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.
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.
A caricature of how philanthropy stimulated social change in “the good old days,” derisively called Philanthropy 1.0, describes the process this way: first, private funding helped successfully develop an innovation; the innovation then gained recognition; and finally the government rushed in to adopt it and take it to scale. (If you build a better mouse-trap, the world will beat a path to your door.) In the cynical modern perspective, this process of adoption, if it ever really happened, stopped with the Great Society programs of the Johnson administration.
Today, in the supposedly more complicated age of Philanthropy 2.0, program sustainability is thought to derive from complex business plans (e.g., combining government support with earned revenue and public fundraising) or from political advocacy processes, including stakeholder capacity development, lobbying, and ultimately, legislative action.
But the world is wide, and every once in a while, if you do build a better mousetrap, work hard to polish it, connect it to stakeholders, and remain patient—the world will come to your door. This week we are celebrating a new partnership with the National Institute on Aging, our third, to sustain the Jahnigen and the Williams career development awards, two programs pioneered by the Hartford Foundation over the last 10 years through a new R03 award mechanism entitled GEMSSTAR—Grants for Early Medical/Surgical Subspecialists’ Transition to Aging Research.
What will it take to ensure that all physicians are competent to care for their large and growing numbers of older patients?
Despite being only 13 percent of the population, older adults (those over 65) are big users of health care. For example, they make up 35 percent of office visits to the average general internist, 50 percent of visits to cardiologists, and 55 percent of visits to ophthalmologists. Except for pediatricians, all physicians will encounter older adults in their practice. But medical training does not reflect these demographic and epidemiological realities; standards of medical education do not require geriatric clinical training experiences (clerkships) during medical school. Yet medical education continues to require all doctors in training to treat children and deliver babies, regardless of future specialty.
While attending the American Geriatrics Society scientific meeting this past weekend, I had a glimpse of the future: Medical students participating in the MSTAR (Medical Student Training in Aging Research) program were in full force at the conference, showcasing their potential for leading the way in improving the health of older adults through research and clinical practice. I found myself encouraged and enthusiastic about the health care that will be delivered to the older adults of tomorrow, as I could not have been more impressed by the students, their intellectual prowess, and the drive they exhibited to find solutions for health problems facing our aging population.
I met students like Kathleen Abalos, who just finished her second year of medical school at the University of Virginia. Last summer she traveled to Johns Hopkins University through the MSTAR national competition. Over the past 16 years, MSTAR–administrated by the American Federation for Aging Research (AFAR)– has provided nearly 1,400 medical students like Kathleen with the opportunity for a mentored experience in aging research. (For more information, see also our Grants at Work article on the MSTAR program.) The future Dr. Abalos was passionate and articulate about her scientific project examining the differences between the autopsied brains of older adults who had Alzheimer’s disease and expressed symptoms, and those who were asymptomatic. She, like the other MSTARs, presented during a special “poster session.” This is like the grade school science fairs we all used to attend, only at a much higher level of sophistication—no vinegar and baking soda volcanoes here!
MSTAR’s goal is to encourage more students to pursue aging-related medical careers, and it appears to work. Hopefully, Kathleen will help continue the statistical trend that shows the success of MSTAR—20 percent of the earliest cohorts have gone on to aging-related medical careers, and 9 percent have gone on to pursue academic geriatric careers, far exceeding the 1 percent national average. MSTAR students go on to be the leaders who develop the scientific knowledge and educate other physicians about the best care of older adults. Kathleen, who had already started an aging special interest group at her school, is a promising MSTAR to watch.
Most people agree that loan forgiveness for medical students who agree to undergo geriatrics training would be a good thing. The American Geriatrics Society has a nice summary of the topic here. However, the idea has yet to be practically implemented… with the exception of South Carolina. Click here to read about South Carolina’s program, which forgives up to $35,000 in debt for each year of geriatrics training if doctors agree to establish a geriatrics practice in the state.
Interestingly, the Senate version of the current health reform legislation includes several different loan repayment provisions. Some are intended to help increase the pediatric health care workforce. Some are aimed at dentistry and dental faculty. There is also a fairly robust nursing faculty loan forgiveness program. And finally, there is reasonable attention to public health workers. However, as far as I can see, loan repayments are not offered to geriatric physicians (or even to the broader group of “primary care provider” physicians.) Since the Senate’s bill incorporates what remains of Wisconsin Senator Kohl’s “Retooling for an Aging America Act,” I think it is a more likely vehicle than the House bill, but I could be wrong.
The theme of the Foundation’s annual report this year was leadership–leadership to change the way the US health system prepares health professionals to care for older adults and the resulting quality of care they receive. These are big changes because of the size of the industry involved (16% of GDP and growing) and the counter-cultural nature of the issues–aging of the population, problems in everyday quality of care, and the need for an enhanced workforce–none of which are “sexy” issues.
This week we are very proud of the leadership shown by Lewis A. Lipsitz, MD of Harvard Medical School, Hebrew Senior Life, and the Beth Israel Deaconess Medical Center in Boston. Dr. Lipsitz, Director of the Hartford Center of Excellence in Geriatric Medicine and Training at Harvard University, is a long-time Foundation grantee and advisor. Recently he issued a clarion call for change in an op-ed in the Boston Globe talking about the need to strengthen geriatric medicine, improve care of older adults, and ensure that all physicians have basic competence in their care.
As part of its theory of change, the Foundation has made big bets on the specialty of geriatric medicine. (Click here for a nice summary of what geriatricians do.) Unfortunately, we are losing the numbers game. Geriatric medicine is the only specialty in which a physician takes a pay cut in return for additional advanced training. Why? Because almost all older adults are covered by Medicare, and Medicare pays relatively poorly for the core services of geriatric medicine: office-based evaluation and management services (diagnosing, adjusting medicines, referring to specialties, coordinating care, educating patients and family members). Therefore, geriatricians make about 10 percent less than generalists who treat older adults, but not exclusively older adults, and of course much, much less than specialists in the procedural areas such as dermatology, radiology, or gastroenterology.
It gets worse. To provide real geriatric care, the physician needs to work with a team of professionals: social workers, nurses, physical and occupational therapists, nutritionists, and others. Many of these services cannot be billed directly to Medicare and need to be covered out of (already meager) practice revenues. Finally, to add insult to injury,
The day after I posted a blog about the importance of medical students receiving education in geriatrics, Rosanne Leipzig, MD, published an excellent op-ed in the New York Times on the same topic entitled “The Patients Doctors Don’t Know”. Dr. Leipzig, who leads the Foundation’s Center of Excellence in Geriatric Medicine at Mount Sinai School of Medicine in New York, is a long-time Foundation grantee and a national leader in geriatrics education working also with stakeholders such as the Donald W. Reynolds Foundation and the American Board of Internal Medicine.
In her piece, Dr. Leipzig crystallizes our concerns about the current quality of care for older adults, through an all too common example of poor care. She also describes the progress that has been made to identify the required basic competencies for health professionals to do better. Finally, she makes some excellent public and educational policy recommendations to achieve that competence.
Please share Dr. Leipzig’s article widely with those who are interested in care of older people. Even more important, please share it with those who should be interested but aren’t yet. I believe that this piece can explain in a nutshell what we all mean when we talk about the urgent need to improve the quality of geriatric health care. Continue reading →
One of the problems we face in our work at the Foundation is that ageism and ignorance about what it takes to provide high quality health care to older adults is so ingrained that most of the time it is hard to notice. The want-to-be cardiologist who says that he doesn’t plan to take care of older adults is real. I have met him and he is very nice, if a bit confused about demographics and billable patient populations.
We are all like fish in the sea–we couldn’t describe water if we wanted to. And yet every once in a while, something pops out that helps you see the world more clearly. In this post I want to record something a trainee said that penetrates to the fundamental attitudes and preconceptions that need to change.
Senior Mentor Program at Medical University of South Carolina