedic Surgery. Common reasons for referral include: cognitive impairment, delirium, recurrent falls, functional decline, and medication optimization.
Outpatient Geriatric Medicine Clinics
Modified schedule during COVID-19 pandemic; please ask your Supervisor for more details.
Residents and clerks will have the opportunity to participate in several outpatient clinics during this rotation. These clinics will be scheduled prior to the rotation, based on the schedules of both the learners and the supervising Geriatrician(s). Dr. Gagnon has a full-day clinic every Thursday in the Outpatient Department (OPD); Dr. McLeod has a half-day clinic Wednesday mornings in OPD; and Dr. St. Onge has a half-day clinic on alternate Fridays in OPD. There is also a more urgent Geriatrics referral scheduled in the IMRAC clinic every Tuesday afternoon. Please refer to “Clinic Information” on the Rotation Website for more information.
During this rotation, Learners are expected to:
1. For new consultations:
Complete a Comprehensive Geriatrics Assessment (CGA) through appropriate chart review (including review and inclusion of interdisciplinary assessments), history and physical examination (relevant to the Geriatric patient; including cognitive testing, as appropriate), review of medications (current and home), and review of relevant labs and imaging.
Work collaboratively and respectfully with the Case Managers, including incorporating the details of their assessments (especially functional and cognitive history, and collateral information) into your CGA,
Formulate an impression and plan based on your assessment, focusing first on the reason for referral.
After review with the Geriatric Medicine Attending, communicate findings and recommendations promptly to the referring service (via an updated consultation note on Dovetale, and possibly an in-person discussion).
Complete this updated (and spell-checked) consultation note within 24 hours of reviewing a patient with the Geriatric Medicine Attending.
2. For follow-up patients:
Complete chart reviews, and targeted history and physical examinations, for follow-up patients assigned to their care.
Continue to follow to assigned patients at least twice weekly, until discharged from the consult service (or discharged home). Leave clearly written notes in a patient's chart each time a follow-up is completed.
Provide cross-coverage for patients of other residents on the service when they are absent.
Possibly send a brief follow-up note to a patient's Family Physician (and other involved MDs) regarding updates or outstanding issues arising from the Geriatrics consultation. (E.g. results of cognitive testing, new cognitive diagnoses, orthostatic vitals once ambulatory, results of kitchen/driving assessment, etc.) These items may not be included in the MRP discharge summary but should be conveyed to a patient's Family Physician.
This can be can be accomplished by "routing" a progress note. Ask your Attending for more assistance and details re same.
Provide handover (using the Geriatrics "Handover/To Do" section on Dovetale for active patients at the end of the month.
Interprofessional Collaboration
Geriatric Medicine offers a unique opportunity to focus on and develop skills in interprofessional collaboration. During this rotation, residents and clerks will work closely with the Geriatrics Case Managers. Residents and clerks are expected to be responsive to the requests of case managers when they are requested to reassess a patient, and decisions to discharge a patient from the service must be mutually agreed upon. Though there is naturally some overlap of roles and expertise to allow the service to work most effectively as a team, in general we follow these principles:
Responsibilities of the Case Manager:
Receive, triage and assign referrals.
Clarify with the referring team when the reason for referral is unclear.
Obtain collateral history from a patient's family member, next of kin, or close contact, regarding prior cognitive, mood and/or functional problems
Identify and obtain relevant records from prior Geriatric Medicine or Geriatric Psychiatry assessments
Perform initial cognitive screening, when indicated.
Generate an initial Case Manager’s assessment/problem list (via a Progress note in Dovetale), identifying areas that need further assessment and clarification by the physician.
Liaise with Residents after the initial consult has been reviewed to establish the follow-up plan.
Take primary responsibility for patient/family education, support, and counseling about dementia, delirium and other geriatric syndromes.
Attend Family Meetings regarding discharge planning and community services.
Advise and help implement effective non-pharmacologic strategies to prevent and manage geriatric syndromes.
Responsibilities of the Learner (Resident/Clerk):
Review the patient's past and current medical problems to understand how these are contributing to his/her/their current status.
Review the patient's course in hospital to understand the trajectory of their current issues.
Perform a detailed medication review (including use of PRN medications).
Read the Case Manager’s collateral history (in their progress note on Dovetale) and most recent iinterprofessional care team notes, to understand the patient's past and current functional and cognitive status.
Include information gathered by the Case Managers in the Consultation note on Dovetale.
Perform a thorough physical exam and review all relevant medical tests.
Using all of the above sources, generate a final assessment and problem list, with recommendations, and present this to the Geriatric Medicine Attending.
Within 24 hours of reviewing a patient with the Attending, complete an updated consultation note in Dovetale, which includes the outcome of that review (Imp/Plan and relevant issues), any recommendations (and rationale for same), and who will be responsible for implementing each of them (ie MRP or Geriatrics team).
Liaise with case managers after the initial consult has been reviewed to establish the follow-up plan.
Take primary responsibility for follow-up of medical issues identified, tests ordered, and any medication changes made to prevent and manage geriatric syndromes.
Review and collaborate with case managers on follow-up issues that arise
Review follow-up issues with the attending geriatricians on Mon/Thurs or Tues/Fri (or similar).
Orthogeriatrics Model
Since 2010, we have collaborated with multiple services to provide an “Orthogeriatrics” service for all older adults admitted to hospital with a fall and fragility hip fracture. Strong evidence exists to support the involvement of a Geriatrics service for these patients, with the goal of reducing the rate of peri-operative delirium (Marcantonio et al, 2001), while also addressing the Geriatric syndromes of falls and fracture (osteoporosis). Our role is primarily to address these three issues.
An internist often consults on these patients to address their perioperative cardiovascular risk and acute/chronic medical issues, such as hypertension, coronary artery disease, and DMII. To minimize overlap and duplication, we do not manage acute medical issues (other than delirium) for our Orthogeriatrics patients. If you are concerned about an acute medical issue for an Orthogeriatrics patient, please notify your Attending Geriatrician and the Charge Nurse on the 7-Surgical floor so that appropriate action can be taken. If you have any questions regarding this, please ask the Attending Geriatrician.
To ensure effective collaboration, we have been asked to always communicate any orders or changes in treatment to the Orthogeriatrics patient’s bedside nurse. Also, please refrain from ordering any labs or imaging that you cannot personally follow-up on in a timely fashion. Specifically, DO NOT order labs or imaging to be completed on a Saturday or Sunday. Any orders completed on a Friday should specify that they are to be done on Monday.
Resources & Recommended References
Links to “key” papers in Geriatric Medicine, and other recommended resources, are contained on the Rotation Website. Please see tab labelled "Teaching Topics", on the left sidebar.
Schedule & Teaching
In general, residents can expect that the Attending Geriatrician will meet with residents in the mornings to provide teaching on oral exam scenarios or geriatric medicine topics, review consults, and round on patients. In the afternoons, except for academic half day, residents are expected to complete assessments on newly assigned consults, follow-up on the other patients on their list as needed, and liaise with case managers to coordinate care plan. A detailed rotation calendar, as well as a clinic schedule, will be emailed to residents at the start of the rotation.
Rounds
Attendance at Internal Medicine Grand Rounds (Thursdays 8:00-9:00 a.m., via Zoom or similar) and at Geriatric Medicine Grand Rounds (2nd or 3rd Monday of each month, 3:00-4:00 pm, via Zoom) is encouraged during this rotation.
Daily teaching rounds (16:00-17:00) on the Clinical Teaching Unit (CTU) are organized by the Chief Resident and occasionally focus on a Geriatrics topic. Please speak to your Attending Geriatrician for more information.
Lockers
Residents may use the lockers in the CTU Residents Lounge (4th floor Mary Grace Wing, at the end of the hall on CTU-West) OR in the on-call area (Martha wing) to store personal items.
Evaluations
For each resident, a summary evaluation is prepared, based on case discussions, chart reviews and direct observation. All staff geriatricians contribute to the final evaluation, and feedback from other staff (e.g. Nursing, Allied Health, and Case Managers) is also solicited.
Residents are expected to evaluate the rotation formally and we also very much welcome informal input about how we can do better. Most months there will be 2 primary supervisors, and it is important that you complete online evaluations on both of them. If MedSIS does not permit this, please let the non-included supervisor know.
Please do not hesitate to notify the site coordinator, Dr. Heather McLeod, regarding any problems, concerns, or questions that arise during the rotation.
Teaching Topics
Dementia
Delirium
Depression (in the elderly)
Falls & Osteoporosis
Polypharmacy
Frailty
Hospital Associated Disability/Deconditioning
Weight Loss & Nutrition
“Failure to Cope”
Urinary Incontinence
Chronic Constipation
Parkinson’s Disease
Driving Assessment
Consent & Capacity
Elder Abuse
Management of Chronic Disease
Comprehensive Geriatric Ax
Please click on the subpage links for program-specific Learning Objectives.
Information regarding Internal Medicine EPAs can be found by clicking HERE.