General Residency Training Program Objectives : Geriatric Component

 

This is a comprehensive list of objectives, focused on elderly patients, which supports the Royal College of Physicians and Surgeons, Objectives for Training in Psychiatry 2007 and Specialty Training Requirements in Psychiatry.

It is understood that longitudinal opportunities to see elderly patients with psychiatric disorders can and will take place in all adult psychiatric patient settings throughout the PGY-I to PGY-V years. However, dedicated geriatric psychiatry training, relevant to general psychiatry practice, will include two blocks (Block 1 and 2), each of three months duration (6 months total) completed either separately or as one continuous 6 month training block, preferably during the PGY II and PGY III years (Junior Residency). Block 1 will focus on knowledge acquisition and early skill development (introductory knowledge and some working knowledge level) of the medical expert CanMEDS role, specific to the elderly patient. Block 2 will re-expose the trainee to elderly patients with a focus on consolidation of knowledge and enhanced skill development of competencies across all CanMEDS roles at the junior residency level (working knowledge). Ideally the entire rotation (or at least Block 2) will be completed in the PGY III year, when the PGY II experience has already provided the resident some of the early basic and foundational psychiatric knowledge and skills necessary for practice across the life span. Both geriatric psychiatry blocks will be supervised by psychiatrists with enhanced knowledge and skills in geriatric psychiatry. The overall objective of this dedicated geriatric psychiatry experience is to enable the general psychiatry trainee, at this junior residency developmental stage to acquire:

  • Working Knowledge Level Competency in assessing, diagnosing, treating and managing elderly patients with generally typical presentations of specific age-related psychiatric disorders, as relevant to general psychiatry.
  • Working Knowledge Level Competency in assessing and managing uncomplicated patients with long term psychiatric disorders, who have grown old, as relevant to general psychiatry.
  • Confidence in recognizing situations in the psychiatric care of complex elderly patients that are outside the scope of general psychiatry, and when consultation with a dedicated geriatric psychiatrist would be appropriate for optimal patient care.

1. The trainee will participate in a continuous evaluation process.

2. Royal College Objectives of Training in Psychiatry 2007, provides the basis for the key competencies and enabling competencies of these specific objectives for geriatric psychiatry content in general psychiatry training. Expected levels of achievement for core competency will be defined as:

Introductory knowledge – Able to recognize, identify, or, describe principles

Working Knowledge (W) – Able to demonstrate core aspects of psychiatry, such as basic interviewing, problem formulation and treatment. The resident can understand the scientific literature. Psychiatry residents choosing to undertake a selective in the senior years of training would be expected to achieve a greater depth and breadth in level of core competency and demonstrate Proficient level competency.

Proficient (P) – Able to demonstrate working knowledge enhanced by a developmental, cultural, and geriatric age appropriate perspective, allowing detailed interviewing and bio-psychosocial problem formulation with capacity to teach, consult, assess and manage referrals in patients with typical presentations of specific age-related psychiatric disorders. The resident can review the scientific literature.

At the completion of geriatric training, the resident will have acquired the following competencies and will function effectively, at a junior residency level.

Medical Expert

Key Competencies
1. Function effectively as junior residents, considering all of the CanMEDS roles to provide optimal, ethical and patient-centered medical care when dealing with elderly patients.
2. Acquire clinical knowledge, skills and attitudes required to function effectively as a junior resident in general psychiatric practice involving elderly patients.
3. Perform a complete and appropriate assessment of elderly patients, at the junior residency level.
4. Use appropriate preventive and therapeutic procedural skills effectively, at the junior residency level, for psychiatry practice involving elderly patients.
5. Demonstrate proficient and appropriate use of procedural skills, at the junior residency level, both diagnostic and therapeutic.
6. Recognize limits of expertise and seek appropriate consultation with other health professionals

Enabling Competencies

For Key Competency 1:
1. Function effectively, as a junior resident, considering all of the CanMEDS roles to provide optimal, ethical and patient-centered medical care when dealing with elderly patients

1.1. Effectively perform a consultation in the elderly patient, including the presentation of well documented assessments in written and verbal form in response to a request from another health care professional

1.2. Identify and appropriately respond to relevant clinical issues arising in the care of elderly patients including:

1.2.1. Awareness of factors influencing the elderly patients reaction to the psychiatrist and others

1.2.2. Awareness of ones own reactions when dealing with elderly patients

1.2.3. Boundary issues

1.2.4. Burden of medical, surgical and psychiatric illness to elderly individuals, families, caregivers and systems.

1.2.5. Capacity/ Competence

1.2.6. Confidentiality

1.2.7. Co-morbidity

1.2.8. Consent, in both capable and incapable elderly patients

1.2.9. Culture and spirituality

1.2.10. End of life issues

1.2.11. Family issues involving elderly patients

1.2.12. Legal and forensic matters

1.2.13. Long term illness and rehabilitation

1.2.14. Psychiatric manifestations of medical and neurological illness

1.2.15. Stigma

1.2.16. Suicide, self harm and /or harm directed towards others

1.2.17. Therapeutic alliance

1.2.18. Trauma, abuse or neglect

1.3. Effectively and appropriately prioritize professional duties when faced with multiple patients and problems.

1.4. Demonstrate compassion and patient-centered care.

1.5. Recognize and respond to the ethical dimensions in Psychiatric decision making concerning elderly patients.

For Key Competency 2:
2. Acquire clinical knowledge, skills and attitudes required to function effectively as a junior resident in general psychiatric practice involving elderly patients.

2.1. Establish, apply and maintain knowledge of the clinical, socio-behavioral, and fundamental biomedical sciences relevant to Psychiatry and to the elderly patients. The resident develops competence to interview, assess and treat elderly patients with mental illness. The level of competence in each of the knowledge skills and attitudes must be assured at the level of Introductory or Working Knowledge for purpose of core competence in each of:

2.1.1. Residents, dealing with elderly patients will achieve working knowledge level in the following:

2.1.1.1. Etiology, symptoms, course of illness and treatment of:

2.1.1.1.1. Anxiety disorders in late life
2.1.1.1.2. Adjustment disorders and V codes in late life.
2.1.1.1.3. Alcohol and other substance abuse disorders in late life.
2.1.1.1.4. Behavioral and psychological symptoms of dementia (BPSD).
2.1.1.1.5. Delusional disorders and other psychoses occurring in late life.
2.1.1.1.6. Dementias including Alzheimer and Vascular dementias. Introductory level knowledge of less common dementias, such as Lewy Body Dementia, Fronto-temporal Dementia
2.1.1.1.7. Delirium and the disturbed behavior resulting from this condition.
2.1.1.1.8. Developmental disabilities, including mental retardation in older patients.
2.1.1.1.9. Mood disorders in late life.
2.1.1.1.10. Movement disorders, both resulting from degenerative brain conditions and secondary to pharmacotherapy side effects.
2.1.1.1.11. Personality disorders continuing into late life.
2.1.1.1.12. Psychiatric disorders secondary to medical conditions.
2.1.1.1.13. Psychiatric complications of neurodegenerative diseases such as Parkinson’s Disease
2.1.1.1.14. Psychotherapeutic constructs – individual, family and group, as appropriate to the elderly
2.1.1.1.15. Schizophrenia, both late onset and early onset, in patients who have aged.
2.1.1.1.16. Sleep disorders in the elderly.
2.1.1.1.17. Somatoform disorders.

2.1.1.2. Mental Health legislation and regulations as they pertain to the elderly, including dependant adult legislation, mental health acts, physicians duty to report suspected lack of fitness to operate a motor vehicle, aware of provincial variation in these regulations across the country.

2.1.1.3. Normal and abnormal biological, psychological and cognitive aspects of the aging.

2.1.1.4. Psychopharmacology and somatic therapies appropriate and inappropriate as treatments for typical presentations in the elderly.

2.1.1.5. Systems of mental health care and delivery, community resources, institutions, services and alternative living environments available for the elderly.

2.1.1.6. Elder abuse.

2.1.1.7. Principles of capacity/competency determination in multiple domains, including the elderly persons’ ability to manage property, grant a power of attorney, consent to placement in a supervised living setting and consent to medical treatment.

2.1.1.8. Caregiver stress

2.1.2. Residents, dealing with elderly patients, will have an introductory knowledge of the following:

2.1.2.1. Etiology, symptoms, course of illness and treatment of:

2.1.2.1.1. Sexual dysfunction in the elderly

For Key Competency 3:
3. Perform a complete and appropriate assessment of elderly patients, at the junior residency level.

3.1. and functional and cognitive impairment.

3.2. Perform an appropriate physical and neurological examination, including an assessment for the presence of movement disorders in the elderly patient

3.3. Demonstrate working knowledge in selecting appropriate investigative methods in a resource effective and ethical manner including:

3.3.1. Medical investigation or consultation in elderly patients with co- morbid medical conditions

3.3.2. Collateral information gathering from multiple sources, in elderly patients who may not themselves be reliable sources of information.

3.3.3. Neuropsychological investigations

3.3.4. Structured cognitive, mood and behavioral assessment tools as required for the complete assessment of the elderly patient

3.3.5. Neuroimaging

3.4. Demonstrate working knowledge regarding appropriate assessment of capacity, in the elderly patient, in the possible specific domains of consent to medical treatment, manage property, designate a Power of Attorney or consent to placement in a supervised living environment, when so requested.

For Key Competency 4:
4. Use appropriate preventive and therapeutic procedural skills effectively for psychiatry practice involving elderly patients

4.1. Demonstrate working knowledge in implementing an effective management plan in collaboration with patients, their families/caregivers and referring health care professionals, including:

4.1.1. Developing and implementing an integrated bio-psychosocial treatment plan based on the complete assessment of the elderly patient, including:

4.1.1.1. Interpretation of results of appropriate laboratory investigations and radiological examinations as these relate to the elderly patient with psychiatric disorders and co-morbid medical conditions.

4.1.2. Assessing suitability for and prescribing appropriate psychopharmacological treatments in the acute and maintenance management of psychiatric disorders in elderly patients.

4.1.3. Assessing suitability for and prescribing somatic treatments such as ECT in elderly patients. Delivery of somatic treatments such as ECT may require collaboration with a Geriatric Psychiatrist.

4.1.4. Assessing suitability for, prescribe and deliver appropriate psychological treatment in elderly patients.

4.1.5. Assessing and managing treatment emergent side effects of psychopharmacological, somatic and psychological therapies in elderly patients.

4.1.6. Assessing and managing treatment adherence.

4.2. Demonstrate working knowledge in safely managing disturbed behavior in elderly patients presenting with delirium.

4.3. Demonstrate working knowledge of management strategies for behavioral and psychological symptoms of dementia (BPSD).

4.4. Ensure appropriate informed consent is obtained for therapies, from the capable elderly patient or substitute decision maker.

4.5. Ensure elderly patients receive appropriate end of life care.

For Key Competency 5:
5. Demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic.

5.1. Demonstrate effective, appropriate, timely performance of diagnostic procedures relevant to psychiatry involving elderly patients (including but not limited to diagnostic interviewing, standardized screening tool administration, and neuroimaging interpretation).

5.2. Demonstrate effective, appropriate and timely performance of therapeutic procedures relevant to Psychiatry involving elderly patients (including but not limited to ECT).

5.3. Ensure appropriate informed consent is obtained for procedures, from the capable elderly patient or substitute decision maker.

5.4. Appropriately document and disseminate information related to procedures performed and their outcomes.

5.5. Ensure adequate follow-up is arranged for procedures performed and that elderly patients and their families/caregivers are informed of the plan.

For Key Competency 6:
6. Recognize limits of expertise and seek appropriate consultation with other health professionals

Demonstrate insight into limitations of expertise via self- assessment

Demonstrate effective, appropriate, and timely consultation of another health professional as needed for optimal care of older persons with mental illness.

Arrange appropriate follow-up care services when needed for optimal care of older persons

Communicator

Key Competencies

1. Develop rapport, trust and ethical relationships with elderly patients and their families or caregivers
2. Accurately elicit and synthesize relevant information and perspectives of elderly patients and their families/caregivers, colleagues and other professionals
3. Accurately convey relevant information and explanations to elderly patients, families, caregivers, colleagues, and other professionals
4. Develop a common understanding on issues, problems, and plans with elderly patients, families, caregivers, colleagues and other professional
5. Convey effective oral and written information about a medical encounter

Enabling Competencies

For Key Competency 1:
1. Develop rapport, trust and ethical relationships with elderly patients and their families or caregivers

1.1. Respect the elderly patient’s confidentiality, privacy and autonomy.

1.2. Listen effectively to elderly patients and, when appropriate, to their substitute decision makers.

1.3. Recognize transference and counter-transference towards the aged and the aging process

1.4. Effectively facilitate a structured clinical encounter in a variety of settings where elderly patients are usually assessed, including community settings and long term care.

For Key Competency 2:
2. Accurately elicit and synthesize relevant information and perspectives of elderly patients and their families/caregivers, colleagues and other professionals

2.1. Gather information about a disease, but also about the elderly patients’ beliefs, concerns, expectations and illness experience.

2.2. Seek out and synthesize information from other sources, such as family, caregivers and other professionals. Information from the elderly patient may be inaccurate or incomplete if cognitive impairment is present.

For Key Competency 3:
3. Accurately convey relevant information and explanations to elderly patients, families, caregivers, colleagues, and other professionals

3.1. Deliver information to an elderly patient, family, caregivers, colleagues and other professionals in a humane manner and in such a way that it is understandable, and encourages discussion and participation in decision-making

For Key Competency 4:
4. Develop a common understanding on issues, problems, and plans with elderly patients, families, caregivers, colleagues and other professionals

4.1. Identify and explore problems from the elderly patient perspective.

4.2. Respect diversity and differences including the impact of gender, religion, cultural beliefs and other potential sources of difference on decision-making.

4.3. Address challenging communication issues such as sensory impairment, cognitive impairment, frailty and other communication issues pertinent to elderly patients.

For Key Competency 5:
5. Convey effective oral and written information about a medical encounter

5.1. Maintain clear, accurate and appropriate records.

5.2. Provide timely reports to referring colleagues in written and verbal form when requested.

5.3. Consider requests for information from other care providers and individuals; make appropriate decisions regarding release of clinical information.

Collaborator

Key Competencies

1. Participate effectively and appropriately in an interprofessional healthcare team as a junior resident
2. Effectively work with other health professionals to prevent, negotiate and resolve interprofessional conflict

Enabling Competencies

For Key Competency 1:
1. Participate effectively and appropriately in an interprofessional healthcare team as a junior resident

1.1. Clearly describe the roles and responsibilities of junior and senior residents caring for elderly patients, to other professionals, and the roles and responsibilities of other professionals within the geriatric health care team

1.2. Work with others, both within the team and with other members of the circle of care, to assess, plan, provide and integrate care for individual elderly patients (and groups of patients)

1.3. Participate effectively in interprofessional team meetings, in a way that is informed by an appreciation for relevant team dynamics

1.4. Enter into interdependent relationships with other professions for the provision of quality care. This may include working with primary care providers in a shared care model, community agency professionals, other community resource personnel, and other medical specialties as part of the extended health care team

1.5. Recognize the roles of family members and caregivers of elderly patients as important members of the health care team

1.6. Respect team ethics, including confidentiality, resource allocation and professionalism

1.7. Appreciate the contributions of local community resources, such as day and other respite programs, meals on wheels, seniors’ centres, home care agencies, driving testing facilities, and others, as integral components of the spectrum of services available to elderly persons and their caregivers

For Key Competency 2:
2. Effectively work with other health professionals to prevent, negotiate and resolve interprofessional conflict

2.1. Identify and address conflicts in the therapeutic environment or between providers effectively in order to enhance the therapeutic milieu. This may include conflict in any environment in which the patient resides, including inpatient units, long term care, or within a family care situation.

Manager

Key Competencies

1. Participate in activities that contribute to the effectiveness of their healthcare organizations and systems;
2. Manage their residency practice and career effectively;
3. Allocate finite healthcare resources appropriately;
4. Serve in administration and leadership roles, as appropriate for junior residents

Enabling Competencies

1. Participate in activities that contribute to the effectiveness of their healthcare organizations and systems

1.1. Describe the structure and function of the healthcare system as it relates to the provision of care to elderly individuals, including an awareness of health care financing and physician remuneration issues

2. Manage their residency practice and career effectively

2.1. Set priorities and manage time to balance patient care with other practice requirements and other activities

3. Allocate finite healthcare resources appropriately;

3.1. Recognize the importance of just allocation of healthcare resources for the elderly

4. Serve in administration and leadership roles, as appropriate for junior residents

4.1. Understand relevant elements of planning health care delivery concerning elderly patient

Health Advocate

Key Competencies

1. Respond to individual patient health needs and issues as part of patient care;
2. Respond to the health needs of the communities that they serve
3. Identify the determinants of health of the populations that they serve;
4. Promote the health of individual patients, communities and populations.

Enabling Competencies

1. Respond to individual elderly patient health needs and issues as part of patient care;

1.1. Identify the health needs of the elderly patient, even when numerous, or not presented overtly, and respond in a role appropriate fashion to issues where advocacy is required

2. Respond to the health needs of the communities that they serve;

2.1. Identify opportunities for advocacy, disease prevention, and health promotion for elderly individuals in the communities they serve, and respond appropriately

3. Identify the determinants of health of the populations that they serve;

3.1. Identify the determinants of mental health for elderly persons and communities, including barriers to access to care and resources

3.2. Demonstrate an awareness of the major barriers that stigma and ageism have on the patient, family, health profession and community, towards early detection, diagnosis and treatment of mental illness in the elderly

4. Promote the health of individual patients, communities and populations.

4.1. Demonstrate awareness of major regional, national and international advocacy groups in mental health care for older persons

4.2. Demonstrate the ability to advocate for older persons with other agencies and health professionals when elder abuse is present

Scholar

Key Competencies

1. Maintain and enhance professional activities through ongoing learning
2. Critically evaluate information and its sources, and apply this appropriately to practice decisions
3. Facilitate the learning of patients, other psychiatrists, families, students, residents, other health professionals, the public and others, as appropriate;
4. Contribute to the creation, dissemination, application, and translation of new medical knowledge and practices.

Enabling Competencies

1. Maintain and enhance professional activities through ongoing learning

2. Critically evaluate information and its sources, and apply this appropriately to practice decisions

2.1. Demonstrate the ability to critically appraise and integrate evidence from the literature into treatment decisions regarding older persons, recognizing the limitations in the literature when elderly population cohorts have not been specifically studied

3. Facilitate the learning of patients, other psychiatrists, families, students, residents, other health professionals, the public and others, as appropriate;

3.1. Participate in the education of family physicians, medical students, and members of the multi-disciplinary team, community agencies, families and non-family caregivers to facilitate optimal psychiatric care of older persons

4. Contribute to the creation, dissemination, application, and translation of new medical knowledge and practices.

Professional

Key Competencies

1. Demonstrate a commitment to their patients, profession and society through ethical practice;
2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation;
3. Demonstrate a commitment to physician health and sustainable practice

Enabling Competencies

1. Demonstrate a commitment to their patients, profession and society through ethical practice;

1.1. Exhibit appropriate professional behaviours in practice with patients, families and care providers of all types, including honesty, integrity, commitment, compassion, respect and altruism.

1.2. Demonstrate a commitment to delivering the highest quality care, to the process of regular self-assessment, and to maintenance of competence

1.3. Recognize and respond appropriately to ethical issues encountered in practice.

1.4. Recognize the principles and limits of patient confidentiality as defined by professional practice standards and the law

1.5. Demonstrate understanding and a capacity to apply legislation pertaining to health care consent, substitute decisions, and capacity evaluation in a way that allows for the protection of a vulnerable elderly person’s interests while also being respectful of the autonomy of the elderly patient

2. Demonstrate a commitment to their patients, profession and society through participation in profession-led regulation;

3. Demonstrate a commitment to physician health and sustainable practice