Geriatrics Recruitment Resources

The following three programs were selected because of their different programmatic resources, institutional environments, and approaches to managing academic geriatrics growth and development. Each profile reflects a common drive to extend and integrate programmatic, professional, and institutional strengths. Some of the approaches described here may stimulate others to consider program development and management in new ways.

1. Boston University Medical Center Hartford Center of Excellence in Geriatrics; Rebecca Silliman, MD, PhD, Director. Dr. Silliman is also Professor of Medicine and Public Health; and Chief, Section of Geriatrics.

In a nutshell: The CoE at this private university with modest funding incorporates an integrated clinical model, collaborative research, and interdisciplinary training with a focus on training educators.

Integrated and indispensible. “We try to make ourselves indispensable to everybody. In addition to the patients we serve, we are also available to university faculty and staff—and their parents! That is part of being indispensable,” Dr. Silliman said. Compared with larger state schools, this private institution has modest resources. The CoE is notable for several reasons, according to Dr. Silliman. “Boston University Medical Center is the safety-net hospital for Boston. There are only a handful of CoEs whose main hospitals are safety-net hospitals. We run a tight and integrated care system that feeds the hospital. In turn, we are efficient in our admissions and discharges. We are good citizens, we have some of the best teachers in the institution, and we help the entire institution as much as possible.” The CoE is also well known for its home visiting program for frail older adults and other clinical services. The section of geriatrics faculty includes 16 physicians, 12 advanced practice nurses, and a social worker.

A mixture of funding streams. “Our funding approach is to have multiple strategies, and try and do them all well. We embarked on a new clinical program focusing on dually eligible patients, and clinical revenues have grown substantially. We receive a fair amount of money from the hospital, with whom we have been historically related through our home care program, which dates from 1875.” (The hospital, rather than the medical school, receives the overhead payments from section grants.) “We have revenue streams that support our administrative director, two secretaries, and a part-time administrative staff person. Educational grants support our fellowship program and a long-standing required fourth-year clerkship is supported by the School of Medicine. Hospital funds flow through the department of medicine to support clinical work. Our research grants support our research enterprises, and that is it. We get a modest amount of indirect dollars back and I use that to support a grants manager, and a portion of our fiscal administrator’s salary. The program receives little in the way of individual donations or bequests, as few patients served by this hospital are wealthy.”

Sound administration blended with learning about leadership. “We are not robust in terms of administrative support, but we have a great administrative director and are fortunate to have a fiscal manager who has been here since the 1980s and knows everything and everybody,” Dr. Silliman explained. “Many physicians have been promoted to managerial positions because of their research—not because of their abilities as leaders. Most are not born leaders, and most have to learn. I recommend participating in a program such as the Hartford Geriatrics Leadership Development Program. I learned a lot from this program.”

Collaboration with a competitive edge. Dr. Silliman and her team participated in the Hartford-RAND Interdisciplinary Geriatric Health Care Research Center that helped lay the groundwork for their Pepper Center grant and a new initiative for interdisciplinary clinical research and teaching activities. Dr. Silliman said that Boston Medical Center (BMC) has a strong mission and message of collaboration that ‘comes down from on high,’ because we are a safety-net hospital.” She emphasized, “Geriatrics has always been collaborative and interdisciplinary. We work strategically with multiple disciplines, which is better than going it alone. Whether it is through fellows working with other sections, or senior researchers, that is how I believe we make progress in research, and it helps BMC to be competitive.” To get the Pepper Center funded, “we took advantage of all the resources we had here to make it work by putting different people’s priorities together.” While this process does not work all the time, Dr. Silliman recommends building “on the strengths you have, recognizing that sometimes collaboration is more about the individual than the discipline.” (See Chapter II for further information on BMC’s decade-long program infusing geriatrics into other specialties.)

Mentoring as a priority. Dr. Silliman enriches her geriatrics mentoring by also mentoring outside of geriatrics. She mentors for a K-30 program for junior faculty, and for BMC’s Center of Excellence in Women’s Health, including an NIH-funded K-12 initiative, Building Interdisciplinary Research Careers in Women’s Health (she is a co-PI with Karen Freund, MD). About five years ago, Dr. Silliman decided to stop doing clinical care. “I have clinicians who work with me, who do clinical care as well or better than me, but they can’t do what I do. You make time for the things that are important to you.”

2. Emory University/University of Alabama at Birmingham (UAB) Southeast Center of Excellence in Geriatric Medicine and Training (SCEGM); Richard Allman, MD, Co-Director. Dr. Allman is also Director of the Birmingham/Atlanta VA GRECC; Director of the Center for Aging and the Division of Gerontology, Geriatrics, and Palliative Care; the Deep South Resource Center for Minority Aging Research; and Parrish Endowed Professor of Medicine at UAB.

Ted Johnson, MD, MPH, has served as the SCEGM Co-Director based at Emory University since March 2008. Dr. Johnson is Associate Director and Atlanta Site Director, Birmingham/Atlanta VA GRECC and Interim Director, Division of Geriatric Medicine and Gerontology at Emory University. (Note: In Spring 2008, former SCEGM Co-Director, Dr. Joseph Ouslander, moved from Emory University, where he also directed the Center for Health in Aging, to the Charles E. Schmidt College of Biomedical Science at Florida Atlantic University where he is Professor of Clinical Biomedical Science and Associate Dean for Geriatric Programs).

In a nutshell: Based on a unique collaboration between Emory University (Atlanta) and the University of Alabama (Birmingham), the SCEGM marked its 10th anniversary in 2008.

Finding Partners. “When Dr. Joseph Ouslander moved to Emory University, he contacted the Hartford Foundation about collaborating with UAB. We had also contacted Hartford and they expressed an interest in doing something in the Southeast,” Dr. Allman said. The resulting SCEGM has served as a model and foundation for other joint ventures, which have included a two-site GRECC within the VA. Dr. Allman also directs the UAB Center for Aging, which is linked to the SCEGM, the GRECC, and two NIA-funded Centers—the Deep South Resource Center for Minority Aging Research and the Roybal Center on Applied Gerontology.

Synergy through collaboration and a little competition. “Emory and UAB have a common vision, shared responsibilities, and ownership for the CoE,” says Dr. Allman. “In establishing the joint CoE, Dr. Ouslander and I had an equal voice with the interdisciplinary steering committee. Each site brought unique expertise to the table. We also had synergistic goals and common scientific interests that we thought could be strengthened through collaborating.” Dr. Allman can also raise the expectations of what his own university or health system can do for geriatrics by using Emory’s or the VA’s investments as examples. This helped facilitate palliative care at UAB.

Sharing resources, balancing benefits. However, Dr. Allman said, “making sure everyone benefits can be a challenge. Sometimes it will appear that one institution or individual is benefiting more than another. When sharing ideas, there can be intellectual property issues. Although at times we are competing for fellowship applicants or funding, we support each other and remain committed to our collaboration over the long haul. We share curricula, exchange information about applicants, and maintain an ongoing dialogue. Sometimes mistakes are made and we discuss those.”

Commitment to communication. Dr. Allman emphasizes that communication is a key to their joint success. “Establishing the collaboration was challenging. We set aside the time for frequent communication to accomplish all the upfront work. We continue to make communication a priority by holding face-to-face meetings every three months, and, in between, by using monthly video- or teleconferencing. We also have joint staff meetings with the GRECC, which has enriched the research strengths of the overall program, as well as provided additional educational resources and support for videoconferences.”

The advantage of distance. As a two-site program, they have turned the challenge of the physical distance between sites into an advantage. “We are close enough to make commuting possible but there is an advantage to not being too close. We rent two vans for senior and junior faculty and utilize the two-and-a-half-hour drives between Birmingham and Atlanta for planning and mentoring. This is very precious time in the van.” Informal gatherings incorporate a pre-meeting social get together, sometimes held at faculty homes.

Support for fellows and junior faculty via collaborative recruitment, mentoring, and review. The two medical schools recruit fellows jointly using a common SCEGM form. Candidates are asked if they are applying to Emory, Alabama, or both. They share interviews within a day of each other so the candidate only has to make one trip to the region. “If we want to offer a position, we let our partner know and coordinate that.”

“If a junior faculty member at one institution applies for support from the SCEGM (for salary support, pilot research funding, or funding for an educational or quality improvement project depending on whether they are in the research or clinician-educator track), content experts from the other institution review the proposal. When someone writes a proposal, they get a friendly peer review,” Dr. Allman observed.

Joint mentoring is another advantage. Dr. Allman cited a UAB geriatric medicine fellow with an interest in long-term care administration who benefited from mentoring from Dr. Ouslander (“an expert in that area”). This fellow later went to Emory for a year of advanced training in long-term care administration. An Emory fellow traveled to UAB for four two-week training experiences in palliative care over a one-year timeframe. “There are face-to-face mentor meetings with the content mentor at the other site. We highlight presentations by junior and senior faculty at quarterly SCEGM meetings. Junior faculty benefit greatly from receiving peer review and mentoring from faculty at another medical center. By responding to reviews from experts external to one’s own institution, fellows and junior faculty learn how to deal with critiques of their work that are part of getting proposals funded and papers published,” Dr. Allman said.

Collaboration as a foundation for future efforts. Along with serving as a model for the joint GRECC, the SCEGM serves as a model for a collaborative five-year P30 grant received in 2007 from the National Institute on Aging (NIA) to establish a multi-institutional Deep South Resource Center for Minority Aging Research. One of only six in the country, Center partners include the UAB Morehouse School of Medicine, Tuskegee University, and the University of Alabama at Tuscaloosa. The SCEGM has also become a regional resource. It supported the initiation of Mercer College of Medicine’s own geriatrics program. It also offers conferences and a regional resident award event for internal and family medicine residents to learn about careers in geriatrics. “A third of our fellows have come from this recruiting event.” (For more information on this event see the companion publication to this report, Approaches to Recruiting Premedical and Medical Students and Residents to Careers in Geriatric Medicine, at: http://www.geriatricsrecruitment.org/ManualOne/ResidentAwardSummit)

Recommendations for others contemplating a two-site program. Dr. Allman urges others to approach such a collaboration as a long-term commitment, with an emphasis on regular, ongoing communication. “You need to have leadership at both places, a common vision, and regular face-to-face communication. Things will not always go smoothly, and you will work through this. Also, it helps to identify mutual or complementary interests so you can take advantage of strengths at both institutions, such as our joint efforts in palliative care.”

“We know some colleagues who have a harder time collaborating, and sometimes there are personal or institutional problems. Others may not pursue joint CoEs because they don’t think it will work. But, people are really surprised that is does. We find this is one of the most professionally rewarding things we have ever done. We discussed whether we would be separate centers if we had the opportunity. We concluded that we are better together than apart. I want to look good to the other director. And that can trickle down as various faculty move around, because everyone knows everyone else. Both institutions take great pride in the collaboration, and it is consistent with the NIH Roadmap for Interdisciplinary Research.”

3. Indiana University School of Medicine Hartford Center of Excellence in Geriatric Medicine and Training; Christopher M. Callahan, MD. Dr. Callahan is Cornelius and Yvonne Pettinga Professor and Director of the Indiana University Center for Aging Research. (The Indiana University Hartford Center of Excellence in Geriatric Medicine and Training is directed by Steven R. Counsell, MD.)

In a nutshell: At this state university, an important goal has been the building of a research shop in collaboration with the Center of Excellence in Geriatric Medicine.

Build a new program collaboratively. “The most gratifying thing for us is that we built this program in an urban public hospital starting from zero research in geriatrics,” Dr. Callahan said. “We represent the research arm of the larger geriatrics program and are embedded within the Regenstrief Institute. We collaborate with other programs that contribute to the critical mass of researchers.” Two thirds of the Center for Aging Research’s funding comes from extramural sources, such as the NIH and the Hartford Foundation, and 10 to 15 percent from endowed chairs and local philanthropy.

Get through the early years. “You pass through developmental stages when you are trying to get these centers off the ground. They have a 50 percent mortality rate in the first five years, but if you survive the first five years you have a better chance of surviving long-term,” Dr. Callahan said.

Assemble a critical mass of researchers. “No one makes it on their own anymore. You can’t have a research shop with only one or two people, and you don’t reach a critical mass until you have four or five physician investigators and four or five staff. However, you can usually only start with half of that, so there is a premium on recruiting a few key people in the early stages.”

Recruit strategically. “Candidates need a push and a pull—something they are not getting where they are. You have to lure them with something they want, fill in the missing piece for them,” Dr. Callahan explained. Among his own bargaining chips are “an unusual primary care laboratory served by electronic medical records and a reasonable amount of financial resources so we can recruit by offering packages to expand people’s scope of research. Sometimes people are looking for a brand new place to build, or junior people feel crowded where they are.” He urges looking towards the universities that are “net exporters of researchers, because there are not enough spots.” “Reach out to their leadership who can encourage people to come and look at your research center because you are up and coming,” he said. He cautions, however, against spending an excess amount of time recruiting.

Stay focused. In the early years, “Faculty can get distracted into other academic missions. It can be hard to ascertain whether it’s the university or the program that has distracted them. Perhaps they are not enjoying the research enterprise. There are a lot of competing opportunities that are equally compelling. You will see institutions announce that they are going to devote a significant amount of time to research, but when you look back, they have not, and instead have focused on clinical duties.”

Seed the program with pilot projects before initial funding runs out. “The capacity to have piloted things has become more critical to a successful grant application. With start-up funds from the university, we received substantial funding from the Regenstrief Institute for infrastructure, administrative support, shared staff, and pilot research grants. Pilot research projects can be critical to a successful grant application over time. As you are revising a grant, it can be more competitive because you can show progress through the piloted project.”

Create endowed chairs. A challenge for the second five-year period of supporting a research center is establishing endowed chairs in order to bring in more senior leadership. “The endowed chairs were a safety net that allowed us to put together packages to attract new faculty,” Dr. Callahan explained. Geriatrics has three newly endowed chairs (one held by Dr. Callahan; one held by Dr. Counsell, who directs the Indiana University geriatrics program and CoE; and a third that was used to recruit a senior researcher.)

Avoid “expensive” money. “When someone gives you $50,000 and in return expects an additional $500,000 from philanthropy and intramural resources, it’s costing you more than you’re getting. Sometimes you may have to pursue a grant that is ‘off theme’ or somewhat outside your faculty’s area of expertise, but this can become expensive money—it costs you more, lowers morale, and shakes you from your focus. You and the funder can become unhappy,” Dr. Callahan said.

Learn to say no! Maintaining focus is crucial as a research shop matures. “The more successful you are, the more you have to say no in order to stay focused on your research themes and areas of expertise. You may disappoint some people, but it may be necessary to say no to some enticing opportunities—a grant or partnership—in order to maintain your focus,” he said.

Resist premature leadership. For academic leadership, “the most critical thing is scientific credibility [publications and funding]. You don’t even get into the chair or dean’s office until you have that.” However, “a unique risk in academic geriatrics is that people are prematurely promoted to leadership positions because the pool is so small. You will be around the table with other people in the medical center with a longer track record of accomplishment. You can get by for a short period of time if you don’t yet have the experience, but eventually they will pull out your CV.”

When seeking support, adapt to “different worlds.” “While the division chief, associate dean for research, and department chair are all looking at the same metric, the metric changes when you go out in the community. No one is concerned about publications. They want to know about the health of the community, your impact on the local economy, and stories about lives you have saved. In the community, the culture, body language, the way they debate, what they mean when they say ‘we are committed,’ and the timeframes are all different. I can use a word in the medical center and go into industry and the word means something different.” Unlike academia, “industry will be going in a new direction tomorrow.” Of traveling between two worlds he said, “That makes it exciting.”

Employ a low cost strategy: enjoyment. Dr. Callahan talks with pride about “a research center where people are enjoying themselves. It is very palpable to visitors and people you are recruiting. You have to put energy into creating an enjoyable place to work. It does not happen by accident and may be the only thing that helps with retention. Anyone can offer people more money, but having a shop where people are enjoying themselves does not cost a lot of money.” Leaders need to “pay attention and get rid of hassle factors. We are proud of faculty development and have taken a very broad approach to developing leaders—people who are balanced and enjoyable to work with. It is good for us, produces the kind of environment we want to work in, and has turned out to be a recruiting tool. After all, we are competing with institutions in a more desirable place. We can’t sell an ocean-front location.”

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