Peter Pan, Meet Father Time
Image: Dr. Laurie Jacobs, Chief, Division of Geriatrics
Geriatrics Training for the Oncoming Patient Boom
by Julia Hess
As the country’s senior citizen population skyrockets—roughly 18 million Americans age 75 and over, with 77 million baby boomers on their tail—the stock of geriatricians has dwindled to around 7,000, adding only 300 specialized medical school graduates each year.
Geriatricians are paid less than most other physicians and surgeons (around $150,000, compared to salaries of $400,000+ in other disciplines). Older patients are labor intensive, with complex medical histories, coexisting conditions that complicate the diagnostic process, and different reactions to even the most commonly prescribed medications. And geriatrics has historically held low status among specialties, seen as “depressing” and “a waste of talent” better spent on patients who will live longer.
“We’re an ageist culture, and history is against us,” said Dr. Laurie Jacobs, professor of clinical medicine and chief of the Einstein-Montefiore Division of Geriatrics. “Even if we go full blast in training geriatricians, there’s no way we could adequately prepare for the ‘silver tsunami’ that’s about to hit us.”
With funding from the Donald W. Reynolds Foundation, Jacobs and colleagues have created geriatrics training initiatives in virtually every area of medical education. Through the program, students, residents, and practicing primary care physicians learn to treat the complex medical and neuropsychiatric syndromes present in older people.
Geriatrics training at Einstein begins in the first year of medical school, with required workshops in sexuality and aging, health care systems, ethics, and elder abuse, as well as a clinical rotation taking medical histories from older adults during home visits, in nursing homes, and in the hospital. Third- and fourth-year students spend a two-week rotation with older patients in hospitals, clinics, extended care facilities, and home visits. Those interested in further study opt to develop an in-depth medical and psychosocial history over several visits with a community-dwelling older adult, pair with a faculty mentor in geriatrics or an aging-related field, become involved in the Einstein student chapter of the American Geriatrics Society (AGS), or pursue aging-related basic or clinical research. Students have presented work at national meetings and published scholarly research articles, and many have been accepted for the American Federation for Aging Research/National Institute on Aging MSTAR (Medical Student Training in Aging Research) Program.
Kara Stavros (2009) served as vice-president of the AGS student chapter and completed a MSTAR project at Harvard on delirium and clinical assessment of attention in older adults, publishing a first-authored article in the Journal of the AGS. “I considered geriatrics before starting medical school, and the program gave me so many opportunities to cultivate this interest,” Stavros said. “Geriatrics can be combined with almost anything; regardless of the specialty I choose, I’ll use what I’ve learned.”
Rohit Ramanathan (2011), also a MSTAR scholar, spent a summer at Johns Hopkins investigating whether the enzyme chitotriosidase would serve as a potential marker of aging and frailty. ”I don’t know exactly what I want to do in two years, but I want to pursue more geriatrics-related research,” he said. ”There’s so much we don’t know about aging.”
The clinical experience challenged Ramanathan’s assumptions as well. ”I used to think that treating old people would be depressing because you couldn’t really help them,” he said. ”But I learned that it’s not always about saving lives. Sometimes, if you can help someone feel better for the time they have, you’ve done your job.”
Internal medicine and family medicine residents take part in a month-long geriatrics residency rotation covering aging-related issues such as dementia, falls, and delirium. Residents attend regular conferences covering complex medication management, geriatric psychiatry, functional assessments, and bioethical issues in elderly care. In working with patients, they hone skills in physical examinations and cognitive assessments. “Our residents and students emerge with a greater sensitivity and skill in working with older patients,” said Dr. Keerti Sharma, director of residency rotation. “They get to work with highly functional people who teach them about growing older in the healthiest possible way.”
“The patients were the best teachers,” said Jennifer Gonik (2011). “At first I was intimidated and overwhelmed because they had so many illnesses and complications. But then I realized that everything I was learning about in class—from CHF to hyperthyroidism—I saw in real life. It was incredible.”
Clinical training emphasizes the importance of involving the patient in medical decision making, and provides residents and students a first-hand look at the specialty’s unique big-picture vantage. Sharma recalled a recent experience in which a fourth-year medical student planning to pursue radiology assisted her in seeing a highly functional 92-year-old patient. After the visit, the student remarked that he could clearly see why she had chosen geriatrics. “I had no illusion that this student would suddenly decide to change fields, but I appreciated how he was enlightened by everything we had learned in that hour with the patient,” she said. “It’s something you don’t get in a more focused specialty.”
While fruitful in what it teaches, the close-knit, long-term interaction between geriatrician and patient is also a challenge in training the next generation. The rotation’s transient nature can be disruptive, according to Sharma. Older patients are reluctant to discuss medical issues or concerns with a new resident, and trainees may not notice subtle changes that their regular doctor would see. “After four or five years we become extended family with our patients,” she said. “These nuances often have much larger implications in a patient’s well being. We want our residents to enjoy the experience and grow from it, and at the same time we want our patients to be happy. We are constantly working to address this.”
Another challenge arose from a surprising anomaly—low geriatric patient volume at some of the training sites. Einstein-Montefiore’s family medicine clinics in the south Bronx, a young immigrant population area, provide care for fewer older adults than in similar programs across the nation.
In an ongoing effort to train the masses, the geriatrics program sponsors faculty lectures and workshops for attending physicians throughout the Montefiore network, the Bronx, and New York City. Geared to specialists in emergency medicine, orthopedics, cardiology, and obstetrics and gynecology, lecture topics include delirium, hip fractures, ethical issues in treating heart disease, and Clostridium difficile colitis (a contagious, potentially fatal GI infection common in nursing homes and hospitals).
Response to the program has been consistently positive, with high ratings on lectures and feedback commending the well-roundedness, exposure and usefulness of the rotations. But is it changing attitudes about geriatrics as a profession? “Baby boomers will certainly make the idea of aging sexier, but I doubt we’ll ever be as hot as, say, surgery or cardiology,” said Jacobs, a veteran of the field.
But with two years of medical school and decades of practice ahead of her, Gonik offers a hopeful perspective. “Students have been very receptive to geriatrics programming, and our AGS meetings always get much bigger turnouts than expected. From the feedback, I don’t get the sense that geriatrics is uncool. It’s such a broad, multidimensional diverse field that a lot of people find it appealing for different reasons.”