Chapter III: Training Subspecialty Physicians in Geriatrics
1. Joint Fellowships and Junior Faculty Support
The challenge: To diffuse geriatrics knowledge throughout academic medicine by engaging subspecialty fellows and junior faculty
Summary
Efforts are underway across CoEs and other geriatrics programs to diffuse geriatrics information and skills into clinical teaching and research across subspecialties. Strategies include partnering with subspecialties for joint fellowships and joint junior faculty training and utilizing flexible funding models that adapt to the interests and availability of trainees. While “geriatricizing” has become a buzzword for this kind of effort, a senior leader offered a caution regarding the term and the mindset behind it. “People don’t respond well if you say, ‘we are going to geriatricize you.’ It sounds like a hostile takeover, so do it one by one, make the matches, don’t be too explicit. Joint fellowships are one great approach.” Another leader reported that his geriatrics program actively seeks out subspecialty fellows from different departments. While his program does receive some inquiries from potential subspecialty fellows who are interested in geriatrics, “They don’t necessarily come to us. Joint fellowships are more likely to come about from us being out there doing the integrating.”
Strategies
Engage subspecialty leadership to gain access to trainees. Consider strategies to build rapport regarding training with subspecialty leaders. Identify high-profile leaders who will support a collaborative program. Form an advisory board incorporating some of those subspecialty leaders.
Offer more than money. To attract fellows and “seal the deal,” geriatrics can offer other attractive resources. Duke University, for example, uses its focus on creating academic cross-specialty relationships in mentoring and career development as draws to their joint fellowship training program, which integrates geriatrics for fellows and junior faculty in the surgical and medical subspecialties. At Yale University, incentives include the opportunity to work with experts in human-subject research.
Focus on a commitment to geriatrics, whether or not it comes first. Keeping fellows engaged in academic geriatrics throughout their training and beyond should be the paramount goal, several leaders emphasized. “Most fellows spend more time in either geriatrics or another specialty,” Dr. Ken Schmader of Duke University said. Citing his colleague Dr. Harvey Cohen’s leadership in gero-oncology, Dr. Schmader observed that at Duke “some people who have trained in geriatrics and oncology have a primary appointment in oncology, but are active in geriatrics issues. Others, who joined our faculty, are more involved in geriatrics but with an oncology orientation.”
Target specialties where interest is high. Local culture matters, so determine which programs are best for joint training at your institution. On some campuses it may be more challenging to get some subspecialties focused on aging-related research, because there is much more money in other clinical disciplines, such as cardiology. One geriatrics program that had little success with cardiology made inroads with other subspecialties, such as rheumatology, infectious disease, hematology, oncology, and pulmonology.
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A recruitment message for potential subspecialty trainees. “Because trainees who participate in joint fellowships have a niche, they are appealing candidates for funding—they are well-trained and have access to double funding streams.” Mary Tinetti, MD, Yale University |
Take advantage of board certification requirements. Increasingly, subspecialty boards incorporate aging-related questions. The development of a curriculum in cardiology and geriatrics for fellows was a product of Duke’s mini-fellowship in geriatric cardiology. That curriculum responded to the need to address geriatrics questions on the cardiology board exams and was an opportunity to partner with a well-resourced group, the American College of Cardiology. (See section on Mini-fellowships in Geriatrics below.)
Stay in touch after training ends. Many geriatrics leaders emphasized the importance of staying in touch with geriatrics fellows who go on to additional subspecialty training in other disciplines. For example, Dr. Schmader continued to serve as senior mentor on an aging research project for a fellow who had completed a geriatrics fellowship and was returning to cardiology.
Take a first step. At the University of North Carolina, Dr. Jan Busby-Whitehead noted that her involvement with second- and third-year rheumatology fellows is not a true shared fellowship. Rather, the fellows receive some funding through the geriatrics CoE. “A rheumatology fellow doing aging research agrees to participate in education in the geriatrics program, but is not jointly boarded. This was a first step in opening relations with the Arthritis Center.”
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Close-ups Drawing on excellence in research to build a joint fellowship program. Bringing geriatrics to Yale University’s extremely talented medical subspecialists meant that the CoE “gained some of the best and the brightest and raised the prestige of aging-related research,” recalled Dr. Tinetti. One of the first strategies she and her colleagues used to jump-start the joint fellowship effort was to create an advisory committee made up of high-profile senior subspecialty faculty. Over time, this created visibility and helped to identify trainees for geriatrics. As time went on, “success begat success, faculty and trainees became aware of the joint fellowship approach, and subspecialists began to come to geriatrics unsolicited.” To recruit subspecialty fellows, “having money helped, but geriatrics also had an infrastructure for human research that did not exist elsewhere at Yale. This provided opportunities for joint fellows to develop an intellectually challenging niche within their specialty that offered unique directions for future research grants.” Yale trainees have stayed in academia and have focused on geriatrics research issues, generating an increased interest in aging within their specialty. Dr. Tinetti also cited a curriculum in pulmonary medicine and infectious disease that trainees developed and then used to train other scholars, which helped create a “critical mass” of academicians in infectious disease who focused on aging. Of the joint research and training approaches at Yale, Dr. Tinetti noted: “The biggest surprise is how well it has worked; it has brought geriatrics into the subspecialties in a way that has moved beyond the individual.” She emphasized that it is crucial to stay involved with trainees after the geriatrics funding ends so people stay focused on aging. “Otherwise the temptation is for people early in their careers to go after whatever money is out there.” A Flexible Awards Program. At the University of Chicago, Dr. William Dale co-directs a flexible awards program with Marshall Chin, MD, a general internal medicine specialist. Open to junior and senior faculty in geriatrics and other disciplines, the program offers three pilot grants per year for research, innovative teaching, faculty development, or trainee opportunities. The program was developed because the geriatrics program is relatively small, with 12 faculty, several of whom are researchers. Geriatricians are required to partner with someone in another department or division; applicants from other departments are asked to find a geriatrics partner. “This made people look around and find someone they did not know with whom they could partner.” Dr. Dale noted that when someone really wants to work in long-term care, he and Dr. Chin strategize and “play off each other to find the right partner, as general internal medicine has more researchers than geriatrics.” |
2. Mini-fellowships in Geriatrics
The challenge: To develop continuing education in geriatrics that fits the career needs and scheduling issues of mid-career physicians
Summary
Mini-fellowships in geriatrics have the potential to reach a broad audience of physicians, including academic subspecialists and those in private practice, some of whom may have teaching responsibilities at community hospitals. A number of mini-fellowship models have emerged, ranging from year-long programs (integrated with trainees’ ongoing responsibilities) to courses lasting three to four days, sometimes with a follow-up program. The successful models have identified appropriate trainees, created an education model that fits their busy schedules, and incorporated curricula that can be readily translated by trainees into their own teaching and clinical practice. Since 2004, the Donald W. Reynolds Foundation has supported a consortium of four academic institutions (Duke, Mount Sinai, Johns Hopkins, and UCLA) to offer a mini-fellowship model (FD~AGE Physician Mini-Fellowships in Geriatrics) for physicians from around the country. While core geriatrics content is incorporated at all sites, each institution has individualized its teaching in terms of specialty or professional tracks, themes, or practice settings.
Strategies
Design a user-friendly training format. Brief training—three- or four-day programs—is more adapted to the schedules of busy mid-career physicians.
Offer more than didactic training. Duke’s mini-fellowships incorporate “reverse site visits” by fellowship participants, which keep geriatricians and trainees connected and reinforce trainees’ education.
Create a train-the-trainer program. Duke offered mini-fellowships in oncology, cardiology, infectious diseases, and gastroenterology using a train-the-trainer model. The courses target two main groups: faculty from academic medical centers and physicians from community hospitals who may do some teaching and are interested in knowing more about taking care of older patients.
Build on the need to master new geriatrics content in subspecialty board exams. New aging-related content in subspecialty boards and maintenance of certification examinations means that faculty and other subspecialists will likely need additional education in geriatrics. At one institution, a leader reported that their mini-fellowships are attracting new subspecialists as a result of new requirements and questions related to geriatric patients. For example, dermatology recently found that it would need to build competencies in geriatrics for boarding. While some subspecialists who are faced with such new requirements may pursue mini-fellowships for that purpose only, others are interested because they are caring for more elderly patients and their own parents.
Offer continuing education that meets the institutions’ as well as physicians’ needs. Institutions and departments may view continuing education in geriatrics for their faculty as important, and could be amenable to providing support, whether funding or release time for faculty to attend.
For more information about the FD~AGE Consortium Mini-fellowships, see: http://knowledgemap2.mc.vanderbilt.edu/pogoe/node/456
For more about the Duke mini-fellowships, see: http://careinaging.duke.edu/facultydevelopment/fellowships/
For more about the Johns Hopkins mini-fellowships, see: http://www.hopkinsmedicine.org/geriatrics/education/Reynolds/dwr_jhu.html
For more about the Mount Sinai School of Medicine mini-fellowships, see: http://www.mssm.edu/geriatrics/education/mini_fellowship/index.shtml
For more about the UCLA mini-fellowships, see: http://www.geronet.med.ucla.edu/centers/reynolds/mini_fellowship.htm
For more information on Boston University Medical Center’s faculty scholars program, see the companion publication to this report, Approaches to Recruitment to Advanced Fellowship Training and Faculty Positions in Academic Geriatrics, at: http://www.geriatricsrecruitment.org/ManualTwo/FacultyScholars
Also see the BMC geriatrics section’s web site at: http://www.bmc.org/geriatrics/educationFacultyPhysicians_CEGM_FacultySch...
3. Training Hospitalists in the Care of Older Adults
The challenge: To infuse hospital medicine with geriatrics knowledge and skills
Summary
Hospital medicine is one of the fastest growing specialties. In 2007, there were 20,000 practicing hospitalists in the U.S. This was up from a few hundred in the mid-1990s. The Society for Hospital Medicine projects 30,000 hospitalists by 2010, many of whom will work for managed care organizations. Hospitalists are increasingly appearing as physicians-of-record for hospitalized frail older adults, and they often take an active role in elderly patients’ care transitions. Given the dearth of board certified geriatricians, some leaders have developed teaching programs to increase the skills of hospitalists who care for older adults, including mini-fellowships (see Resources in the preceding section) and longer training. Longer teaching timeframes are particularly suited to academic medical centers with a critical mass of academic hospitalists. Two institutions that have support from the Donald W. Reynolds Foundation to train hospitalists are the University of California, San Francisco (UCSF), and Harvard Medical School, whose programs are described below. There are growing opportunities for hospitalists and geriatricians (and others) to partner on other hospital-related initiatives, such as improving care transitions for frail older people.
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Quick support for geriatrics training for hospitalists. “My only surprise is that I have not had to sell this program to anyone—trainees, hospitalists, the department of internal medicine. Everyone was on board.” Melissa Mattison, MD, Harvard Medical School and Beth Israel Deaconess Medical Center |
Strategies
Use a self-assessment and train-the-trainer approach to train academic hospitalists. Encourage trainees to identify topics in which they need additional geriatrics education, and build their capacities as teachers. Incorporate core competencies related to the care of older patients into the curriculum.
Consider a longer time frame for training hospitalists. A longer time frame for teaching is particularly well-adapted to academic medical centers. It also supports opportunities for informal and case discussion, practice improvement with oversight, development of teaching skills, and confidence building. For example, UCSF’s 40-hour Acute Care of the Elderly (ACE) program focuses on the care of hospitalized older adults and transitions in care. Led by two geriatrician hospitalists, this program offers “teaching and faculty development to learn geriatrics, improve teaching techniques, and develop geriatrics curriculum.” All interested hospitalists at any of the UCSF-affiliated teaching hospitals are eligible to participate in this program.
Use teaching materials and tools tailored for hospitalists. (See Resources below.)
Make it convenient for trainees. Create a training format based on convenient times and hospital locations. Encourage informal as well as formal interactions. Don’t forget lunch.
Add value to in-house teaching. Consider ways to provide free tuition for hospitalists to attend geriatrics continuing education programs, particularly those that address care for hospitalized older adults.
Consider other collaborations. One example is the cooperation between geriatrics and hospitalists in managing care transitions. (See Resources below.)
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Close-up Building inpatient excellence. Hospitalist training is one of the components of Harvard Medical School’s Advancement of Geriatrics Education (AGE) Project, which is directed by Dr. Lewis Lipsitz, with funding from the Donald W. Reynolds Foundation Aging and Quality of Life Program. Geriatrician Melissa Mattison, MD, an instructor in medicine at Harvard Medical School, leads the hospitalist component. Her practice and the hospitalist teaching program are based at Beth Israel Deaconess Medical Center, a Harvard teaching hospital. Using a “train-the-trainer” model, she teaches hospitalist scholars, who then become responsible for teaching residents and medical students. They volunteer to participate in the year-long program that centers around monthly discussions about geriatrics topics over lunch. Scholars select discussion topics based on a self-assessment of their educational needs. Dr. Mattison said that the chosen topics have been consistent over the three years, and reflect those areas where geriatricians would have anticipated a need for further education. Some of these topics are medication dosing, safety, and metabolism; delirium; and pain management. Dr. Mattison also reviews with the scholars the Society of Hospital Medicine core competencies relevant to the care of older adults. Scholars also attend two days of a five-day continuing medical education (CME) course in geriatrics. These are the days that address care of hospitalized elderly patients. She has incorporated materials and assessment tools developed by the University of Chicago’s CHAMP (Care of Hospitalized Aging Medical Patients) program. By the end of the third round of training, the Harvard program will have trained 20 faculty hospitalists. In 2009, the program will add a session for all 34 hospitalists at Beth Israel Deaconess as well as at other area hospitals. Dr. Mattison noted several factors that reinforce participation: inviting past scholars to attend current sessions, including lunch in the hospitalist suite and free tuition for the CME training as well. The hospitalist suite is a nexus for ongoing informal discussions about cases and issues between Dr. Mattison and the hospitalist scholars. Holding training in the hospitalist suite has also allowed other hospitalists to see the program in action. The program has received support from the director of hospital medicine, the chair of medicine, and the chief of geriatric medicine. “Who wouldn’t be supportive?” she asked. “Hospitalists are doing this on their own time, and the biggest expense is the two days of time when you need to get coverage for them while they attend the CME program—that and the free pizza.” |
For information about geriatrics education for hospitalists, including teaching resources, see: http://knowledgemap2.mc.vanderbilt.edu/pogoe//kmsearch/node/Hospitalists
To download a special supplement to The Hospitalist on caring for the hospitalized elderly patient, see: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Search_Advanced_...
For information about the University of Chicago’s CHAMP mini-fellowship for practicing hospitalists, teaching materials including pocket cards, and assessment tools, see: http://champ.bsd.uchicago.edu/CourseOverview.html
For information about the Donald W. Reynolds Foundation support for geriatrics training for specialists, including two programs that target hospitalists (Harvard Medical School and the University of California, San Francisco), see: http://www.dwreynolds.org/Programs/National/Aging/Cohort3.htm
For information about the Society of Hospital Medicine’s Project BOOST (Better Outcomes for Older Adults through Safe Transitions), see: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Search_Advanced_...
To download the Care Transitions for Older Adults Implementation Guide, see: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Search_Advanced_...
Continue to Chapter Four, Selected Profiles of CoE Directors and the Programs They Lead ⇒
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