Education Columns

John Fleming, MD, past director, Geriatric Fellowship, Florida Hospital Family Medicine Residency, Orlando, FL

Clinical experience with a geriatric patient population is required for family medicine resident physicians. A unique setting for this experience can be found in a Continuing Care Retirement Community (CCRC), providing interaction with patients in Skilled Nursing and Assisted Living units within the facility, as well as the interdisciplinary staff.

Since 1992, the Florida Hospital Family Medicine Residency Program has enjoyed an ongoing partnership with a freestanding not-for-profit off-campus CCRC. Presented here is a brief history of that relationship as it has evolved over the years. All of the activities described continue to the present.

• 1992: Partnership agreement between The Mayflower Retirement Community (a 256-unit independent living facility with 60 skilled nursing [SNF] and 31 Assisted Living [ALF] beds) and the Florida Hospital Family Medicine Residency, to establish a clinical teaching experience at the CCRC. A monthly block rotation for third-year residents was begun first. The resident functions as a house physician 5 days weekly, primarily being responsible for the patients admitted to the residency service but available for others as well. Teaching rounds with faculty occur regularly, emphasizing geriatric assessment, unique features of nursing home medicine, and the importance of an interdisciplinary team approach to care.
• 1998: Establishment of an ACGME-accredited Clinical Fellowship in Geriatrics at the Family Medicine Residency, currently with three positions annually, incorporating The Mayflower as a principal long-term care facility (LTCF) teaching site.
• 2001: Establishment of a longitudinal experience for second- and third-year family medicine residents, who are assigned two or three SNF or ALF patients, presenting them at monthly team meetings with a faculty attending. These “team rounds” include a didactic presentation by the fellow and/or input by various facility staff.
• 2004: Addition of clinical rotation in geriatrics for fourth-year medical students at Florida State University College of Medicine, The Mayflower being a principal clinical teaching site.
• 2005: One of the graduating geriatric fellows becomes the first “residentialist” physician at The Mayflower, providing on-site longitudinal care for the independent residents.

The Mayflower provides:

• Bi-weekly dining room lunch meetings for all levels of learners along with facility leadership, allowing interdisciplinary discussions of clinical as well as systems issues.
• Lunch at monthly Q/A meetings, attended by faculty and learners.
• Other activities include quarterly ethics forum, retired physicians luncheon, “brown bag” medications review at annual Health Fair.

The residency provides on-site physician presence (a key marketing tool), on call coverage, and academic environment.

Learners participate in family meetings, care plans, and interact regularly with facility staff, including nursing, therapists, pharmacists, social services, dietary, and others.

Residents and fellows deliver in-service presentations to facility staff, also personal presentations to patient assemblies (music, mission trips, etc).

Elements That We Believe Contribute to the Strength and Longevity of This Association:

A faculty geriatrician with the residency also serves as medical director of the CCRC, thus ensuring communication at the highest levels in both organizations.
The concept of an academic facility needs to be continually emphasized, urging all of the interdisciplinary members to participate in teaching along with patient care. This can present a challenge to some, especially older staff, but our experience has been consistently favorable over time.
The CEO and Board of Directors of the facility need to be fully supportive and kept abreast of program developments.

In summary, we report almost 20 years of an affiliation with a family medicine residency and a CCRC, which we feel has and continues to enhance geriatric medical education.