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Experts in the Elderly


 

The average young or middle-age person probably finds a hospital stay stressful, uncomfortable, and inconvenient. The experience can be strikingly more disruptive for a geriatric patient.

A frail elderly person can easily succumb to delirium, a fall, dehydration, polypharmacy, and deterioration in basic life skills, quickly turning even a routine hospitalization into a catastrophic downhill slide. But if a patient is lucky, she will be treated by a geriatric hospitalist—a physician who by training and temperament is uniquely suited to care for her.

Geriatric hospitalists bring heightened sensitivity and experience to treating and preventing the common syndromes that can overwhelm the elderly during hospitalizations. Fredrick Sherman, MD, FACP, medical director of Senior Health Partners and professor of geriatrics at the Mount Sinai School of Medicine in Manhattan, has been a geriatrician since the 1980s. He sees a great opportunity for hospitalist geriatricians to improve the metrics by which hospitalist programs are judged: reduced length of stay, bounceback, and morbidity. They do this, he says, with a unique blend of skills, mindset, and temperament.

“In one or two minutes at the bedside, a geriatric hospitalist can do a basic functional assessment of an elderly patient,” he says. “We can understand their ADL [activities of daily living] skills, mental status, and what resources we have to mobilize during the hospital stay and for a safe discharge plan. We don’t want to turn hospitalists into social workers, but geriatricians can teach them a body of knowledge to help them better understand and develop a holistic approach to elderly patients.”

How geriatricians work best, though, can be somewhat out of synch with hospital medicine’s fast pace. “Many hospitalists are younger and have been trained very recently,” Dr. Sherman says. “They quickly learn to take care of a 55-year-old with a [myocardial infarction], but they sometimes lack a global view of geriatric patients that is more a frame of mind than about the physician’s technical skills.”

ACEs for Older Patients

Acute Care of Elders (ACE) units are designed to treat the elderly hospitalized with acute medical conditions. Generally consisting of fewer than 30 beds, they are designed to resemble home more than a hospital. Activity rooms for congregate meals, kitchens, recliners, low beds, carpeting, art, and music areas are common features. Geriatricians, advanced practice nurses, physical and occupational therapists, and social workers work together create a kinder, gentler approach to care.

Based on a model developed at University Hospitals of Cleveland in conjunction with the Case Western Reserve University’s School of Nursing, the physical and psychological hospital environment has been adapted by ACE unit clinicians to prevent the functional decline observed in about 35% of hospitalized geriatric patients. Simple things—fasting before diagnostic procedures, unfamiliar routines, medication changes, and enforced bed rest—can throw a senior into decline. ACEs get patients up and moving, keep them oriented through home-like environments, and connect them through congregate meals and activities. —MP

Challenges Ahead

As hospital medicine groups integrate geriatricians into their ranks, they will have recruited major players invested in improving the care of hospitalized elderly patients. There’s a lot at stake in caring for them.

The Healthcare Cost and Utilization Project’s (HCUP) most recent figures of what hospitalizations of the elderly cost is staggering. Medicare patients account for 76% of public spending on hospital care. The costliest diagnoses for Medicare-paid hospitalizations are coronary arteriosclerosis ($44 billion), acute myocardial infarction ($31 billion), and heart failure ($29 billion). Further, 90% of elderly patients with osteoarthritis are hospitalized for elective hip or knee joint replacement therapy.

The expertise of board-certified hospitalist geriatricians will be hard to disseminate throughout the corps of hospitalists. Only a tiny fraction of the nation’s hospitalist programs claim special expertise in geriatrics. Researchers from the University of Colorado Health Sciences Center and the Mayo Clinic College of Medicine conducted a cross-sectional survey of the hospitalist community in 2003-2004 to determine the impact of the hospitalist movement on acute care geriatrics. They found:

  • Out of 1,415 hospitalist programs, 11 reported geriatric innovations.
  • Four developed core clinical activities, four used geriatric QI measures, three used comprehensive geriatric assessments, and two had specific protocols for elderly patients discharged to nursing facilities; and
  • In terms of staffing, four had hospitalists with no special geriatric training, four employed fellowship-trained geriatricians, two had general hospitalists and geriatricians, and four used advanced practice nurses with and without geriatric training.1

Adding to the difficulty of building a cadre of geriatric hospitalists is the national paucity of geriatricians. According to the American Geriatrics Society (AGS), there were 9,000 board-certified geriatricians in 1998. A decade later there are 7,600—and the pipeline is narrow. Of 9,780 medical school graduates in 2004, only 321 were geriatricians. The AGS estimates that the United States needs 14,000 geriatricians now and 36,000 in 2030, when there will be an estimated 70 million adults 65 years and older.

But there’s hope. Hospital medicine programs, growing by leaps and bounds, offer a new career path for physicians interested in geriatrics. As the number of hospitalists continues to grow, there’s room for physicians to have an impact by staying tuned in to the special clinical, psychosocial, emotional, spiritual, and environmental needs of elderly patients.

A GOOD Career

Despite the difficulty of persuading family practice and internal medicine residents to consider a career in geriatrics, these doctors consistently report the highest career satisfaction of any sub-specialists.

A snapshot of 88 physicians with formal geriatric trained showed:

  • 89.5% planned to pursue recertification;
  • 95% felt that a geriatric fellowship had a positive career impact;
  • 87% recommended pursuing geriatric fellowship training;
  • 75% devoted at least half of their practice to caring for the elderly;
  • 64% had yearly incomes between $100,000 and $200,000; and
  • 25.6% had incomes greater than $200,000.

The Breed

According to Leslie Libow, MD, distinguished clinical professor at the Jewish Home and Hospital of New York in Manhattan, physicians who pursue a career in geriatrics do so because they have the right psychological make-up to work with elderly people.

He should know. In 1968, Dr. Libow petitioned the American Board of Internal Medicine (ABIM) to recognize geriatrics as a sub-specialty of internal medicine. Shortly after ABIM recognition, Dr. Libow established a geriatric residency/fellowship at Mount Sinai—still a national leader in geriatric education.

Being a geriatric hospitalist allows physicians with a simpatico set of personality traits to thrive. One study of geriatricians who had been practicing for up to 25 years found that they shared these traits:

  • Highly value enduring relationships;
  • Enjoy making small but potent changes in their patients’ lives;
  • Like to make a difference personally and for society;
  • Prefer working in a multidisciplinary team;
  • Prefer democratic, not autocratic, decision-making;
  • Desire the intellectual challenges of geriatric medicine and like to teach; and
  • Perceive that they have a distinct and different career path than other physicians.2

That essentially describes Purnima Joshi, chief of medicine, at Kaiser-Permanente Mid-Atlantic States at Washington Hospital Center in Washington, D.C. She directs a group of 12 hospitalists, is the group’s only geriatrician at the 800-bed tertiary care facility, and enjoys teaching residents about geriatric medicine. A family physician by trade, she was grandfathered into geriatrics in 1992 and recertified in 2002.

“I love working with the frail elderly and practicing Kaiser’s brand of medicine because I don’t do billing—I just treat patients,” Dr. Joshi says. Additionally, Kaiser simplifies record-keeping on inpatient and outpatient treatments and makes communicating with Kaiser’s outpatient doctors about post-discharge care smooth and efficient.

Dr. Joshi explains that being a geriatric hospitalist is different than specializing in general internal medicine because she customizes the approach for each patient—including tailoring therapies to life expectancy. “Guidelines and evidence-based medicine are fine and very important, and we use geriatric guidelines on our teaching service,” she says. “But geriatrics liberates your thinking as a doctor. You treat the whole person—a diabetic with three days to live, and a 90-year-old with delirium and decubitus ulcers.”

She calls herself a surrogate primary care physician, seeing 12 patients most days. She consults frequently with other hospitalists on their toughest geriatric issues and makes daily multidisciplinary rounds—with discharge planner, pharmacist, physical therapist, palliative care specialist, nurses, and resident in tow.

“We keep length of stay and guidelines in mind, but the patient is the center of my universe,” Dr. Joshi asserts. “I deliver holistic, patient-centered care and use gentle teaching tools for our residents. I have the luxury of taking time to see the patient and talk to them and their families. It’s wonderful.”

Dr. Joshi’s attitude toward her profession reflects a consistent national finding: Geriatricians rank No. 1 in nearly every study of physician career satisfaction, from the American Medical Association to the American Geriatrics Society.

Across the country, Alpesh Amin, MD, MBA, FACP, professor and chief of general internal medicine and executive director of the University of California at Irvine’s School of Medicine Hospitalist Service, is making the most of the two geriatricians on his 15-hospitalist team. Starting about eight years ago, Dr. Amin—also a member of SHM’s board of directors—turned to his hospitalist geriatricians for a host of services: geriatric assessments, co-management of psychiatric problems, perioperative consults, critical care, and palliative care consults.

“Geriatricians have such knowledge and insight into elderly patients to share with the other hospitalists,” says Dr. Amin. “That’s why they work well side by side with internal medicine and family medicine hospitalists. They keep us aware of issues in geriatrics and the literature on what works best with these patients.”

Knowing that geriatricians are scarce, Dr. Amin accesses their expertise by using a system that focuses team members’ attention on their knowledge. There are journal clubs, frequent consults, monthly meetings, teaching rounds, geriatric fellowships, and other opportunities that keep the geriatrician’s unique perspective front and center for other team members. “They are so in tune with issues related to delirium, polypharmacy, falls risk, etc.,” he says. “Our model incorporates that expertise, and it works very well. We truly work as a multidisciplinary team with ownership and accountability of the special needs of our geriatric patients.”

We don’t want to turn hospitalists into social workers, but geriatricians can teach them a body of knowledge to help them better understand and develop a holistic approach to elderly patients.

—Fredrick Sherman, MD, FACP, medical director of Senior Health Partners and professor of geriatrics at the Mount Sinai School of Medicine in Manhattan

A New Generation

The rapid growth of hospital medicine has encouraged new physicians to choose this career path.

Claudene George, MD, recently completed a two-year geriatric fellowship at Mount Sinai Hospital in New York City and is starting as a geriatric hospitalist at Montefiore Hospital in the Bronx. “Becoming a geriatrician sort of surprised me because I thought I’d go into internal medicine,” she says. “But I love the approach to caring for the whole person and communicating with their families.”

As part of her contract at Montefiore, she negotiated a half-day-per-week rotation at the hospital’s outpatient clinic—part of her commitment to being a well-rounded physician.

“The geriatric assessment up front is essential to find out what the patient’s and family’s goals of care are,” says Dr. George. “If they’re 80 years old and want to stay at home, we need to help them do that safely. That may mean linking them to the [visiting nurse service], a home aide, or adult day care.”

She points out that an inpatient stay also offers seniors the opportunity to be seen by subspecialists and do a lot in a short period of time. “As a hospitalist geriatrician you can see change almost immediately; you can have an impact,” she concludes.

As the hospitalist movement affords career opportunities to geriatricians, young physicians can obtain financial incentives to pursue a career in geriatrics. For instance, in 2006 South Carolina enacted a Geriatrician Loan Forgiveness program, helping physicians to repay up to $35,000 of medical school loans if they complete a geriatrics fellowship and practice in South Carolina for five years after completing medical training.

Victor Hirth, MD, medical director for the Division of Geriatric Services of Palmetto Health of Columbia, S.C., has recruited eight geriatric fellows, two of whom will be hospitalists. A recent recruit, Andres Leone, MD, went to medical school in Ecuador, recently completed a geriatric fellowship in South Carolina, and works as a hospitalist half time and at a free clinic for Hispanics half-time. “The flexibility to work as a hospitalist and in an outpatient clinic feels right to me,” says Dr. Leone.

While the number of geriatric hospitalists today is small, some predict their growing presence is inevitable.

“The baby boomers will deluge us, and they will demand so much more of hospitalists in the near future,” Dr. Sherman says. “They will have complicated issues and be very inquisitive geriatric patients.” TH

Marlene Piturro is a frequent contributor to The Hospitalist.

References

  1. Wald H, Huddleston J, Kramer A. Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs. J Hosp Med. 2006 Jan;1(1):29-35.
  2. Shah U, Aung M, Chan S, et al. Do geriatricians stay in geriatrics? Gerontol Geriatr Educ. 2006;27(1):57-65.

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