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  DIVISION OF GERIATRICS
 
Geriatric Services
  Fellowship Program
 
 
King/Drew Medical Center Geriatrics Fellowship Program

Faculty

Chief and Program Director: Arnel M. Joaquin, M.D.

Attending Physicians
Merlyn Asuncion, M.D. - Assistant Professor of Medicine
Kalpana Ganesan, M.D. - Associate Professor of Medicine
Vinod Patel, M.D. - Assistant Professor of Medicine
Rafael Salas, M.D. - Assistant Professor of Medicine
Sunil Singhania, M.D. - Assistant Professor of Medicine

OBJECTIVE

To provide a culturally sensitive comprehensive geriatric care in the urban minority community that is adaptable to the community's ever changing needs and to the evolving standards of care in the medical arena.
  1. LEARNING OBJECTIVES
    1. Acquire knowledge and/or management skills in the following areas:
      1. Theories and mechanisms of aging
      2. Biological changes of aging
      3. Pathophysiology of common illnesses of aging
        • Dementia
        • Cardiovascular disease
        • Arteriosclerotic heart disease
        • Valvular heart disease
        • Hypertension
        • Peripheral vascular disease (including aneurysms)
        • Depression
        • Parkinson's Disease
        • Falls
        • Chronic obstructive lung disease/pulmonary function
        • Pneumonia (including tuberculosis)
        • Urinary incontinence/renal function
        • Urinary tract infection
        • Prostatic disease
        • Diabetes mellitus
        • Thyroid disorders
        • Calcium metabolism and disorders
        • Osteoporosis
        • Crystalline joint disease
        • Osteoarthritis
        • Rheumatoid arthritis
        • Polymyalgia rheumatica/temporal arteritis
        • Paget's disease
        • Osteomalacia
        • Hip fractures
        • Cerebrovascular diseases
        • Diverticulosis
        • Decubitus ulcer
        • Herpes zoster
        • Skin disorders (actinic keratosis, cancers, seborrhea keratosis)
        • Postmenopausal complications
        • Thermoregulation (beat and cold disorders)
        • Anemia
        • Malignancy (lymphoproliferative. myeloproliferative. leukemias)
        • Malnutrition
        • Alcoholism
        • Visual impairment
        • Hearing loss
        • Dental/oral problem
        • Sexual dysfunction
      4. Clinical pharmacology
      5. Psychosocial aspects of aging
      6. Principles of geriatric rehabilitation
      7. Preoperative assessment and Postoperative management
      8. Preventive medicine (screening, immunization, exercise, nutrition)
    2. Acquire clinical skills
      1. Obtain complete and accurate medical and psychosocial history of the elderly including level of function, living status, support systems and interpersonal interactions,
      2. Perform a complete and relevant physical examination with special attention to the following:
        1. Orthostatic changes in blood pressure and pulse
        2. State of nutrition, level of communicability
        3. Skin: decubiti, xerosis. excoriation, ischemic changes, tumor, trauma
        4. Eyes: Visual acuity, tonometry, peripheral vision, cataracts
        5. Ears: hearing acuity and vestibular function
        6. Mouth: dentition, oral lesions, xerostomia
        7. Cardiovascular: murmur, gallops, bruits, peripheral pulses, aneurysms
        8. Pulmonary: chest deformity, respiratory excursion, sputum production
        9. Abdomen: masses, aneurysm, organomegaly. hernias, fecal impaction rectal mass, occult fecal blood
        10. Genitourinary: testicular or scrotal masses, Prostate, bladder distention, pelvic examination
        11. Musculoskeletal: gait, posture, joint deformities, mobility, range of motion, edema. venous insufficiency, ulcers, callous
        12. Neurological: mental status (Folstein), speech, tremors, peripheral neuropathy
    3. Develop an appropriate diagnostic approach to common symptom complexes in the elderly
      1. Weight loss
      2. Anorexia, nausea or vomiting
      3. Fatigue, malaise or weakness
      4. Falls, syncope, dizziness or drop attack
      5. Urinary incontinence
      6. Depression, apathy or insomnia
      7. Recent memory loss, disorientation or dementia
      8. Constipation or diarrhea
      9. Gastrointestinal bleeding
      10. Fever
      11. Pain syndromes (chest, back, abdomen etc.)

    4. Develop skills in interacting with other health care professionals (interdisciplinary, multidisciplinary or team approach)
      1. Nurses
      2. Social workers
      3. Psychologists
      4. Physical and occupational therapists
      5. Pharmacist
      6. Dietician

    5. Ambulatory management of elderly patients
      1. clinics
      2. Residential and senior centers
      3. Home visits

    6. Skills and knowledge in long-term care
      1. Community nursing home
      2. Veterans administration nursing home
      3. Non-institutional settings (e.g., home, senior centers)

    7. Acquire teaching skills
      1. Inservices
      2. Formal didactics
      3. Seminars
      4. Clinical bedside teaching rounds
      5. Regional and national conferences

    8. Acquire research skills
      1. Epidemiology, research design and biostatistics
      2. Identify a research problem
      3. Review relevant literature
      4. Design, conduct and analyze data of research project
      5. Write a grant proposal
      6. Write papers
      7. Write and present abstracts at national meetings

    9. Acquire knowledge and skills in administration
      1. Conduct and organize conferences and team meetings
      2. Prepare budgets for research
      3. Prepare reports an evaluation of health care personnel
      4. Meet with health care members to resolve administrative issues
      5. Meet with administrators of nursing home, training programs and geriatrics services
  2. FACILITIES
    1. Senior Treatment and Restorative (STAR) Unit

      Description: The Star Unit has a capacity of 11 beds and is located in 3B. Patients are admitted directly from ER, Outpatient Clinics or transferred from other services including Internal Medicine, Surgery, Orthopedics, OB-Gyn, etc. All patients 65 years and older with acute medical problems may be referred for transfer to the geriatric unit. Patients between the ages 55-65 years are admitted on a case by case basis.
      Exclusion criteria are:
      1. Patients needing monitored or critical care bed
      2. Patients whose acute problems are resolved and ready to be discharged*

      * patients who have a need for skilled nursing placement prior to discharge may be referred to the Geriatric service for continuity of care in an affiliated facility.

    2. LONG-TERM CARE - SKILLED NURSING CARE (Pending)

      The 5 full-time faculty and 2 part-time faculty from the Division of Geriatrics at KDMC, will supervise the training in this facility. Each attending physician will supervise fellows, residents and medical students in regular weekly rounds at the nursing home (see typical schedule). In this experience they will learn nursing home policies and procedures, common problems that can be handled in a skilled nursing facility as opposed to acute hospital, and administrative skills pertaining to nursing homes.

    3. OUTPATIENT SERVICES

      Description: The Hubert Humphrey Comprehensive Health Center Geriatrics Clinic is a primary care clinic serving elderly patients 65 and above (exceptions to age cut-off are on a case to case basis). Patients are screened medically and functionally and a comprehensive geriatric assessment is done on selected patients who are identified to have problems with the initial screening. Multidisciplinary approach is emphasized. Patients discharged from any specialty in the hospital may be referred, as well as from the emergency department. Clinic hours are Mondays, Thursdays, and Fridays 8:30 AM -12 Noon.

    4. OUTREACH HEALTH SCREENING PROJECT

      Description: The Outreach Clinics are on-site health screenings for elderly residents in the community. This is funded through the City of Los Angeles Department of Aging and currently about 15 health centers are involved throughout LA County. This is a service oriented project, and the elderly patients are screened for medical conditions and referred to their personal physician or to a physician in their vicinity if they do not have one.

  3. LECTURES, TOPIC SESIONS, JOURNAL CLUBS
    Selected topics in Geriatrics are given by trainees and attending physicians on a regular basis. The following are some of the topics covered throughout the year:
    • Allergy problems of the elderly
    • Ambulatory care of the elderly
    • Aminoglycoside therapy in the aged
    • Anemia and hematologic disorders in the elderly
    • Anesthesia: Preparing the elderly patient for surgery
    • Antimicrobial therapy in the aged
    • Arthritis in the elderly
    • Biological changes with age
    • Cancer and cancer screening of the elderly
    • Cardiovascular disease in the aged
    • Cerebrovascular disease in the elderly
    • Death, attitudes of the elderly toward
    • Dementia, approaches to in the elderly
    • Demography of aging
    • Dental problems of the geriatric patient, common
    • Depression in the aged
    • Diabetes and the elderly
    • Discharge planning and placements: Decisions and dilemmas
    • Diverticular disease in the elderly
    • Elder abuse, the medical and psychosocial aspects of
    • Gram-negative sepsis in the elderly
    • Hearing system, effects of aging on the
    • Hospice
    • Immunology of aging
    • Improving the quality of life in a geriatric setting
    • Infection in the aged
    • Kidney, the aging
    • Learning and memory problems of the elderly
    • Long-term care and the elderly
    • Lung disease in the elderly
    • Marriage and the family in old age
    • Nurses and nurse practitioners, roles of in geriatrics
    • Parkinson's disease
    • Peripheral vascular surgery, indications for surgery in the elderly
    • Problems of aging and aged: An overview
    • Problems of psychological and behavioral assessment of the elderly
    • Psychosocial aspects of aging
    • Psychotropic drugs and the elderly
    • Rehabilitation and the aged
    • Senile dementia
    • Skin problems of the elderly, common
    • Spiritual assessment and the needs of the elderly
    • Social services, the aged and
    • Stroke patient, principles of rehabilitation in the
    • Suicide in the elderly Theories of aging
    • Urinary Tract Infections: Special problems in the aged

  4. DURATION OF PROGRAM
    The fellowship program is accredited for 1 year.

  5. FELLOWSHIP ROTATIONS
    Required rotations:
Geriatric Fellows Typical Schedule

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
Fellow
1		 AMB/
NH		 AMB/
NH		 AMB/
NH		 RES/E AGS GP/
NB		 CS AGS RES/
E		 CS AGS CS
Fellow
2		 AGS RES/
E		 CS AMB/
NH		 AMB/
NH		 AMB/
NH		 AGS GP/
NB		 CS RES
/E		 CS AGS
Fellow
3		 CS AGS RES/
E		 AGS CS CS AMB/
NH		 AMB/
NH		 AMB/
NH		 AGS GP/
NB		 RES/
E
Fellow
4		 RES/
E		 CS AGS CS RES/
E		 AGS GP/
NB		 CS AGS AMB/
NH		 AMB/
NH		 AMB/
NH

Key:

AGS/C: Acute Geriatric service / Consultations (Daily Rounds)
AMB/NH: Ambulatory Clinics - Mon, Thurs, Fri AM Geriatrics Clinic
CS: Community Screening - Wed (AM), Thurs (PM) (Senior Centers), Fri (AM) Geriatric Clinic
GP/NB: Geropsychiatry/Neurobehaviour
E: Elective
RES: Research

Vacation: 20 Days - May be taken in a few days increments at any time provided there is arrangement for coverage

Back - up System: For emergency coverage only
Fellow 1 - Fellow 2
Fellow 3 - Fellow 4

Continuity Clinics: Thurs AM - Fellow 1, 3
Friday AM - Fellow 2,4

Acute Geriatrics Service/Consultations (3-4 months)
Location: 4C, based on availability of beds
# of Beds: 15

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
AM 8:30-9:30 Morning Report/M and M, etc Attending Consultation/Work Rounds (time by internal arrangement) 10:30-12 Chair Geriatric Rounds Attending Consultation/Work Rounds (time by internal arrangement)
9:30-11:00 Attending Rounds
Work Rounds 11-12 Grand Rounds Work Rounds Work Rounds Work Rounds
Lunch (Geriatrics Grand Rounds every 1st and 4th Wednesday)
PM Consultation/Work Rounds
Education/
Research time		 1-2 PM Subspecialty Geriatric Lecture 2-4 Staff Meeting (twice a month) Education/
Research time		 1:30-2:30 Core Lecture

Emergency Coverage 5 PM to 8 AM Internal Medicine team on call
Medical Resident, Fellow and Attending Physician available 24 hours on beeper
Fellows may arrange for weekend coverage with other fellows internally
Residents may also make arrangement for weekend coverage with other residents
Fellows are required to attend continuity clinics (once a week)

Ambulatory Clinics/Nursing Home (3-4 months)

Monday Tuesday Wednesday Thursday Friday
AM 8:30-12 Geriatrics Clinic Education/Research time

11-12 Grand Rounds		 Education/Research time 8:30-12 Geriatrics Clinic 8:30-12 Geriatrics Clinic
Lunch (Geriatrics Grand Rounds every 1st and 4th Wednesday)
PM NH Rounds with Attending Physician NH work rounds/Education time Education/Research time

2-4 Staff Meeting (twice a month)		 Education/Research time NH work rounds

* Nursing home rotation pending

Home Health/ Community Screening, Friday AM Geriatrics Clinic (3-4 months)

Monday Tuesday Wednesday Thursday Friday
AM 8:30-12 Geriatrics Specialty Clinic Home visit 8:30-11

11-12 Grand Rounds		 8-12 HELP Community Screening Continuity clinic Continuity clinic
Lunch (Geriatrics Grand Rounds every 4th Wednesday)
PM Education/Research time 1-2 Geriatrics Specialty Lecture Series Education/Research time

2-4 Staff Meeting (twice a month)		 1-5 HELP Community Screening Education/Research time

Fellows are required to attend 1 continuity clinic per week.
Occasionally, weekend Free Clinics are arranged. Fellows are required to attend.

Geropsych/Neurobehaviour Rotation (1 month)
Coordinator: Gloria Rodriguez
Phone: 323-563-4959
Fax: 310-637-3765

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:30-12 Memory Disorder Clinic
Dr. Saxton		 Rounds with Geropsych Team

11-12 Grand Rounds		 Rounds with Geropsych Team Rounds with Geropsych Team

or

* 8:30-12 Continuity Clinic		 Rounds with Geropsych Team

or

* 8:30-12 Continuity Clinic		 Rounds with Geropsych Team Rounds with Geropsych Team
Geriatrics Grand Rounds every 1st and 4th Wednesday
Geropsych consults
Education
Research time

4-5 UCLA Brain
Matters Lecture Series**		 1-2 Geriatric Specialty Lecture Geropsych consults
Education
Research time		 Geropsych consults
Education
Research time		 Geropsych consults
Education
Research time

* Fellows are required to attend one continuity clinic every week.
Dr. Loreta Mulokas, Rm. 1078 Augustus F Hawkins Bldg. pager 310-501-8914

Brain Matters Lecture series, Room C-240 (Street Level) Reed Building, 710 Westwood Plaza

Call Schedule:
No in-house calls, fellows are required to have beeper calls for the nursing home and inpatient services.
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