Harborview Medical Center

Gerontology Service

Faculty Contact
Itamar Abrass, MD
Professor of Medicine
Division Head, Medicine/Gerontology and Geriatric Medicine

Box 359755
325 9th Avenue
Seattle, WA 98104

Phone: (206) 341-4500
Email: itamar@uw.edu

Overall Educational Purpose
· To learn an interdisciplinary approach to health care of older adults including:
· Diagnosis and management of medical problems of older adults.
· Medical care of the older surgical patient, including pre-operative evaluation and post-operative management.
· Comprehensive assessment of functional status and appropriate levels of care.
· Discharge planning to optimize use of community and outpatient services available to older adults.
· Assessment and management of ambulatory community-based older adults.
· Care of institutionalized long-term care patients.

Team Structure
· Attending
· Fellow
· R2/R3
· R1

Principle Teaching Methods
Case discussion and review
Case discussions and reviews occur during attending rounds, during interdisciplinary team rounds, and during consultation rounds. In the clinic setting, all cases are discussed at the time of the patient visit. Institutionalized long-term care patients are discussed during rounds at the facility.

Core topics are covered during discussion sessions included in attending rounds.

Didactics in geriatrics include Geriatric Grand Rounds (clinical topics), journal club (critical review of the literature), and research conference (research in progress) on a weekly basis. Residents also attend Medical Grand Rounds, Resident’s Conference, and Chief of Service Rounds.

Educational Content
Mix of Diseases
Patients presenting to the inpatient or outpatient services demonstrate a full range of acute and chronic medical problems seen in older adults. The inpatient unit accepts transfers from other services with few direct admissions. Since there is an active consultation service, patients with acute surgical problems, particularly trauma and orthopedic patients, are frequently seen. Special interest is in those patients with multiple interacting problems that threaten independent function.

Patient Characteristics
All patients are 65 years of age or older. Although patients represent a full spectrum of socioeconomic status, many are frail and indigent. The ethnic mix reflects that of the City of Seattle and King County.

Types of Clinical Encounters
Patients seen during the rotation are inpatients, outpatients, and residents of a long-term care facility. Residents perform full history and physical at the time of the first encounter, and are responsible for the daily care and management of inpatients on the geriatrics unit. Consultations include initial visit and follow-up until discharge or transfer to the geriatrics service.

Outpatient visits include initial assessment and development of a management plan. Care at the long-term care facility is in conjunction with an on-site nurse practitioner.

Although procedures such as paracentesis, thoracentesis, arthrocentesis, and lumbar puncture are occasionally performed, most patients on the service are sufficiently stable not to require procedures such as placement of arterial or central lines. A procedure relatively unique to the service is bedside urodynamics.

Harborview Medical Center has a full range of services for patient care including emergency room, intensive care units, radiology, laboratory services, and a full mix of medical and surgical services and consultants.

Rotation Specific Schedule
10:00-11:00 Residents’ Report (2WH-81)
11:00-12:30 Attending Rounds (4EH)

8:00-12:30 Clinic (4W Clinic)
12:00-1:00 Chief of Service Rounds (R&T)
1:45-2:45 Interdisciplinary Team Conference (4EH)
2:45-3:45 Psychiatry Rounds (4EH)

10:00-11:00 Residents’ Report (2WH-81)
11:00-12:30 Attending Rounds (4EH)

8:00-9:00 Grand Rounds
9:15-10:15 Resident Teaching Conference
11:30-12:00 Interdisciplinary Team Conference (4EH)
12:00-1:00 Interns’ Report (R&T)
1:00-4:30 Clinic (4WH)

8:00-9:00 Division Conference (R&T 117)
10:00-11:00 Residents’ Report (2WH-81)
11:00-12:45 Attending Rounds (4EH)

Call and Weekend Responsibilities
Call is from home alternating one week on and one week off. R1s are on with the Fellow and Attending. R2/3s are on with the Attending. Weekends alternate as the week on call.

Principle Educational Materials Used
Recommended Readings
At the beginning of the rotation, all residents are given an orientation package that includes among other issues goals of the rotation, specific responsibilities (their own and those of other members of the interdisciplinary team), core topics to be mastered, and the evaluation format. Each resident receives, compliments of the Division, a copy of Essentials of Clinical Geriatrics (3rd Ed) Kane, Ouslander, Abrass for their own library to be used as core reading material for the rotation. Reprints of core manuscripts on geriatric topics are kept in a binder on the inpatient unit as a reference source. The Division library is also available to residents, as are the reprint files of the Division faculty.

Methods Used in Evaluating Resident and Program Performance
At the end of the rotation, the resident is evaluated in writing and their performance reviewed with them verbally by every attending and fellow he or she has interacted with for a significant amount of time. The evaluator rates the resident on a nine-point scale in each component of clinical competence (i.e. patient care, medical knowledge, practice based learning improvement, interpersonal and communication skills, professionalism, system based learning, educational attitudes, leadership, overall clinical competence).

The resident is given the opportunity to evaluate in writing the quality of the curriculum and the extent to which the educational goals and objectives of the rotation have been met. The resident also evaluates the teaching competence of each attending and fellow with whom s/he has interacted for a significant amount of time.

Explicit Lines of Responsibility for Care of Patients on this Service
A faculty member of the Division of Gerontology and Geriatric Medicine directly supervises all patient care, in all settings. All patients are discussed and the attending physician sees and examines all patients. On the inpatient and consultation services a geriatric medicine fellow provides supervision for residents and students.

R1 level residents are primarily responsible for caring for inpatients on the geriatrics service under direct supervision of an R2/R3 level resident. Geriatric medicine fellows and attending physicians are also involved in supervision of the service. The R2/R3 level resident has primary responsibility, in concert with the geriatric medicine fellow, for consultations.


Last Revised February 10, 2004 by Itamar Abrass, MD