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Residency Curriculum

Prerequisites   General Competencies   General Objectives (PGY I)   Goals   Geriatric Goals Trauma / Surgical Care Goals     Rotations:   PGY I PGY II PGY III PGY IV PGY V PGY VI   Jr/Sr Objectives: Unit 2 Unit 3 Unit 4 Unit 5 Unit 6 Unit 7

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Rotations:   PGY I PGY II PGY III PGY IV PGY V PGY VI   Jr/Sr Objectives: Unit 2 Unit 3 Unit 4 Unit 5 Unit 6 Unit 7

Surgical Geriatric Curriculum Goals and Objectives 
The following guidelines provide the structural basis for increasing resident expertise in caring for the special needs of elderly patients.

Curriculum Goal: Following study and implementation of the General Surgery curriculum, the surgical resident will be prepared to manage or co-manage the health care needs of prospective surgical geriatric patients.

I. Principles of Normal Aging
II. Pathophysiology in the Elderly Patient
III. Preoperative Assessment of the Elderly Patient
IV. Operative Management of the Elderly Patient
V. Perioperative Care of the Elderly Patient
VI. Long-Term Recovery/Rehabilitation of the Elderly Patient
VII. Financing, Utilization, and Reimbursement Issues
VIII. Patient Outcomes

 

I. Principles of Normal Aging
The resident will acquire a working knowledge of general principles of aging while recognizing the considerable heterogeneity of patients age 65 and older. The general principles will include the study of:

1. Demography of aging
2. Biology of aging relative to age-related physiologic changes
3. Preventive geriatrics: health maintenance

The resident will be prepared to recognize, interpret, and manage the principal elements in the Psychology of aging that present as the patient’s psychologic status, cultural value system, and personally-preferred lifestyle. Elements of the Psychology of aging will include applying principles of:

1. Neuropsychiatric aging: brain-behavior relationships (dementia, acute delirium/changes in mental states)
2. Hypothalamic function and regulation of body temperature

The resident will be prepared to identify age-related physiologic changes and apply that knowledge during surgical counseling and decision-making. Age-related physiologic changes will encompass:

1. Aging relative to tissues, organ systems, immune functions, and nutritional needs
2. Endocrine and metabolic alterations (e.g., carbohydrate and insulin metabolism)
3. Changes in laboratory values (e.g., expected changes in normal blood chemistries)

 

II. Pathophysiology in the Elderly Patient
The resident will develop clinical management strategies, considering the unique aspects of geriatric pathophysiology.
Knowledge of disease processes will include the study of:

1. Mortality: leading causes of death for those 65 and older
2. Morbidity: leading causes of disability
3. Factors affecting altered disease presentation
4. Comorbidity: chronic diseases superimposed on acute disease
5. Geriatric syndromes (dementia, failure to thrive, fractures, malnutrition, sleep problems)

The resident will be prepared to analyze and apply information about medication to principles of age-related pharmacokinetics, pharmacodynamics, and adverse drug reactions. Physiologic and Psychosocial implications will build upon a working knowledge of:

1. Changes in drug metabolism and excretion
2. Adjustment of doses and age-specific side effects
3. Use of psychotropic agents and pain medications
4. Identification of possible adverse drug-drug interactions
5. Significance of financial problems imposed by polypharmacy

 

III. Preoperative Assessment of the Elderly Patient
The resident will modify his/her approach to evaluation and diagnosis in a manner that is effective, efficient, and in accord with the special needs and limitations of the geriatric individual. Factors to consider will include:

1. Developing attitudes toward and communicating with the elderly; age bias
2. Establishing lines of communication with health care team: personal physician/geriatrician, social worker

The resident will be prepared to obtain and utilize patient data for decision making prior to surgery. Full geriatric assessment of patient baseline data will include consideration of:

1. Functional capabilities: activities of daily living, mental and physiologic health
2. Psychosocial variables: ethnic factors, cultural mores, social supports, and community relations
3. Differences in health care preferences according to perspectives of patient, referring physician, and surgeon
4. Considering risks to desired surgical outcomes: comorbidity, frailty, and social supports

The resident will be prepared to implement interventions that minimize legal and ethical risks to the patient’s individual rights and liberties. Interventions will require consideration of the following factors:

1. Weighing aggressive approach with patient’s right to autonomy: legal right to self-determination and perceptions of quality of life
2. Rights regarding competence and advance directives: informed consent, surrogate decision making, long-term care, extent of care, living wills, and decisions about death
3. Cost:benefit ratio determination

 

IV. Operative Management of the Elderly Patient
The resident will monitor and act upon coexisting requirements of care to maintain patient stability. Monitoring of patient surgical needs will include:

1. Planning and supporting the selection and management of local, regional, and general anesthetics
2. Managing conscious sedation
3. Maintaining body temperature and metabolic homeostasis during surgery
4. Following Halsted’s Principles during surgical intervention

 

V. Perioperative Care of the Elderly Patient
The resident will determine and act upon the continuing needs of the surgical patient based upon patient communication and interaction, use of patient data, and analysis of surgical outcome. Perioperative decisions will require:

1. Management of complications such as sepsis, cardiac problems, diabetes, pulmonary and renal failure.
2. Determining need for prophylaxis for common complications like DVT and PE, aspiration pneumonia
3. Sustaining patient with homeostasis, fluid management, ventilator support, wound and antibiotic management
4. Determining management for deconditioning, use of Foley catheters and NG tubes, use of invasive monitoring
5. Management of directive care issues such as life sustaining mechanisms: supportive care, extent of care issues

 

VI. Long-Term Recovery/Rehabilitation of the Elderly Patient
The resident will be prepared to utilize information and resources to maximize positive outcomes. Data and resource utilization will include application of rehabilitation principles:

1. Optimizing patient health and maintaining function
2. Communicating with the patient and family regarding quality of life issues
3. Directing long-term recovery and rehabilitation for home, community, and/or institutional settings
4. Applying non-institutional support systems and institutional services for patient and family

 

VII. Financing, Utilization, and Reimbursement Issues
The resident will be prepared to analyze the continuum of care available to that patient, considering the complex factors inherent to implementation when matching health services to individual needs and resources. The consideration of factors related to health services will include an analysis of:

1. Elderly patient rights to benefits: age-based and needs-based services and entitlements
2. Delivery of health services available to the patient and his/her family
3. Cost:benefit ratio determination; economic impact of operative procedure
4. Implications of long-term care: the recovery period, quality of life

 

VIII. Patient Outcomes
The resident will analyze and utilize his/her surgical data in systematic fashion. Analysis and utilization of surgical data will include:

1. Selecting, maintaining, and analyzing a patient outcome database
2. Comparing patient outcomes with local medical community and national standards
3. Initiating improvements in patient care based on patient outcome data