Last year, I was concerned and puzzled by what looked like continuing and consistent declines in first-year geriatric fellows in Internal Medicine (IM) and Family Medicine (FM) based programs, despite improving financial incentives. This year, there is an abrupt improvement, with first-year fellows in IM and FM rising by almost 20 percent.
It’s funny, the things we remember from our school days. We all have fond memories of friends and favorite teachers, and, hopefully, things we learned and experiences that helped make us the persons we are today.
But what matters most is being able to link your education—lessons learned through study, experimentation, and experience—to your life and your chosen field in a way that helps others. Or, in the case of the new funding portfolio I now oversee, what we call “Linking Education to Practice.”
Communicating with persons and their families about serious illness and complex health care decisions is a skill that requires training and practice just like any other medical procedure, according to Diane Meier, director of theCenter to Advance Palliative Care. Dr. Meier offers health care professionals ten critical steps to follow when having difficult conversations, such as with someone whose scans have shown progression of an incurable cancer.
While physicians, nurses, and others specializing in palliative care — which adds an extra layer of support to provide relief from symptoms, pain, and stress associated with serious illness — can be expected to have mastery over this kind of communication, most health care providers don’t receive adequate training in this essential skill. Delivering “bad news” is something that all health professionals need to be ready to do, in a way that gives patients ownership and control over the exchange of information, focuses on listening to the patient more than talking, and allows people to be the “captain of their medical ship,” just as Dr. Meier describes.
Normally one of the advantages of expecting the worst is that all one’s surprises are good ones. But this year, I am both surprised and dismayed at the new figures on physician enrollment in geriatric fellowship training reported in the December 5 education issue of the Journal of the American Medical Association.
Somehow, despite all of the hullabaloo surrounding health reform, which has done some very good things for pay and attention given to geriatrics and geriatricians, the number of first-year fellows has fallen again from last year’s precarious situation, discussed in Falling Leaves, Falling Numbers.
While the number of internal medicine-based fellowship programs has risen by one (from 104 to 105), the number of first-year fellows has fallen from last year’s reported 215 down to 195, a drop of nearly 10 percent. Similarly, the number of family medicine-based programs has increased by one and the number of first-year fellows has fallen from 64 to 56.
If you have been following our blog series covering the 2011 Annual Report, then you know that our team has captured moving stories from older adults themselves who have benefited from the programs and services funded by the Hartford Foundation. I would like to highlight one such video about Patty, who has dementia but whose family observed a complete personality change in her after she fell and fractured her hip.
Delirium, for the inexperienced health care provider, is hard to differentiate from dementia. Patty was fortunate to have had Dr. Lalith-Kumar Solai, a psychiatrist from the University of Pittsburgh Center of Excellence in Geriatric Psychiatry, as her doctor. He adjusted Patty’s medications and was able to determine that Patty also had an untreated urinary tract infection. With antibiotics, the infection cleared and so did Patty’s delirium. The family was relieved to see their mother return to her usual calm and loving personality.
As the Grants Manager at the Foundation, my access to grantees is mostly limited to the reports they periodically send to us and the occasional evaluation site visit I attend. So, my focus is usally on the numbers: how grantees spend the money we awarded them and whether they are up to date on their requirements. But these numbers giveonly half the story of what we, as a Foundation, fund and how those funds contribute to improving the health of older adults.
Last week, along with many of my Foundation colleagues, I attended an event at the Weill Cornell Medical College featuring the exciting “end products” of one of our projects, the Medical Student Training in Aging Research Program (or MSTAR). The program enables medical students from across the country to learn about geriatric medicine and conduct research projects that aim to improve the care of older adults.
Shown in the picture are seven of the students and their mentors who participated in the program at the Cornell Division of Geriatric Medicine in New York (also a Hartford Center of Excellence in Geriatric Medicine). Their work showed me the wide range of problems that can befall an elderly patient and the solutions that can improve their care and produce better health outcomes.
Looking for a feel-good read this summer? Check out the “Diary of an MSTAR” blog on the American Federation for Aging Research website. The postings from participants in AFAR’s Medical Student Training in Aging Research (MSTAR) program will give you hope that we’ll have future scientists finding cures for diseases like Alzheimer’s and physicians who will have the skills and compassion needed to take care of us as we age.
Take this excerpt from a July 10 post by Jerome Atputhasingam of the University of California, San Francisco. He is one of 140 scholars spending his summer at a top medical school geriatrics division, participating in the MSTAR mentored research, clinical, and educational experience:
When I entered the examination room at the UCSF’s Memory and Aging Center (MAC), I was completely unaware of who I would meet inside. Having just started my MSTAR project, I was only beginning to get a grasp of my environment and barely had a clue about the types of patients seen at MAC. On this particular day, I was greeted by an older aged woman and her husband. As I began to introduce myself, I realized that the woman struggled to introduce herself back to me. She had a hard time speaking words, much less complete sentences.
Trust is the name of the game when we visit our physicians. We trust them to have our health as priority #1, that they will be honest and upfront with us, and we trust that they are competent and skilled in their practice. We have good reason for this trust, especially when it comes to our doctors’ competence. We all know that physicians spend years and years in grueling, rigorous education and training. Medical schools accept the cream of the crop from undergraduate institutions. But what are these bright, hard-working medical students really learning and will it actually help them care for us and our loved ones, especially if the loved one is 85 years old with diabetes, cognitive impairment, and a history of falling?
This has been a fundamental question posed by many of us in the aging and health field, including our partners at the Donald W. Reynolds Foundation. Like us, Reynolds has dedicated millions of dollars to addressing the very real gaps that exist in educating health professionals in the care of older adults. I just attended the 9th annual meeting of the Reynolds Aging and Quality of Life grantees in St. Louis and was struck by how intertwined our foundations’ work has been. Since 2000, one component of the Reynolds initiative has awarded grants to 40 academic health centers to strengthen their geriatrics training at the medical student and resident level. These grantees come together every year to share the progress they continue to make and the educational tools they have developed.
Our program director, Chris Langston, reminded me that at the same time this Reynolds initiative started, we were also doing our part through geriatrics-focused curricular change grants to another 40 medical schools (with some Reynolds overlap) in partnership with the Association of American Medical Colleges (AAMC). He referred me to a 2004 special edition of the AAMC’s journal, Academic Medicine, which highlights our work. A concise and articulate forward to the edition outlines our rationale and program design. Profiles of the medical schools’ efforts show incredible innovation and creativity in weaving geriatrics throughout existing curricula. While much has been accomplished through both the Reynolds and Hartford grants, as well as our subsequent partnership with the AAMC and American Geriatrics Society to articulate minimum geriatric competencies for medical students, many of the issues raised years ago still hold very true and need to be revisited. The forward notes:
Last week, Chris Langston asked readers to assist us with our future grantmaking and strategic plan (Help Us Spend $100,000,000!). He requested input to help us define the nature of the problem in improving the health of older adults. I hope we get responses not only from seasoned health care leaders, but also from new health professionals just entering the field (in addition to feedback from other sectors and the general public).
Weill Cornell MSTAR/Adelman/Jewish Foundation for the Education of Women Scholars presented their aging research projects for Cornell, AFAR, and Hartford staff in New York.
I know one group we can certainly learn from–MSTAR Scholars. Participants in the Medical Student Training in Aging Research program take the summer between their first and second year of medical school to conduct mentored research and receive clinical training in geriatrics. I was fortunate to hear several fantastic scientific presentations from MSTAR students in the New York area at the end of the summer (see photo). For those of you not as lucky, you can still “meet” many of these students by reading their own words online. Many of them recorded and posted their experiences in the lab, classroom and clinic in the blog Diary of an MSTAR Student. This remarkable collection gives us insight into issues facing older adults from the trainee perspective and a glimpse into the future where these soon-to-be physicians will help us find the solutions we need to improve care for older patients.
It’s September again, which for most means falling leaves, the end of vacations, and kids returning to school. For those interested in medical education, it also means the annual special issue on the topic in the Journal of the American Medical Association.
I always turn directly to the charts at the back showing the number of trainees in the various specialties of medicine. “Geriatric” appears in three places—as specializations within internal medicine, family medicine, and psychiatry, and their numbers have never been large. And that’s probably okay.
Given that it’s been clear for over a decade that we won’t ever have the geriatrician workforce needed to deliver care directly to the older adults who could benefit, our notion has long been that we have to mainstream geriatrics expertise into all physicians. Therefore, our interest in geriatric specialists focuses on their potential as educators, researchers, and leaders of that mainstreaming process rather than as a clinical workforce . Nonetheless, those geriatricians (in internal medicine, family medicine, or psychiatry) represent the raw material for faculty development and a critical resource.