Residents will develop and demonstrate by their actions that they:

Patient Issues:

1. Consider first the well-being of patients. They will value "caring" as much as, or more than, "curing" in the appropriate context.
2. Show an awareness of their own strengths and limitations in dealing with aging, disability and death and knowledge of how this may affect their treatment of patients.
3. While appreciating their primary responsibility is to their patient, residents will incorporate the input of patients and their families in the planning of care and the setting of treatment goals, acknowledging the importance of the family (in the broadest sense) on the overall well being of the patient. Residents will integrate the patient's own belief and value structure in the development of a treatment plan. They will recognize the right of the competent patient to accept or reject any physician and any medical care recommended.
4. Demonstrate an awareness of the potential dangers of a patient's inappropriate dependency upon the formal health care system or other care providers. The resident will promote the patient's self-reliance, independence, and autonomy through promotion of self-care and respect of personal dignity.
5. Balance the proper use of investigations and treatment for individual patients with the social obligation to control health care cost by avoiding redundant investigations and treatments in the care of patients.
6. Incorporate validated basic and clinical research findings into clinical practice.
7. Manifest a commitment to life-long learning and desire to improve personal skills in order to provide better care.
8. When death of the person appears to be inevitable allow this to occur with dignity and comfort. The physician is under no obligation to provide futile treatment.
9. Balance the respect of autonomy with the duty to use their expertise for the benefit of patients. Where conflict occurs the resident should assess competency, ensure the patient is informed, listen, educate, correct misunderstandings, and try to persuade the patient to accept indicated treatment. In informed, competent patients, the wishes of the patient must be respected.
10. Demonstrate a willingness to receive and act upon feedback (both positive and negative) obtained from colleagues, other health care workers, patients, and their families/care-givers .

Team Issues:

1. Develop and maintain a team environment that respects and appreciates the skills of other health care professionals and informal care-givers.
2. Demonstrates an understanding of team dynamics and the problems which may occur in an interdisciplinary team. The resident should understand: common causes of team dysfunction; different types of team management methods; common causes of conflict in a team; case management principles; division of labour in the team and definition of individual responsibility in the team.

Health Care System Issues:

1. Recognize their professional limitations and accept the need to utilize the special skills of other consultants and health care practitioners to provide better care.
2. Respect the role of attending family physicians, actively soliciting their input in the assessment of older patients, in the development of a care plan, and in follow-up.

Ethico-legal Issues:

1. Protect information provided by or about patients, keep it in confidence, and divulge it only with the permission of the patient except when otherwise required by law.
2. Practice in a fashion that is above reproach and will not take physical (including sexual), emotional or financial advantage of the patient. The resident will inform the patient and the supervising physician when personal morality or religious conscience prevent the recommendation or performance of some form of therapy.
3. Before initiating research involving patients, ensure that such research is appraised scientifically and ethically, approved by a responsible committee and is sufficiently planned and supervised that individuals will not suffer harm.

Psychomotor Domain

By the end of training the resident will be able to:

Physician/Consultant Skills:

1. Assess a real or simulated clinical presentation of an older person with:
   • altered hearing and tinnitus
   • balance and/or gait disturbance
   • bleeding and bruising
   • bony fracture (hip, pelvis, tibial plateau, humerus)
   • constipation
   • cough
   • dental/oral complaints
   • depressed mood
   • disorders of sleep
   • disorder of speech and language
   • disturbances of vision and ocular movement
   • dizziness and vertigo
   • dyspnea
   • edema (including abdominal swelling and ascites)
   • failure to thrive/weight loss
   • falls
   • fatigue
   • fever and chills
   • foot problems
   • functional decline (impairments of basic and/or instrumental activities of daily living)
   • hypertension
   • intellectual impairment (delirium, dementia)
   • jaundice
   • joint pain (acute or chronic, monoarticular or polyarticular)
   • numbness and other sensory disturbance
   • pain (acute or chronic, generalized or localized)
   • paralysis
   • sexual dysfunction
   • skin rash
   • skin ulcer (i.e., decubitus ulcer, arterial ulcer, venous ulcer)
   • swallowing problems
   • tremors
   • urinary/faecal incontinence
   • weight gain or loss
   • other common clinical problems encountered in the frail elderly.
2. Obtain an accurate and reliable history from an older patient and/or care-giver which would include: a reported functional assessment (i.e., basic and instrumental activities of daily living), a thorough medication history, and a detailed psychosocial history (including factors such as values, motivation, morale, family and social interactions, household composition, and presence/type of actual or potential caregiver).
3. Perform and record an accurate and reliable integrated physical examination with specific attention to a cognitive status examination, screening for depression, screening for hearing and visual impairments, and an assessment of balance and gait. The examination will be modified and interpreted in light of the age of the patient.
4. Perform a task or symptom analysis where appropriate by: a) selecting a major symptom or disability, b) determining the exact maneuvers necessary to complete the task or define the exact components of the symptom, and c) determining the contributing causes for the symptom or disability by a targeted history, physical and laboratory evaluation.
5. Interpret the data obtained during the assessment of a patient in a meaningful fashion so that justifiable conclusions are made; construct a differential for the presentation(s) itemizing the more common potential causes/etiologies for the presentation(s); and, choose the probable underlying cause(s) for the presentation using diagnostic strategies such as probabilities, rules of simplification (where appropriate), and hypothetico-deductive reasoning.
6. Develop a rational, relevant, practical, and comprehensive management plan including the need for further diagnostic studies. This incorporates the concept of Comprehensive Geriatric Assessment which requires evaluation of medical, functional, cognitive-affective, and socio-environmental domains of the patient.
7. Identify other health care practitioners (including consultants) and available health care resources which can be utilized in planning the care of an older patient.
8. Assess an older person with multiple physical, cognitive/psychiatric, functional, and/or social problems. This requires the ability to deal effectively and efficiently with clinical complexity by strategies such as priorizing problems in consultation with the patient and other health care professionals when appropriate.
9. Communicate effectively with patients, care-givers, physicians, and other health care professionals. This includes the ability to convey bad news to patients and their families in a flexible, understanding and balanced manner.
10. The ability to identify a patient who is dying (having a progressive illness that is expected to end in death and for which there is no treatment that can substantially alter the outcome).
11. The ability to define Palliative Care (care directed towards improving the quality of life of those who are dying). This includes: the relief of pain and other symptoms (eg. dry/painful mouth, dysphagia, hiccups, abdominal distension, terminal restlessness); providing support for the dying patient and family; showing an understanding of the process of bereavement and ability to manage the psychological problems faced by patients and their caregivers.
12. Incorporating the knowledge and demonstrating the skills required for effective Palliative Care. This is based upon respecting the values and preferences of the individual patient. It requires effective communication skills and working with an interdisciplinary team that attends to the needs of the patient and caregivers.
13. Use the telephone effectively to assess and communicate with patients, care-givers, health care workers, other physicians, and community agencies.
14. Perform a competent consultation on referred patients to inform, educate, advise the referring physician and solve the problem(s) in as far as is possible, and to give the patient a realistic assessment of the problems while respecting the skills of the referring physician.
15. Demonstrate effective consultation by utilizing strategies to improve compliance with recommendations such as responding promptly to the request, providing frequent follow-up (when appropriate), verbal contact with the referring physician, and limiting the number of recommendations.
16. Demonstrate an understanding of family dynamics, and factors which cause family dysfunction.

Specific Geriatric Medicine Specialty Skills:

1. Conduct an accurate and reliable abbreviated cognitive screening examination such as the Folstein Mini-Mental State Examination.
2. Conduct an accurate and reliable screening assessment of both basic (bathing, dressing, toileting, transfer, continence, feeding) and instrumental (telephoning, transportation, shopping, meal preparation, medication management, housework, handyman work, management of finances) activities of daily living on an older patient using standardized self-report instruments such as the Barthel Index and the Lawton Scale.
3. Perform an accurate and reliable assessment of basic mobility skills (e.g., arise from sitting, walk 3 meters, turn, return to seat, sit down).
4. Administer accurately and reliably a screening instrument for depression such as the Yeasavage Geriatric Depression Scale (short or long versions) or other screening instrument that they can describe adequately (including content, sensitivity, specificity, method of administration and interpretation).
5. Conduct and/or participate in a multidisciplinary or interdisciplinary meeting in an effective and efficient manner.
6. Conduct and/or participate in a family conference in an effective and efficient manner.
7. Assess an older patient for the need or potential for rehabilitation and plan/implement rehabilitation in collaboration with the patient, family, consultants, and other health professionals (e.g. occupational therapist, physiotherapist). This would include setting treatment goals, predicting likely outcome, and determining likely duration of rehabilitation.
8. Assess an older patient for the need for both community-based and facility-based continuing care.
9. Perform a pre-operative assessment, including an evaluation of surgical risk, and provide support in postoperative management, with particular reference to the very elderly person.
10. Conduct a nutritional assessment of an older patient.
11. Identify indications for and demonstrate the ability to perform a home visit. This includes an assessment of the home for fall hazards, suitability for the patient, emergency assistance arrangements, modifications in place, or indicated but not currently in place, and proximity/helpfulness of neighbours/relatives. Medication availability/use, actual/required ADL skills, and presence/attitudes of care-givers should also be assessed during a home visit.
12. Assess whether an older patient is able to appreciate adequately the nature of a proposed treatment/intervention, its anticipated effect, and the alternatives (competency to consent to treatment).
13. Assess the competency of a patient to make personal decisions (e.g., self-care, choice of residence). This entails detecting the presence of cognitive impairment, assessing its severity, and determining its impact on decision-making capacity.
14. Assess older patients for financial competence, including evaluation of their ability to assign power of attorney.
15. Assess an older patient for testamentary capacity.
16. Assess the competency of a patient to drive a motor vehicle. This includes detecting conditions which may interfere with the person's ability to drive safely. Residents must be aware of their duty to inform the patient of such a finding and their responsibility in the province of practice to inform the Motor Vehicles branch of the provincial government.
17. Detect signs of care-giver stress and analyze specific causes. The resident then should be able to propose a plan to deal with the care-giver stress.
18. Detect risk factors and the presence of abuse of elderly patients. This requires the ability to define abuse of older adults, listing the various types of abuse. Residents should be able to demonstrate a strategy for preventing abuse of seniors. They should be able to clearly document on a medical chart direct quotes, observed behaviour, findings on physical assessment and interventions relating to suspected abuse. They should be aware of resources which can be of use in the management of a victim of elder abuse. Based on this knowledge and the assessment information, they should be able to develop and communicate a care plan for potential victims or actual victims of elder abuse.
19. Demonstrate the ability to detect and manage drug and alcohol-related problems. For example, screening for alcohol abuse may be done by use of the CAGE tool. The resident will be able to assess for abuse of CNS depressants such as benzodiazepines and narcotics. The resident must be aware of the common manifestations and complications of these substances of abuse, the features of withdrawal, and the treatment of substance-using behaviour. The resident will be aware of the various ways that alcohol abuse presents in the elderly, and different approaches to management.

Administrative/Educational Skills:

1. Teach effectively a variety of learners at different levels of need, utilizing a variety of techniques (e.g. lecture, case presentation/discussion).
2. Demonstrate knowledge of the skills needed to plan and manage health care services for the elderly. Planning entails identification of opportunities or problems, consideration of alternative strategies to act on opportunities or ameliorate the problems, and choosing the preferred means. Management requires understanding of budgeting and the control of performance. (Analysis of performance is where expected outcomes are compared with actual outcomes).
3. Demonstrate both knowledge of critical concepts and skills relating to the functioning of multidisciplinary and/or interdisciplinary clinical teams. This includes the ability to define teams, delineate membership, help set team goals/objectives, define tasks/roles of team members, provide leadership (when appropriate), determine how decisions are made, describe communication patterns, evaluate and provide constructive feedback, demonstrate abilities in conflict management and negotiation, and describe barriers to effective and efficient team care.
4. Demonstrate the ability to be an effective member or officer of a committee. This entails knowledge of the purposes of committees; required actions before a meeting; how a meeting proceeds; how to participate in a meeting; the role of the chair, the secretary, the treasurer and other officers; writing of minutes; action to be taken after a meeting; types of meetings (formal meetings, formal committees, informal committees, working parties and discussion groups, negotiations, clubs and societies, conferences and seminars); problems with meetings; analyzing meetings; preparing and presenting reports to meetings; and committee language.
5. Demonstrate the competencies required for physician leadership. These include the ability to: empower/develop other workers; be persuasive; articulate program/institutional mission or goals; lead a group, negotiate, and build relationships with stakeholder groups. The resident will manifest an awareness of how an organization works by demonstrating sensitivity to power and influence relationships.
6. The resident shall understand the principles of program evaluation.

Cognitive Domain

By the end of training the resident will be able to:

Basic Gerontology:

1.      Recite or write definitions for key concepts of basic gerontology such as aging, senescence, and types of aging (i.e., successful, usual, pathological).

2. Outline current theories of aging, mechanisms of aging, and theories about the evolution of senescence. This includes knowledge about the inter-species variability in aging and senescence and animal models of these phenomena.
3. Demonstrate familiarity of the molecular/cellular changes with aging.
4. Recite or write a list of age-associated changes in the anatomy/composition of older persons and in organ function (including sexual function) and demonstrate the ability to identify how these normal age-associated changes may alter disease presentation and/or response to treatment.
5. Demonstrate knowledge of the increasing inter-individual variation of older patients as compared to younger patients.
6. Explain the relationship between aging and disease(s).
7. Demonstrate knowledge of the psychology of aging and psychological theories for successfully aging, specifically disengagement, activity, and continuity theories.
8. Define and demonstrate the ability to detect "ageism" (negative stereotyping of elderly individuals). Give at least three strategies to counteract this (e.g., education, confrontation, reassign staff).
9. Define life-span, life expectancy, active life expectancy, homeostasis, and vigour.
10. Demonstrate the ability to apply basic knowledge to clinical practice (e.g., changes in receptor function, altered effects of drugs and hormones, interpretation of drug levels).

Clinical Epidemiology:

1. Demonstrate (orally or in writing) an understanding of the importance of subject selection and study design (i.e., cross-sectional versus longitudinal) in the interpretation of clinical and gerontologic research. List and explain issues such as validity, reliability, sensitivity to change, and, where applicable, methods of administration (i.e., self-report, performance-based) in the use of standardized instruments for the assessment and monitoring of older patients and in the use and interpretation of laboratory investigations.
2. The resident shall have the skills required to appraise the medical literature including the critical evaluation of proposed treatments for medical conditions. Residents will be able to conduct a literature search independently.
3. Demonstrate (orally or in writing) awareness of the changes in the demographic structure of Canadian society and their implications for physicians and the entire health care system. This includes the ability to summarize morbidity trends (including projections for incidence and prevalence of diseases), mortality trends, and prevalence/distribution/and future projections for disability in Canadian seniors.
4. Demonstrate ability to critically appraise the geriatric medicine literature.

Pharmacology:

1. Define and identify iatrogenic illness, in particular adverse drug reactions.
2. Identify (orally or in writing) change in the pharmacokinetics and pharmacodynamics of medications as a function of increasing age.
3. Demonstrate knowledge of the indications, effectiveness, significant potential drug interactions, significant potential drug-disease interactions, potential adverse effects, cost, and alternatives for commonly used medications in the elderly. A partial listing is as follows: analgesics (non-narcotics, narcotics), antibiotics, anticoagulants, anti-depressants, anti-Parkinsonian medications, cardiovascular agents (ACEI, digoxin, nitrates, calcium channel blockers, beta blockers), diuretics, estrogen replacement therapy, inhaled bronchodilators, insulin/oral hypoglycemics, laxatives, lipid lowering medications, medications for urinary incontinence, (e.g., autonomic nervous system medications), neuroleptics, NSAID, peptic ulcer medications, sedative - hypnotics, steroids, theophylline preparations, thyroid replacement therapy, vaccines, vitamins and mineral supplements.
4. Demonstrate a strategy to review and attempt to reduce medication use if appropriate in older patients.

Health Care System:

1. List the range of resources and their relative strengths and weaknesses available to help in the management of an older patient including community-based long term care, institutional-based long-term care facilities, voluntary agencies, and support from family and other informal care-givers.
2. Demonstrating a knowledge of its financing, organization, respective government jurisdictions, roles/functions of various types of health care practitioners, and roles/types of various types of healthcare agencies/institutions. Demonstrate (orally or in writing) a recognition of the financial aspects of health care, including the need to balance what is "best" for an individual patient with the necessity to control health care costs for society.
3. Demonstrate knowledge of the training, expertise, and government regulations for licensure and referral for members of the core multi-disciplinary team (nursing, occupational therapy, physiotherapy, social work) and selected members of the extended team (speech language pathology, clinical nutrition, pharmacy, psychology).
4. Define long term care. Contrast the indications, relative benefits/risks of institutional and community-based long-term care. Residents will be able to describe the long-term care system and the process of assessment for placement in a facility for their province of practice.

Ethico-Legal:

1. Show the ability to identify ethical issues in clinical practice of Geriatric Medicine and research. This includes principles of biomedical ethics (autonomy, beneficence, non-maleficence and justice) and performing an ethical analysis of clinical problems. Such analysis will aid in decision making, govern choices and help patients and families deal with difficult situations.
2. Demonstrate (orally or in writing) a recognition of the legal/ethical issues pertaining to the care of an older patient such as the assessment of mental competency, and outline the role of the physician in these areas.
3. Define Advance Directive (both Proxy and Treatment), Living wills, Power of Attorney (including Enduring), Guardianship and Trusteeship.
4. Demonstrate the ability to identify ethical issues in clinical practice and research, for example,
   • Distributive justice in an aging society: for example is it ethical to limit health care for the elderly, and ration scarce resources on the basis of age alone?
   • Aging and filial responsibility (eg. topics like "what do children owe their parents?"; the role of others in medical decision making).
5. Demonstrate knowledge on how to determine treatment choices for an incapacitated individual utilizing techniques such as determining the presence of advance directives/living will, obtaining a value history of the person, and determining a surrogate decision-maker for an incapacitated patient.

Geriatric Medicine:

1. Demonstrate knowledge of the types and increasing number of chronic medical problems encountered in older patients and the effect this has on the presentation and management of older patients.
2. Demonstrate knowledge of the various ways illness can present in an older patient such as the classical/medical (symptoms/signs corresponding directly to a specific disease), synergistic morbidity (multiple, generally chronic diseases each contributing to a common, cumulative morbidity), and the unmasking (the occurrence of a stressful event unmasks an underlying, stable or slowly progressive chronic condition) models.
3. Demonstrate (orally or in writing) detailed knowledge of those disease entities which are particularly common in older patients. This knowledge would incorporate currently accepted etiologies, pathophysiology, clinical manifestations, laboratory findings, methods of prevention, methods of treatment and prognosis. This would include knowledge of the following disease states: anemia (various types), anxiety disorders, atherosclerosis, benign prostatic hypertrophy, breast cancer, cardiomyopathy, cataracts, cervical/uterine cancer, chondrocalcinosis and calcium phosphate dihydrate crystal deposition disease (e.g., pseudogout), chronic obstructive lung disease, colon carcinoma, common arrhythmias (e.g., atrial fibrillation, premature atrial and ventricular beats), congestive heart failure, degenerative disk disease/disk herniation, various foot disorders, dehydration and other disorders of fluid and electrolyte balance, delirium, dementia (Alzheimer's disease and other types), depression, diabetes mellitus, diverticular disease, gallstones, glaucoma, gout, herpes zoster, hip fractures, hypercalcemia, hyperparathyroidism, hypertension, hyperthyroidism, hypothyroidism, ischemic heart disease, lung cancer, macular degeneration, osteoarthritis, osteomalacia, osteoporosis, ovarian cancer, Paget's disease of the bone, pancreatic carcinoma, paranoid states, Parkinson's disease and other movement disorders, peptic ulcer disease (including NSAID-induced gastropathy), peripheral vascular disease, pneumonia, polymyalgia rheumatica and giant cell arteritis, presbyacusis, presbyesophagus, prostate cancer, protein-calorie malnutrition, respiratory failure (acute and chronic), rheumatoid arthritis, skin cancer (basal cell, squamous cell, melanoma), soft tissue MSK disorders (e.g., bursitis, tendonitis, rotator cuff impingement), stomach cancer, stroke, tuberculosis, urinary tract infections, uterine prolapse/cystocele /rectocele, valvular heart disease (eg., aortic stenosis), venous disease and thrombophlebitis/pulmonary embolism, and other disease entities encountered commonly in the elderly.
4. Describe (orally or in writing) the relevant anatomy and physiology of micturition, defecation, cognition and balance/gait. The resident will be able to relate how they change as a consequence of increasing age and how they are affected by various pathological states.
5. Define Comprehensive Geriatric Assessments (a multidisciplinary evaluation in which the multiple problems are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person's problems). The resident will state where this approach offers advantages over traditional care.
6. Identify measures to promote health and/or prevent disease by utilizing recognized preventive health care practices in various populations of seniors. This includes the ability to define and give examples of primary, secondary, and tertiary prevention.
7. Interpret the results of a mental status examination, Geriatric Depression Scale, assessment of basic/instrumental activities of daily living, and an assessment of basic mobility skills in a meaningful manner so that justifiable conclusions are reached.
8. Demonstrate knowledge of the indications, effectiveness, cost, and potential adverse effects of medical devices such as assistive devices for ambulation (canes, crutches, walkers, wheelchairs), incontinence supplies/devices (e.g., condom catheter, catheter padding), common orthotic devices/prostheses, and ADL aids.
9. Identify the frail elderly who are the target population for specialized geriatric medicine programs. This group manifests, or are at high risk for developing functional dependency and loss of autonomy.
10. Demonstrate knowledge of the indications, types, benefits, and risks of exercise in various populations of seniors. This also incorporates knowledge of the effects of inactivity/deconditioning.
11. Demonstrate knowledge of the principles of rehabilitation in the elderly. Rehabilitation is a comprehensive effort that incorporates physical, emotional, and social parameters in the process of care. It is a team effort that is multidisciplinary in membership and interdisciplinary in process. It focuses primarily on function and is not necessarily a limited intervention. It may be continuous and on-going.
12. Demonstrate the ability to manage chronic pain in an older patient. This entails knowledge of the pathophysiology of pain, its evaluation, and general management (both pharmacological and non-pharmacological).
13. Define impairment, disability, and handicap, indicating the relationship between the three.
14. Demonstrate knowledge of the indications, benefits, and risks of functional electrical stimulation, transcutaneous electrical nerve stimulation (TENS), thermal agents (superficial heat, diathermy, ultrasound, and cold therapy).

SPECIALTY REQUIREMENTS: Internal Medicine

        Approved residency in geriatric medicine.

PROGRAMS (WITH TRAINING REQUIREMENTS):

Diplomas(Dip):

Six months of approved residency training.

Doctor of Medicine(M.D):

Eighteen months of approved residency training.

Doctor of Philosophy(Ph.D):

Forty eight months(four years)of approved residency training.