5

Strategies to Strengthen Geriatrics Training for Physicians

Strategies to strengthen geriatric training for physicians must be focused at two levels: the overall strengthening of the geriatrics medicine movement and the creation of specific strategies designed for use at various levels of medical education. In a recent report of the Select Committee on Aging of the U.S. House of Representatives, Shortage of Health Care Professions Caring for the Elderly: Recommendations for Change, Jerome Kowal speaking for the Association of Directors of Geriatric Academic Programs (ADGAP) stated:

If we are to achieve our goal of increasing the number of trained academic geriatricians, we need to create incentives for physicians to choose a career in geriatric medicine, to provide greater opportunities for clinical research training, to increase geriatric content of undergraduate and postgraduate medical programs, to improve attitudes towards geriatrics by medical students, housestaff, and academic administrative leaders, and to develop public policy initiatives that will mandate increased geriatrics training and facilitate the development of clinical programs targeting older persons.

A considerable effort must be made to overcome some of the significant factors currently impacting negatively on the interest of people in geriatrics careers. . . . Currently reimbursements are skewed towards high technology subspecialties such that brief evaluations of procedures or tests generate more income in a few minutes than the hours of intense care for very sick patients (Kowal, 1993).

The following strategies have been suggested or follow from the issues identified in previous chapters of this report.



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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions 5 Strategies to Strengthen Geriatrics Training for Physicians Strategies to strengthen geriatric training for physicians must be focused at two levels: the overall strengthening of the geriatrics medicine movement and the creation of specific strategies designed for use at various levels of medical education. In a recent report of the Select Committee on Aging of the U.S. House of Representatives, Shortage of Health Care Professions Caring for the Elderly: Recommendations for Change, Jerome Kowal speaking for the Association of Directors of Geriatric Academic Programs (ADGAP) stated: If we are to achieve our goal of increasing the number of trained academic geriatricians, we need to create incentives for physicians to choose a career in geriatric medicine, to provide greater opportunities for clinical research training, to increase geriatric content of undergraduate and postgraduate medical programs, to improve attitudes towards geriatrics by medical students, housestaff, and academic administrative leaders, and to develop public policy initiatives that will mandate increased geriatrics training and facilitate the development of clinical programs targeting older persons. A considerable effort must be made to overcome some of the significant factors currently impacting negatively on the interest of people in geriatrics careers. . . . Currently reimbursements are skewed towards high technology subspecialties such that brief evaluations of procedures or tests generate more income in a few minutes than the hours of intense care for very sick patients (Kowal, 1993). The following strategies have been suggested or follow from the issues identified in previous chapters of this report.

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions REVISION IN REIMBURSEMENT POLICIES Pawlson (1993) has identified 10 reimbursements that adversely affect the supply of physician services for older people. Among the approaches that he suggests can be used to improve the situation are creating modifiers that denote patients with multiple functional impairments, expanding the number of payment codes for evaluation and management services and further increasing the assigned value for these services, creating a set of payment codes for comprehensive geriatric assessment, and developing Medicare Part B reimbursement for graduate medical education or allowing the time spent by residents in home care, office, and nursing home settings to be reimbursed by Medicare Part A graduate medical education funds. ALLIANCE FOR AGING RESEARCH EFFORTS The Alliance for Aging Research is engaged in the development of leadership centers in geriatrics established through one-time $1.5 million grants (one grant per institution) from a corporate or other private sponsor. They also propose the creation of a National Geriatrics Development Fund to be cosponsored by multiple foundations and individual donors to augment the initial grant to each leadership center. The alliance envisions as many as 10–15 leadership centers in geriatrics at U.S. medical schools (Alliance for Aging Research, 1993). ADGAP PLAN ADGAP has developed a proposal, “Geriatrics in the Next Decade: a Blueprint for Change” (David Lipshitz, ADGAP, personal communication, 1993). The document outlines a number of specific strategies for addressing the work force shortage in geriatrics, the lack of leaders in geriatric medicine, and the lack of support for training in geriatrics medicine by administrative heads of academic programs. Among the strategies proposed are (1) higher salaries for trainees and geriatric fellows, (2) low-interest loans for the development of academic careers in geriatric medicine, (3) a loan forgiveness program for physicians entering training in geriatrics medicine programs, (4) improved reimbursement for interdisciplinary care of geriatric patients, (5) training programs that are aimed at amplifying and fostering the research skills of geriatrics fellows, (6) increased funding for Claude D. Pepper Older Americans Independence Centers and Geriatric Academic Programs, and (7) creation of a 4-year dual certification program that would combine 2 years of training in general medicine and 2 years of training in geriatrics medicine. The report also recommended the development

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions of an aggressive marketing campaign targeted at administrators and students to effect a major change in attitudes toward geriatric medicine. It emphasized the need for marketing professionals to be at the core of this effort. GERIATRICS CURRICULUM AND IMPLEMENTATION GRANTS Besdine (1993) has recommended the establishment of geriatrics curriculum development and implementation grants to medical schools that develop and implement mandatory basic science and clinical curriculum components on aging. He also recommends similar awards to residency programs for the addition of mandatory training in geriatrics. The ADGAP proposal also recommends the development of public policy initiatives that will require institutions that receive a great deal of revenue from Medicare to offer appropriate geriatric training experiences in suitable clinical settings. INCREASING EXPERTISE IN NON-PRIMARY CARE SPECIALTIES At the residency level, the John A. Hartford Foundation awarded the American Geriatrics Society a planning grant for “increasing geriatrics expertise in non-primary care specialties.” The following were among the general recommendations emanating from that planning grant. Work with residency program directors to (a) sensitize them to the need for more training in geriatrics, (b) develop a cadre of leaders with additional expertise in geriatrics, and (c) develop a model core curriculum for training programs. Work with credentialing bodies to review the national medical examinations for their geriatrics contents, to test performance on geriatrics questions, and to explore the development of additional questions on geriatrics. Encourage joint educational activities between geriatrics and non-primary care disciplines. Support research in geriatrics-related topics within each discipline. Work with medical specialties that decide to support graduate courses and symposia on geriatrics topics and special interest groups in geriatrics. CENTERS OF EXCELLENCE In the study carded out by the University of California, Los Angeles (UCLA) in 1981 at the request of the National Institute on Aging, it was suggested that one of the important strategies to be considered in developing a

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions cadre of academic leadership for the field was the creation of a limited number of what was termed Centers of Excellence (Kane et al., 1981a). It was felt that this was particularly applicable in the early stages of the evolution of geriatrics as a field of medicine. This model had been followed in a number of other areas of medicine that were provided core funding to undertake both research and training activities. These centers were expected to supply both personnel and techniques of care to the larger medical field, and the recommendation emphasized that, given the small number of currently qualified individuals available at that time and the broad range of needed talents and disciplines, this approach had very real appeal. That report also emphasized that this consolidation strategy would raise issues of how best to allocate research and training support and pointed out that the Centers of Excellence approach would be of maximal benefit in the early days of faculty training, when most of the needed products of training would not have been deployed. The 1987 Institute of Medicine (IOM) report on leadership for academic geriatric medicine also recommended the creation of centers of academic excellence. The conferees at the IOM prereport writing conference had clearly been influenced by the recognition of the need for contributions from several of the relevant disciplines involved in academic training programs in order to implement strong clinical and research programs in geriatrics in academic medical centers. The report emphasized that the Centers of Excellence would focus on the training of faculty geriatricians in an environment with model teachers for educational training, vigorous basic, clinical, and health services research; and a variety of clinical opportunities. Since publication of the IOM report, the Centers of Excellence concept has developed slowly on the national scene. Most, if not all, centers have been pieced together from multiple funding sources from both the public and the private sectors. This funding has been of varying duration and has been influenced by the national economic constraints of the day. The resulting instability of the support mechanism for the Centers of Excellence approach threatens the continuance of many centers. There is anecdotal evidence, for example, that the recent major reduction in funding by the Bureau of Health Professions in support of its two major programs on aging may make it impossible for some of the established Centers of Excellence to survive. As part of national policy, it would seem to be critical to ensure the survival of those centers that are meeting national needs in training and research in geriatrics. Geriatrics can clearly benefit from the history of academic programs in other areas, most pertinently, oncology. The environment, however, is very different from that when academic programs were established, in that most of the other special areas matured in times of abundant economic resources and not in the current period of economic austerity. Oncology was an unattractive area until the federal government spurred an interest in all research related to cancer. The national commitment guaranteed stable and adequate financial support through

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions the National Cancer Institute, and as a result, oncology developed a high-quality academic identity on the basis of its clinical care, training, and research efforts. This experience provides a valuable model for the future development of academic geriatrics, because there are important parallels between oncology and geriatrics: the existence of a clinical data base, a patient population that cuts across many disciplines, the presence of a defined scientific data base, and a large central funding source that supports research and training on aging. Perhaps the most compelling evidence for the value of the Centers of Excellence model stems from the U.S. Department of Veterans Affairs (DVA) Geriatric Research, Education and Clinical Centers (GRECCs) (Marsha Goodwin, DVA, and John Morley, St. Louis University School of Medicine, personal communication, 1993). Beginning in 1975, GRECCS were established nationwide and now number 16. The staffing model adopted for each GRECC specifies 12 full-time equivalent employees, including a director, three associate directors (research, education and evaluation, and clinical), five researchers (a combination of basic and clinical scientists), and three administrative support staff. These Centers of Excellence have had remarkable success in meeting each of their missions (research, education, and clinical service). Especially noteworthy has been the ability of GRECC researchers to compete for non-DVA research funding. In fact, funding from non-DVA sources has made up an increasing proportion of their total research funding (from 48 percent in 1981 to 79 percent in 1991). Concurrently, the number of publications from GRECCs has risen from 254 in 1981 (8 GRECCs) to 617 in 1991 (12 GRECCs). As mentioned above, approximately 284 geriatric medicine fellows have been trained since 1982, and the GRECCs train more than 1,000 medical, dental, nursing, and associated health trainees on an annual basis. GRECCs have been instrumental in the development of geriatric evaluation and management units and dementia units as well as other clinical programs. Such success argues strongly for stable funding of Centers of Excellence. REPLICATING THE USPHS AND NIH MODEL A modification of the John A. Hartford Foundation-funded Student Research Program might be made. Its purpose would be to further develop and retain undergraduate medical students with an interest in geriatrics medicine. The ultimate goal would be for the students to attain faculty leadership positions when they had completed their formal research and educational training process. The principles have succeeded in successfully recruiting students to such programs in the past, perhaps best typified by U.S. Public Health Service (USPHS) initiatives in directing physicians to underserved communities, might be used. A program of this type might support medical students in their undergraduate years by providing tuition and a small stipend for living expenses,

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions with the provision that the student would spend an equivalent amount of “payback” time in further training in geriatrics. This same model was used by the National Institutes of Health (NIH) in its fellowship programs. Those programs had positive outcomes; several of those who participated in the program remained involved in research either in academic or private-sector laboratories. A program such as this would clearly be subject to attrition or the loss of trainees to other areas, but this would not be a financial burden to the funding agencies because students who did not complete the undergraduate and graduate training programs in geriatrics could be required to repay the scholarship plus interest. A multiplicity of details about a program of this type would need to be addressed, in part on the basis of whether it was funded from public or private sources. JOINT GERIATRIC OR OTHER SUBSPECIALTY TRAINING PROGRAMS A strategy to recruit first-class trainees into physician-scientist training programs in geriatrics medicine must recognize one of the reasons for the difficulty in recruiting trainees that both prospective trainees and departmental chairs have voiced. Potential trainees recognize that it is essential for them to develop specific key skills and expertise in well-recognized areas of scientific investigation to compete successfully for funding and promotion in the demanding environment of academic medicine. Department chairs, in an informal survey carried out at UCLA, perceive the importance of developing physician-scientists with expertise in geriatrics within their departments so that those individuals can assume positions in the academic leadership. However, they often do not see these people coming from the present stream of fellowship trainees in geriatrics because they believe, often for very valid reasons, that trainees in other areas closely related to aging are far superior in terms of their commitments to careers as physician-scientists. Unfortunately, the majority of the geriatric fellowship programs in the United States focus heavily on clinical training in the usual 2-year fellowship program. The majority of the programs are unable to produce graduates who can compete successfully for Research Career Development Awards and other research grants required to build a successful academic career. A large number of top-ranking medical house staff with strong research interests and talents in areas that are very relevant to geriatric medicine (e.g., cardiology, rheumatology, and endocrinology) choose fellowships in these specific areas rather than in geriatrics. These young future academicians find the majority of geriatric medicine fellowship programs less desirable because they perceive that the programs will not prepare them during the training period to be competitive in their specific field of interest.

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions On this basis, this obstacle to recruiting first-rate trainees might be overcome by developing a mechanism for supporting combined fellowship training programs in which the individual would take overlapping fellowship training in geriatric medicine and another subspecialty area. Typically, the trainee might spend the first year in intensive clinical training in either geriatrics or a related subspecialty, and during the first 2 years of this combined clinical training there would be a major educational effort directed at preparing the trainee to become a first-rate investigator. The third and fourth years would then be devoted largely to research in aging as it relates to both special areas. The two clinical and the combined research interests would be developed jointly, and the trainees would emerge from such programs highly competitive for essential First Grants and career development awards. It would also have a beneficial effect on the faculty trainers from both disciplines. In addition, it would produce significant savings in training time and decrease the chances of losing the trainee to a single special area. Typically, at least 1 year of training would be saved, a major advantage in attracting trainees and in financing the program. Such combined programs at an academic institution would also put geriatric medicine at the center of a significant portion of the overall academic faculty training effort. This model is conceptually very similar to the Clinical Scholar Program model that was originally jointly sponsored by the Carnegie Corporation and the Commonwealth Fund and that subsequently has received Robert Wood Johnson Foundation funding. The results of that programs have been outstanding. The requirement for initiating such a program would be the need for a strong host institution with established excellence in both geriatric medicine and subspecialty training, a faculty with the innovative bent and energy needed to put forth the effort required to establish and maintain a successful dual training program, and greater flexibility in the financial support for the combined training effort. SOLVING THE ACADEMIC LEADERSHIP CRISIS IN GERIATRICS BY RETRAINING SPECIALISTS FOR LEADERSHIP IN AGING It has been estimated (Lundberg, 1991) that, in attempting to achieve the national goal of a 50:50 specialist-to-generalist ratio, there is an oversupply of 100,000 specialists and subspecialist physicians. It has recently been suggested on a number of occasions (American Board of Internal Medicine, personal communication, 1993; Lundberg, 1993; Physician Payment Review Commission, personal communication, 1993) that the national primary care problem might be reduced by retraining specialists to gain specific competency in primary care medicine. A similar strategy might be highly effective in geriatrics, as can be seen from the midcareer training programs sponsored by both the John A. Hartford Foundation and the Bureau of Health Professions. It would necessitate

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions the creation of a system of incentives and disincentives that encourages the shift of academic and practicing specialists and subspecialists into geriatrics. Such a system would require a yet-to-be-developed program of retraining or continuing medical education for a population of subspecialist-physicians. Members in the field of geriatrics have already studied the competencies required for the field, and interestingly, these competencies are closely allied to the specific competencies that have been identified by the Pew Health Professions Commission. A next step would be the development of a methodology for assessing the extent to which a potential specialist or subspecialist might have these competencies, and when areas of deficiency are identified, programs could be tailor-made to produce effective faculty in geriatrics with leadership capabilities. Thus, the curricula for these retraining efforts are envisaged to take different lengths of time and offer various types of educational experiences so that individual physicians might achieve competency as leaders in geriatrics faculty. However, retraining would take less time than training new physicians. Several important practical issues must be considered when developing midcareer retraining programs. First, mechanisms for maintaining physician salaries during the retraining period must be developed. Current stipends for midcareer training under the Bureau of Health Professions fellowship training grants are tied to fellowship salaries, which are frequently less than one third of midcareer faculty salaries. Such salary reductions, even if only transient, might be a deterrent rather than an incentive to retraining and would seriously impair recruitment efforts. Second, issues such as relocation during retraining (if this training was to occur outside of the physician's home institution) and institutional support after the retraining period must be addressed by such programs. STRENGTHENING FACULTY DEVELOPMENT AND RETENTION PROGRAMS TO REDUCE ATTRITION FROM FACULTY LEADERSHIP ROLES Previous studies under the auspices of UCLA referred to elsewhere in this report showed that few of those who had formal training in geriatrics were actually assuming the academic roles envisioned for them. It was clear from those data that one of the major obstacles is the excessive amount of clinical and administrative time required of them. The greatest satisfaction with academic geriatrics as a career choice was reported by those physicians whose current activities most closely resembled the models advanced in the 1987 IOM report, that is, an academic leadership role. Job variety and involvement in something other than full-time patient care were associated with more satisfaction by the former trainees. This finding has important implications for the retention of academic geriatricians and emphasizes the importance of faculty leaders (departmental and divisional chairs), facilitating the maintenance of job and role

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions diversity in teaching and research and limiting the amount of clinical service. Although this is a problem for most faculty in clinical disciplines, it seems particularly important to the younger generation of academic geriatricians. RECRUITMENT AND MARKETING STRATEGY Further efforts need to be directed toward changing the attitudes of individuals in leadership positions, medical students, and residents concerning the importance of geriatrics and the major opportunities that exist of they were to embrace the area. Marketing professionals should be involved with professional organizations in highlighting the need, the value, and the opportunities that exist in geriatric medicine. The efforts might begin at the time of enrollment into medical school and be reinforced throughout the undergraduate curriculum. Students who are selecting their residency programs as well as residents who are making fellowship training decisions could also be targeted. INCREASING THE GERIATRIC MEDICINE CONTENT IN NATIONAL EXAMINATIONS Nationally sponsored examinations throughout the medical educational continuum are often not considered to have any major effect on the course content of the undergraduate, graduate, or fellowship training curricula. The realities are that, from the potential examinees' perspective, they very much influence what students learn. There needs to be a systematic study of how the national examinations might contain questions that address the special content areas and, when applicable, the skills that are required for the care of elderly people by physicians. VISIBILITY OF GERIATRICS MEDICINE ON THE NATIONAL AND STATE LEGISLATIVE SCENE Geriatrics and gerontology often appear to be underrepresented in the ongoing efforts at influencing national legislative and funding decisions. In all probability, several factors contribute to this lack of effectiveness, but one is clearly the large number of lobbying organizations involved but the lack of a coordinated lobbying effort. The Alliance for Aging Research has attempted to address this issue, but much more needs to be done. In a multi- and interdisciplinary activity, conflicting priorities understandably arise, and no effective mechanisms for their resolution exist at this time.