recruitment and retention of physiciansiom.nationalacademies.org/~/media/files/activity...

Recruitment and Recruitment and Retention of PhysiciansRetention of Physicians

Sharon A. Levine, MDSharon A. Levine, MDBoston University School of MedicineBoston University School of Medicine

June 28, 2007June 28, 2007IOM Committee on Future Health Care IOM Committee on Future Health Care

Workforce for Older AmericansWorkforce for Older Americans

Recruitment and Retention of Recruitment and Retention of PhysiciansPhysicians

ØØ How do you get physicians interested in getting How do you get physicians interested in getting geriatrics training or acquiring skills at every geriatrics training or acquiring skills at every level?level?ll More geriatriciansMore geriatriciansll Get all physicians to recognize need for special skills Get all physicians to recognize need for special skills

when working with older adultswhen working with older adults•• ResidentsResidents•• Practicing PhysiciansPracticing Physicians•• FacultyFaculty•• SpecialistsSpecialists•• Medical StudentsMedical Students

http://agingstats.gov/chartbook2000/population.html accessed 11/24/06

The Graying of the Population

http://agingstats.gov/chartbook2000/population.html

ØØ BackgroundBackgroundØØ Practicing geriatriciansPracticing geriatriciansØØ Geriatrics FellowshipsGeriatrics FellowshipsØØ ResidentsResidentsØØ Practicing PhysiciansPracticing PhysiciansØØ SpecialistsSpecialistsØØ StudentsStudents

The NeedThe Need

ØØ >> 65 y.o. make up about 50% of visits to 65 y.o. make up about 50% of visits to officeoffice--based physiciansbased physicians

ØØ 45 % of visits to generalists: IM (25%) and 45 % of visits to generalists: IM (25%) and FM (21%)FM (21%)

ØØ Account for 36% acute hospitalizationsAccount for 36% acute hospitalizationsØØ Account for 50% hospital expendituresAccount for 50% hospital expendituresØØ 747 procedures/100,000747 procedures/100,000----twice that for pts twice that for pts

4545--64 and 3 x 1564 and 3 x 15--4444Hing E et al. NAMCS:2004 Summary. Adv Data from Vital and Health Stats; No. 374. NCHS, 2006;Green LA. Acad Med. 2002;77:781-9; Landefeld CS et al. Ann Int Med. 2003;139:609-14

Ambulatory Care Visits to Primary Care and Ambulatory Care Visits to Primary Care and Specialist Physicians, United States, Patients Age Specialist Physicians, United States, Patients Age 65 and over 65 and over

42%42%58%58%53%53%47%47%62%62%38%38%

PrimaryPrimaryCare Care SpecialistSpecialist

Primary Primary CareCareSpecialistSpecialist

Primary Primary CareCareSpecialistSpecialist

200420041990199019801980

Source: CDC, NCHS, National Ambulatory Medical Care SurveySource: CDC, NCHS, National Ambulatory Medical Care Survey

The ADGAP The ADGAP Status of Geriatrics Workforce StudyStatus of Geriatrics Workforce Study

Elizabeth “Libbie” Bragg, PhD, RN

Gregg Warshaw, MD

Methods Methods Primary Data CollectionPrimary Data Collection

ØØ 2001, 2005, & 2007 Surveys of Medical Schools 2001, 2005, & 2007 Surveys of Medical Schools Geriatric Medicine Program Leaders (Allopathic Geriatric Medicine Program Leaders (Allopathic & Osteopathic)& Osteopathic)

ØØ 2001 & 2004 Surveys of Family Medicine 2001 & 2004 Surveys of Family Medicine Residency Program DirectorsResidency Program Directors

ØØ 2002 & 2005 Surveys of Internal Medicine 2002 & 2005 Surveys of Internal Medicine Residency Program DirectorsResidency Program Directors

ØØ 2001 Surveys of Geriatric Medicine and Geriatric 2001 Surveys of Geriatric Medicine and Geriatric Psychiatry Fellowship Program DirectorsPsychiatry Fellowship Program Directors

ØØ 2006 Survey of Psychiatry Residency Program 2006 Survey of Psychiatry Residency Program DirectorsDirectors

Methods Methods Secondary Data SourcesSecondary Data Sources

ØØ AAMCAAMCØØ AMAAMAØØ ABIM, ABFM, & ABPNABIM, ABFM, & ABPNØØ ABMSABMSØØ VHAVHAØØ National Ambulatory Medical Care Survey National Ambulatory Medical Care Survey

(NAMCS) (NAMCS) ØØ Medical Group Management Association Medical Group Management Association

(MGMA)(MGMA)

11,42311,121

2,412

4,089

5,940

8,824

10,85810,530

10,2159,9159,7019,4749,263

8,279

7,1287,1386,875

7,7357,420

7,9767,762

8,3548,143

8,8248,279

5,940

4,089

2,412

0

2,000

4,000

6,000

8,000

10,000

12,000

1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006

Cumulative Certificates awarded Currently Certified Geriatricians

Comparison of Number of Certificates in Geriatric Medicine Awarded

to Number of Currently Certified Geriatricians (Family Medicine and Internal Medicine)

Source: ADGAP Status of Geriatrics Workforce Study

April 2007

Certification and ReCertification and Re--certification in Geriatric certification in Geriatric Medicine by Year of Original CertificationMedicine by Year of Original Certification

45%45%29129140%40%25425419961996

47%47%1568156853%53%77177119941994

50%50%1254125461%61%59759719921992

45%45%1204120466%66%47347319901990

49%49%1659165964%64%75375319881988

%%ReRe--certifiedcertifiedCertifiedCertified

% % ReRe--certifiedcertifiedCertifiedCertified

Internal Medicine Internal Medicine Family MedicineFamily Medicine

YearYear

As of March 2007. Source: ABFM and ABIM. Data compiled by ADGAP Status of Geriatrics Workforce Study

Fellowship ProgramsFellowship Programs

Geriatric Medicine Fellowship ProgramsGeriatric Medicine Fellowship Programs

(Family Medicine and Internal Medicine)(Family Medicine and Internal Medicine)

(67%)(67%)296296

442442555535135114014005/0605/06

(73%)(73%)247247

337337747432132111911900/0100/01

(57%)(57%)117117

206206106106223223999995/9695/96

------------215215979792/9392/93

% filled% filled11stst year year

Positions Positions

11stst Yr Yr PositionsPositionsAvailableAvailable

Fellows Fellows Beyond Beyond Year 1Year 1

Fellows Fellows All YrsAll YrsProgramsProgramsAYAY

Source: AMA and AAMC data from the National Survey of GME Programs compiled by ADGAP Status of Geriatrics Workforce Study

Geriatric Psychiatry Fellowship ProgramsGeriatric Psychiatry Fellowship Programs

64%64%137137559292616105/0605/06

63%63%125125778686616100/0100/01

--------773838383895/9695/96

% filled% filled11stst year year

Positions Positions

11stst Yr Yr PositionsPositionsAvailableAvailable

Fellows Fellows Beyond Beyond Year 1Year 1

Fellows Fellows All YrsAll YrsProgramsProgramsAYAY


101

181

222

294

276295

321313

129117118117

292

35

72 7886 91

79 79 85 84 81

0

50

100

150

200

250

300

350

92-93 93-94 94-95 95-96 96-97 97-98 98-99 99-00 00-01 01-02 02-03 03-04 04-05

Geriatric Medicine Fellowship Programs

Geriatric Psychiatry Fellowship Programs

Graduates of Geriatric Medicine and Geriatric Psychiatry Fellowship Programs


4876.34876.3

4457.94457.9

3350.63350.6

2285.22285.2

1897.41897.4

1660.11660.1

Population 75 Population 75 and and older/10,000older/10,000

1.61.648,763,00048,763,0007,9497,94920502050

1.91.944,579,00044,579,0008,5418,54120402040

2.42.433,506,00033,506,0007,8777,87720302030

3.93.922,852,00022,852,0008,873 8,873 20202020

4.04.018,974,00018,974,0007,6317,63120102010

4.74.716,601,00016,601,0007,7627,76220002000

Geriatricians/10,000 Geriatricians/10,000 population aged 75 population aged 75 and olderand older

Population 75 Population 75 and Olderand Older

Number Number GeriatriciansGeriatricians

YearYear

Projection on Future Number Projection on Future Number of Geriatricians in the United of Geriatricians in the United

StatesStates

http://agingstats.gov/chartbook2000/population.html accessed 11/24/06

The Graying of the Population

http://agingstats.gov/chartbook2000/population.html

Geriatric Physician WorkforceGeriatric Physician Workforce PipelinePipeline

ØØ Fewer grads entering primary care residenciesFewer grads entering primary care residencies

ØØ 9,283 MDs graduated from FM & GIM residency 9,283 MDs graduated from FM & GIM residency programs in 2005programs in 2005ØØ 4% entered a GM fellowship in 20064% entered a GM fellowship in 2006

ØØ 1,029 MDs graduated from Psychiatry residency 1,029 MDs graduated from Psychiatry residency programs in 2005programs in 2005ØØ 9% entered a GP fellowship in 20069% entered a GP fellowship in 2006

Source: AMA and AAMC data from the National Survey of GME Programs 2005/2006.

Disincentives Disincentives

ØØ Lower compensation for junior faculty in Lower compensation for junior faculty in geriatrics at academic medical centers c/w geriatrics at academic medical centers c/w FM/IM colleaguesFM/IM colleagues

ØØ Disparities in academic vs. private practiceDisparities in academic vs. private practicell $130 K $130 K vs vs $155 K ($25 K difference)$155 K ($25 K difference)ll Geri earns 76%Geri earns 76%--96% the income of general 96% the income of general

internistsinternists

Weeks WB. JAGS 2004;52:1940-45

Total Annual Compensation for Private Practice Physicians Total Annual Compensation for Private Practice Physicians Net median clinical salary (not including benefits)Net median clinical salary (not including benefits)

11.3%11.3%335,731335,731301,772301,772UrologyUrology11.7%11.7%166,420166,420149,009149,009GIMGIM14.1%14.1%161,331161,331141,400141,400PediatricsPediatrics18.4%18.4%180,000180,000152,000152,000PsychiatryPsychiatry18.5%18.5%205,838205,838173,643173,643PM & RPM & R18.9%18.9%198,991198,991167,199167,199RheumatologyRheumatology20.5%20.5%211,094211,094175,143175,143NeurologyNeurology

3.4%3.4%255,072255,072246,580246,580NephrologyNephrology

5.6%5.6%160,340160,340151,833151,833GeriatricsGeriatrics7.5%7.5%156,011156,011145,121145,121FM without OBFM without OB

31.1%31.1%368,733368,733281,308281,308GastroenterologyGastroenterology% + Change% + Change2004200420002000Practice AreaPractice Area

Source: Medical Group Management Association. Physician Compensation and Production Survey

Medical School Faculty Compensation Medical School Faculty Compensation median salarymedian salary

223,000223,000190,000190,000156,000156,000127,000127,000108,000108,000GeriatricsGeriatrics

213,000213,000188,000188,000153,000153,000137,000137,000132,000132,000Internal Internal MedicineMedicine

289,000289,000239,000239,000225,000225,000190,000190,000150,000150,000GastroenterologyGastroenterology

------175,000175,000154,000154,000136,000136,000123,000123,000Family Family MedicineMedicine

226,000226,000195,000195,000152,000152,000124,000124,00090,00090,000EnEndocrinologydocrinologyChief Chief ProfessorProfessor

AssociateAssociateProfessorProfessor

AssistantAssistantProfessorProfessorInstructorInstructorDepartmentDepartment

AAMC Report on Medical School Faculty Salaries, 2005-2006, January 2007

Solutions to Recruiting Solutions to Recruiting Geriatricians Geriatricians

AGS/ADGAP Fellowship AGS/ADGAP Fellowship Position Paper May 2006Position Paper May 2006

ØØWhat changes in the structure of length of What changes in the structure of length of fellowship training would make geriatrics a fellowship training would make geriatrics a more or less desirable career choice?more or less desirable career choice?

ØØWhat types of formal fellowship training What types of formal fellowship training programs could be created for practicing programs could be created for practicing physicians who are unable to leave physicians who are unable to leave practice to pursue full time geriatrics practice to pursue full time geriatrics fellowship training? (Alternative Pathways)fellowship training? (Alternative Pathways)

What changes in the structure of length of What changes in the structure of length of fellowship training would make geriatrics a fellowship training would make geriatrics a

more or less desirable career choice?more or less desirable career choice?

ØØ Questionnaire: distributed to Questionnaire: distributed to ll SGIM Geriatrics Interest GroupSGIM Geriatrics Interest Groupll ADGAP fellowship directorsADGAP fellowship directorsll AGS special interest group in FMAGS special interest group in FM

77% favored at least 12 months77% favored at least 12 months2 year less desirable due to financial burden of deferred 2 year less desirable due to financial burden of deferred

practicepractice74% liked 2+2 option (2 yrs better for research)74% liked 2+2 option (2 yrs better for research)Limited interest of training beyond four years; 2+1 Limited interest of training beyond four years; 2+1

option inadequateoption inadequate

University of Missouri Focus University of Missouri Focus groupgroup

ØØ Two groups: 6 trainees interested in Two groups: 6 trainees interested in geri geri and 18 uninterestedand 18 uninterestedll Geriatrics positive wanted a geriatrics trackGeriatrics positive wanted a geriatrics trackll Both groups felt either 1 yr following residency Both groups felt either 1 yr following residency

or 2+2 combo would be attractive, since it or 2+2 combo would be attractive, since it would offer better continuity of care would offer better continuity of care

ll No interest in MPHNo interest in MPHll Loan forgiveness would be an incentiveLoan forgiveness would be an incentive

Bottom lineBottom lineØØ Limited interest among residents and faculty in Limited interest among residents and faculty in

lengthening training beyond current 4 yearslengthening training beyond current 4 yearsØØ The possibility of 2+2 program is of interest to The possibility of 2+2 program is of interest to

both groupsboth groupsØØ 2+1 program is seen as inadequate2+1 program is seen as inadequateØØ MDs are attracted to geriatrics because of MDs are attracted to geriatrics because of

challenge of complex older patientschallenge of complex older patientsØØ Debt burden coupled with relative lower Debt burden coupled with relative lower

reimbursement of geriatrics is a disincentivereimbursement of geriatrics is a disincentiveØØ Loan forgiveness might attract more residents to Loan forgiveness might attract more residents to

training in geriatricstraining in geriatrics

Alternative Pathways for Practicing Alternative Pathways for Practicing PhysiciansPhysicians

ØØ AGS Education Committee 11/05 discussed AGS Education Committee 11/05 discussed proposals under consideration by ABIM that proposals under consideration by ABIM that would recognize practice focused on specific would recognize practice focused on specific setting, population or diseasesetting, population or disease

ØØ Recognition of Recognition of focusedfocused practice for older adults practice for older adults might be recognized through a practice pathway might be recognized through a practice pathway as part of maintenance of certification in a way as part of maintenance of certification in a way that fits lifestyle and practice needsthat fits lifestyle and practice needs

Alternative PathwaysAlternative Pathways

ØØ Set time frame, Set time frame, eg eg 10 years beyond 10 years beyond residencyresidency

ØØ Criteria for recognition under maintenance Criteria for recognition under maintenance of certification by, of certification by, egeg::ll Successful completion of GRS, PIM, pass the Successful completion of GRS, PIM, pass the

secured geriatrics examinationsecured geriatrics examinationll Required to demonstrate significant clinical Required to demonstrate significant clinical

experience in practice experience in practice ll CME requirements or miniCME requirements or mini--fellowships like fellowships like

FDFD--AGE programsAGE programsll Opinion LeadersOpinion Leaders

Strategies to Improve Strategies to Improve Recruitment in Geriatrics (2006)Recruitment in Geriatrics (2006)ØØ Annual Reynolds MeetingAnnual Reynolds Meeting——September 2006September 2006

ØØ Brainstorming session defining strategies to Brainstorming session defining strategies to improve recruitment in geriatricsimprove recruitment in geriatrics——Jane Potter, Jane Potter, MD as AGS presidentMD as AGS president

ØØ Strategies identified, discussed and evaluatedStrategies identified, discussed and evaluated

ØØ 65 individuals from 35 medical schools, 65 individuals from 35 medical schools, Reynolds and Hartford FoundationsReynolds and Hartford Foundations

Strategies to Improve Strategies to Improve Recruitment in GeriatricsRecruitment in Geriatrics

ØØ Each of 20 strategies was ranked for global Each of 20 strategies was ranked for global importance, impact if implemented, and the importance, impact if implemented, and the degree of difficulty to achieve implementation. degree of difficulty to achieve implementation. Table summarizes the results following the rank Table summarizes the results following the rank order (from one to 20). order (from one to 20).

ØØ Key elements of the discussion during the Key elements of the discussion during the session are also summarizedsession are also summarized

ØØ Scores for impact and achievabilityScores for impact and achievability

2.112.112.642.64Better marketing of career paths of Better marketing of career paths of geriatriciansgeriatricians

1010

3.153.152.452.45Flexible fellowshipsFlexible fellowships-- fellowships with out fellowships with out walls walls

99

3.283.282.152.15Required geriatrics clerkship in the 3Required geriatrics clerkship in the 3rdrd

year of medical schoolyear of medical school88

4.254.251.771.77Improve reimbursement for geriatrician Improve reimbursement for geriatrician servicesservices

77

2.062.062.382.38Advertise geriatrics as an attractive Advertise geriatrics as an attractive lifestylelifestyle

663.633.631.61.6Increase research funding Increase research funding 554.234.231.411.41Better pay for geriatriciansBetter pay for geriatricians44

1.891.891.821.82Resident initiatives geriatrics journal club, Resident initiatives geriatrics journal club, clinics interest groupclinics interest group

331.91.91.781.78Early mentoring of studentsEarly mentoring of students22

3.213.211.321.32Loan forgiveness for residents who want Loan forgiveness for residents who want to go into geriatricsto go into geriatrics

11Difficulty*Difficulty*Impact*Impact*Strategy/DiscussionStrategy/DiscussionRankRank

*Rank: Each participant was asked to rank their top choices from one to five. Scores were inverted to reflect five as highest and one as lowest. Scores were then summed to create a total point value. Items 13 and 14 were tied.Impact: greatest impact was scored as one, least impact as five.Difficulty/achievability: most easily achievable was scored as one, most difficult as five.

4.224.222.562.56More departments of geriatricsMore departments of geriatrics2020

332.642.64Techniques to enhance attitudes towards Techniques to enhance attitudes towards geriatricsgeriatrics

19193.733.732.882.88Increased compensation for fellowsIncreased compensation for fellows1818

1.711.713.323.32Business cards and immediate outreachBusiness cards and immediate outreach1717

3.693.693.773.77Require medical student applicants to Require medical student applicants to spend time in nursing homes (spend time in nursing homes (NHsNHs))

16163.43.43.173.17Funding to teach nonFunding to teach non--geriatriciansgeriatricians15152.62.62.232.23Better marketing/celebrity advocateBetter marketing/celebrity advocate1414

332.292.29Changing fellowship rules so practicing Changing fellowship rules so practicing doctors can become geriatricians (see #9)doctors can become geriatricians (see #9)

1313

2.322.322.622.62Clarification of role of geriatrician in market Clarification of role of geriatrician in market place place

12123.43.42.592.59Funding for second year fellowsFunding for second year fellows1111




IMPACT BY DIFFICULTY BY GLOBAL IMPORTANCE IMPACT BY DIFFICULTY BY GLOBAL IMPORTANCE RANKING (small numbers = higher rank)RANKING (small numbers = higher rank)

FOR TWENTY "STRATEGIES TO IMPROVE FOR TWENTY "STRATEGIES TO IMPROVE RECRUITMENT IN GERIATRICS"RECRUITMENT IN GERIATRICS"

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

IMPACT

DIFF

ICU

LTY

Median Difficulty = 3.18

Median Impact = 2.36Easy to ImplementLow Impact

Difficult to ImplementLow Impact

Easy to ImplementHigh Impact

Difficult to ImplementHigh Impact

Low ImpactHigh Impact

1 - Loan forgiveness

4 - Better pay: geriatricians

5 - Increase research funding

7 - Improve reimbursement

8 - Geriatrics clerkship

Eas

y

Diff

icul

t

(G (G Hougham Hougham chart from J Potter data, 9/20/06 session at Lisle, IL chart from J Potter data, 9/20/06 session at Lisle, IL Reynolds meeting)Reynolds meeting)

IMPACT BY DIFFICULTY BYIMPACT BY DIFFICULTY BY GLOBAL IMPORTANCE GLOBAL IMPORTANCE RANKING (small numbers = higher rank)RANKING (small numbers = higher rank)


0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

IMPACT

DIF

FIC

ULT

Y


Median Impact = 2.36Easy to ImplementLow Impact





11 - 2nd year fellow funding15 - Teach non-geriatricians

16 - Med students in NHs18 - Better pay: fellows

20- More depts of geriatrics

Easy

D

iffic

ult


0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5IMPACT

DIFF

ICUL

TY


Median Impact = 2.36

Easy to ImplementLow Impact





9 - Flexible fellowships

10 - Market career paths of geriatricians

12 - Role of geriatrician

17 - Immediate outreach

19 - Enhance attitudes

Easy

D

iffic

ult




0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

IMPACT

DIF

FICU

LTY








2 - Early mentoring

3 - Resident initiatives6 - Advertise geriatrics

13 - Retraining MDs

14 - Better marketing of geriatrics

Eas

y

Diff

icul

tIMPACT BY DIFFICULTY BYIMPACT BY DIFFICULTY BY GLOBAL IMPORTANCE GLOBAL IMPORTANCE

RANKING (small numbers = higher rank)RANKING (small numbers = higher rank)FOR TWENTY "STRATEGIES TO IMPROVE FOR TWENTY "STRATEGIES TO IMPROVE

RECRUITMENT IN GERIATRICS"RECRUITMENT IN GERIATRICS"


0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5IMPACT

DIF

FIC

ULT

Y








1 - Loan forgiveness

2 - Early mentoring3 - Resident initiatives

4 - Better pay: geriatricians

5 - Increase research funding

6 - Advertise geriatrics

7 - Improve reimbursement

8 - Geriatrics clerkship9 - Flexible fellowships

10 - Market career paths of geriatricians

11 - 2nd year fellow funding

12 - Role of geriatrician

13 - Retraining MDs

14 - Better marketing of geriatrics

15 - Teach non-geriatricians

16 - Med students in NHs

17 - Immediate outreach

18 - Better pay: fellows

19 - Enhance attitudes

20- More depts of geriatrics

Easy

D

iffic

ult




MentoringMentoring

ØØ Mentors in geriatrics Mentors in geriatrics were cited by half of were cited by half of respondents in a respondents in a national survey of national survey of geriatricians as geriatricians as positively influencing positively influencing their choice of their choice of geriatricsgeriatrics

Medina-Walpole A et al. JAGS. 2002;50:949-955

There will never be enough There will never be enough geriatriciansgeriatricians

So, all students and physicians So, all students and physicians need to learn geriatricsneed to learn geriatrics

ØØMedical studentsMedical studentsØØ ResidentsResidentsØØ FellowsFellowsØØ FacultyFacultyØØ Practicing Practicing

generalists and generalists and specialistsspecialists

Graduate Medical Graduate Medical EducationEducation

Primary CarePrimary CareSpecialties Specialties

Required Time devoted to clinical instruction Required Time devoted to clinical instruction in Geriatric Medicine during 3in Geriatric Medicine during 3--year year

residency programresidency programØØ Internal medicineInternal medicine

ØØ 71% > 4 weeks71% > 4 weeks

ØØ Family medicine Family medicine ØØ 50% > 4 weeks50% > 4 weeks

ADGAP Status of Geriatrics Workforce Study. Surveys of Program Directors in Internal Medicine (2005) and Family Medicine Residency Programs (2004) . IM response rate = 60%, FM response rate = 71%.

Geriatric Medicine Training in FM and IM Geriatric Medicine Training in FM and IM Residency ProgramsResidency Programs

as rated by FM and IM Program Directorsas rated by FM and IM Program Directors

ØØ Curriculum conflicts #1 obstacle to Curriculum conflicts #1 obstacle to implementing GM curriculumimplementing GM curriculum

ØØ Geriatrics rated second most important Geriatrics rated second most important curriculum area curriculum area ØØ ICU/CCU first for IMICU/CCU first for IMØØ Pediatrics first for FM Pediatrics first for FM

ADGAP Status of Geriatrics Workforce Study. Surveys of Program Directors in Internal Medicine (2005) and Family Medicine Residency Programs (2004) . IM response rate = 60%, FM response rate = 71%.

MD Faculty Available to Teach Geriatric MD Faculty Available to Teach Geriatric MedicineMedicine Mean and ± sd Full Time Equivalents

2.2 (± 2.8)3.5 (± 4.6)

2002200220052005Internal Internal MedicineMedicine

(average 53 residents)(average 53 residents)

0.83 (0.83 (± 1.1)1.1)1.3 (1.3 (± 2.7)

2001200120042004FamilyFamilyMedicineMedicine

(average 22 residents)(average 22 residents)

ADGAP Status of Geriatrics Workforce Study Surveys of Program Directors in Family Medicine Residency Programs in 2001 & 2004 and Surveys of Program Directors in Internal Medicine Residency Programs in 2002 & 2005

ACGME Residency Review Committees ACGME Residency Review Committees RequirementsRequirements

ØØ RRCs RRCs of the ACGME responsible for of the ACGME responsible for training requirementstraining requirements

ØØ In 2003, 33 of 99 specialties had specific In 2003, 33 of 99 specialties had specific geriatric requirements*geriatric requirements*

ØØ By 2007, 33 out of 98 specialties had By 2007, 33 out of 98 specialties had specific geriatric requirements* specific geriatric requirements*

ADGAP Status of Geriatrics Workforce Study, as of April 2007

Emergency medicine eliminated their requirement in 2007, and Neuromuscular Medicine added a requirement.

*These numbers include all internal medicine subspecialties, andexclude pediatrics.

Notable Specialties without Specific Notable Specialties without Specific Requirements for Training in Geriatrics Requirements for Training in Geriatrics

ØØ OphthalmologyOphthalmologyØØ General surgeryGeneral surgeryØØ NeurologyNeurologyØØ Dermatology Dermatology ØØ OtolaryngologyOtolaryngology

Source: NAMCS, 2004 & Status of Geriatric Workforce Study, 2007

Barriers to Integrating GeriatricsBarriers to Integrating GeriatricsØØ Lack of good teachersLack of good teachersØØ Insufficient resourcesInsufficient resourcesØØ Need for admin, pt and resident buy inNeed for admin, pt and resident buy inØØ Need for active participation in pt careNeed for active participation in pt careØØ ““We already care for old peopleWe already care for old people””ØØ Not enough Not enough geri geri facultyfacultyØØ Need to establish nonNeed to establish non--traditional training sitestraditional training sitesØØ Lack of fundingLack of fundingØØ Lack of reimbursementLack of reimbursement

Thomas DC et al. Ann Int Med2003:139:628-633

SolutionsSolutions

ØØ Engage the Program DirectorEngage the Program DirectorØØ Develop national consensus among Develop national consensus among

APDIM, SGIM, ACP on APDIM, SGIM, ACP on geri geri competenciescompetenciesØØ Use Use ““carrotscarrots”” and and ““stickssticks””ØØ Develop a best model of careDevelop a best model of careØØ Increase Increase ““great facultygreat faculty”” teaching geriatricsteaching geriatricsØØ Lobby for improved systems of care for ptsLobby for improved systems of care for ptsØØ Provide funding: local and nationalProvide funding: local and national

Thomas et al. Landefeld Ann Int Medl 2003;139:609-614.

Chief Resident Immersion Chief Resident Immersion Training (CRIT)Training (CRIT)

ØØ To foster collaboration among disciplines To foster collaboration among disciplines in the management of complex older in the management of complex older patientspatientsll To incorporate To incorporate geri geri principles into teaching principles into teaching

and administrative roles as and administrative roles as CRsCRsll To develop leadership and teaching skillsTo develop leadership and teaching skillsll To develop a doTo develop a do--able project related to able project related to

resident education in geriatricsresident education in geriatricsll To have fun and foster collegialityTo have fun and foster collegiality

2005 — 2007 Resident Participants

§Anesthesiology (6)§Cardiothoracic Surgery (2)**§Family Medicine (4)*§Internal Medicine (8)§Neurology (5)

§Ophthalmology (3)§Otolaryngology (6)§Psychiatry (5)§Rehabilitation Medicine (3)§General Surgery (1)§Urology (2)§Emergency Medicine (2)

n=47

*Includes one PGY3 resident

**Includes one fellow

2005 — 2007 Resident Participants

§Anesthesiology (6)§Cardiothoracic Surgery (2)**§Family Medicine (4)*§Internal Medicine (8)§Neurology (5)

§Ophthalmology (3)§Otolaryngology (6)§Psychiatry (5)§Rehabilitation Medicine (3)§General Surgery (1)§Urology (2)§Emergency Medicine (2)

n=47

*Includes one PGY3 resident

**Includes two fellows

4.1***3.0N/AN/AReviewing medications for evidence of polypharmacy

4.5***3.54.5**3.6Value of interdisciplinary, collaborative teams4.3***3.44.6**3.6Recognizing dementia4.0**3.33.7**2.8Managing dementia4.9**3.64.7*3.8Recognizing delirium4.6**3.54.4**3.3Managing delirium

3.32.92.72.72.52.32.32.0

Retro Pre-mean

2005

4.4**4.1**4.0**3.8***3.9**3.8***3.8***3.3***

Post-mean

4.2***4.1***4.1***3.9***3.8***3.8***3.9***3.5***

Post-mean

3.12.83.02.92.52.52.62.0

Retro Pre-mean

2006

Decision-making capacityAssessment of living arrangements / supportPre-op assessmentDischarge planningPrinciples of geri-rehabLong-term care servicesFunctional assessmentInsurance coverage

Curriculum Topic

*=p<.05, **=p<.01, ***p=<.001

Gains in Self-Reported Knowledge (1=low, 5=high)

.03.034.74.73.83.8.005.0054.64.63.83.8Recognizing deliriumRecognizing delirium

.007.0074.44.43.43.4.01.014.34.33.63.6Recognizing dementiaRecognizing dementia

NSNS4.44.43.63.6.005.0054.34.33.63.6Managing deliriumManaging delirium

.008.0084.24.23.23.2.008.0084.04.02.92.9Assessment of living Assessment of living arrangements / supportarrangements / support

.001.0014.54.53.03.0.02.024.44.43.73.7Value of interdisciplinary, Value of interdisciplinary, collaborative teamscollaborative teams

<.000<.0003.83.82.32.3NSNS3.33.33.03.0LongLong--term care servicesterm care services

<.000<.0003.73.72.32.3NSNS3.53.52.82.8Principles of Principles of gerigeri--rehabrehab

<.000<.0003.93.92.32.3NSNS3.83.83.43.4Functional assessmentFunctional assessment

3.33.3

3.23.2

PrePre--meanmean

20052005

3.53.5

4.34.3

PostPost--meanmean

NSNS

.001.001

PP--valuevalue

.001.001

<.000<.000

PP--valuevalue

4.34.3

4.04.0

PostPost--meanmean

3.03.0

2.72.7

PrePre--meanmean

20062006

TopicTopic

Managing dementiaManaging dementia

Assessment of decisionAssessment of decision--making making capacitycapacity

Self-reported Confidence to Teach

(Low=1, High=5)

Most Important Gains2005§Knowledge/tools/practice related to dementia and delirium (n=6)§Networking/new relationships with other CRs (n=6)§New and improved skills for work as a CR (n=6)§10 of 12 agreed that CRIT increased their interest in geriatrics

2006§Recognition and management of delirium (n=10)§Discharge planning§Polypharmacy§Skills of being a CR §Teaching skills§14 of 15 agreed that CRIT increased their interest in geriatrics

Most Important Gains2005§Knowledge/tools/practice related to dementia and delirium (n=6)§Networking/new relationships with other CRs (n=6)§New and improved skills for work as a CR (n=6)§10 of 12 agreed that CRIT increased their interest in geriatrics

2006§Recognition and management of delirium (n=10)§Discharge planning§Polypharmacy§Skills of being a CR §Teaching skills§14 of 15 agreed that CRIT increased their interest in geriatrics

Practicing PhysiciansPracticing Physicians

ØØ 5050--70% of generalists 70% of generalists (IM and FM) feel need (IM and FM) feel need for more training in for more training in ll Psychosocial issuesPsychosocial issuesll Caregiver needsCaregiver needsll Community servicesCommunity servicesll Interdisciplinary careInterdisciplinary care

Darer JD et al. Acad Med. 2004;79(6):541-548

Needs Assessment: 1998Needs Assessment: 1998

ØØ Rated 1Rated 1--55ll Confidence, Desire to learn, Peers needsConfidence, Desire to learn, Peers needs

ØØ Eighteen items ratedEighteen items ratedH&P Functional

assessment Multiple problems

Social support Rehabilitation HPDP Nutrition Dementia Incontinence Falls Sensory

impairment Advance directives

End of life Pain control HRT Osteoporosis Sexual function Depression

Robinson BE, Barry PP, Renick NL, et al. Physician confidence and interest in learning more about common geriatric topics: A needs assessment. J Amer Geri Soc. 2001;49:963-967

Needs AssessmentNeeds Assessment-- 19981998

ØØ Responses: ACP=547; AAFP=211Responses: ACP=547; AAFP=211ØØ Topics identified:Topics identified:

ll 1. Dementia1. Dementiall 2. Urinary incontinence2. Urinary incontinencell 3. Functional assessment3. Functional assessmentll 4. Sensory impairment4. Sensory impairmentll 5. Falls5. Falls

Robinson BE, Barry PP, Renick NL, et al. Physician confidence and interest in learning more about common geriatric topics: A needs assessment. J Amer Geri Soc. 2001;49:963-967

Improving the Care of Older Improving the Care of Older Adults by Practicing PhysiciansAdults by Practicing Physicians

ØØ Practicing Physician Education ProjectPracticing Physician Education Projectll Peer educators taught small group, evidencePeer educators taught small group, evidence--based, casebased, case--

based sessions using a toolkitbased sessions using a toolkitll Increased knowledge, attitude and office based practice on Increased knowledge, attitude and office based practice on

target topics; sustained p<.001target topics; sustained p<.001ll Nearly half material presented in communityNearly half material presented in community--based toolkit based toolkit

sessions was new sessions was new Levine et al. JAGS Levine et al. JAGS Online Early Articles, 16Online Early Articles, 16--MayMay--2007.2007.doidoi:10.1111/j.532:10.1111/j.532--5415.2007.01205.x5415.2007.01205.x

ØØ Practice Improvement Modules by ABIMPractice Improvement Modules by ABIMØØ ACOVE toolsACOVE toolsØØ Active mode CMEActive mode CME

Active Mode CME in GeriatricsActive Mode CME in Geriatrics

ØØ Systematic Review of Literature (13 Systematic Review of Literature (13 published articles) and structured published articles) and structured interviews (28) to inventory active learning interviews (28) to inventory active learning techniques (much unpublished, little techniques (much unpublished, little evaluated)evaluated)ll Most effective methods for behavior change:Most effective methods for behavior change:

Multiple methods: written materials or toolkits Multiple methods: written materials or toolkits combined with feedback and strong combined with feedback and strong communication between instructors and communication between instructors and learnerslearners

Thomas DC et al. JAGS .2006;54:1610-1618

Program developmentProgram development

Ø Allow ample time for development of active-mode training (e.g., 9 months for a 2-day retreat)

Ø Address known or commonly experienced barriers

Ø Use high quality existing products to avoid reinventing the wheel

Ø Involve trainers in development from the start to increase investment

Ø Use preset format (templates) in developing electronic products to increase efficiency

Ø Use highly interactive multimedia simulations to save time


Program developmentProgram developmentØ Design quick, less than one minute, interventions for

clinical practice

Ø Connect interventions to activities physicians are already doing in practice

Ø Use case-based training to make content come alive

Ø Use different educational strategies for trainingprecontemplative and contemplative learners

Ø Create public awareness of health issues to motivate physician change


ØØ Always provide CME creditAlways provide CME credit

ØØ Identify thought leaders, or Identify thought leaders, or ‘‘starsstars’’ in in community and get them on boardcommunity and get them on board

ØØ Incorporate a Incorporate a ‘‘carrotcarrot’’ into training, such as into training, such as recertification, performance improvement, recertification, performance improvement, generation of more revenue.generation of more revenue.

Participant RecruitmentParticipant Recruitment


ØØ Hold trainings in a nice setting with good foodHold trainings in a nice setting with good food

ØØ Use technology to reach physicians who have Use technology to reach physicians who have access to equipmentaccess to equipment

ØØ Offer participants preset format (templates) for Offer participants preset format (templates) for obtaining CME creditobtaining CME credit

ImplementationImplementation

Th


Ø Active mode CME takes more development time than traditional lecture driven CME

Ø Active mode CME is more expensive than traditional lecture driven CME

Ø Lack of funding sources for active-mode CME

ØDevelopers are unsure of best practicesØ Lack of space to do office training

Barriers related to Barriers related to development/administration of development/administration of

activeactive--mode CMEmode CME


ØØ Lack of time by already overscheduled physicianLack of time by already overscheduled physicianØØ Reluctance to slow revenue by missing work timeReluctance to slow revenue by missing work timeØØ Geographical constraintsGeographical constraintsØØ Inertia in physiciansInertia in physicians’’ practicespracticesØØ Perception that most change make physicians' lives Perception that most change make physicians' lives

more difficultmore difficultØØ Number of competing content areasNumber of competing content areasØØ Lack of interest in geriatrics programsLack of interest in geriatrics programsØØ Physicians' lack of access to required technology Physicians' lack of access to required technology

(e.g., video(e.g., video--conferencing capabilities)conferencing capabilities)

Barriers related to participation Barriers related to participation in activein active--mode CMEmode CME


Geriatrics Education for Geriatrics Education for SpecialistsSpecialists

ØØ Geriatrics for Specialists Initiative: JAH/AGSGeriatrics for Specialists Initiative: JAH/AGSØØ Jahnigen Jahnigen Scholars: JAH/Atlantic PhilanthropiesScholars: JAH/Atlantic PhilanthropiesØØ New initiative for practicing specialists. Planning New initiative for practicing specialists. Planning

grant to develop quality indicators for surgical pts grant to develop quality indicators for surgical pts and add to ACS work on practice performance and add to ACS work on practice performance assessment: Atlantic Philanthropiesassessment: Atlantic Philanthropies

ØØ Geriatrics Education for Specialty Residents Geriatrics Education for Specialty Residents grants:Hartford/AGS grants:Hartford/AGS ll GeriGeri--Specialist collaboration to develop local Specialist collaboration to develop local geri geri ed ed

programsprogramsll Several went on to become Several went on to become Jahnigen Jahnigen ScholarsScholars

Potter JF, et al.JAGS 2005;53:511-515

ØØ Annual programs for surgery and related Annual programs for surgery and related specialties at AGS specialties at AGS

ØØ T. Franklin Williams Awards for medical T. Franklin Williams Awards for medical subspecialistssubspecialists

ØØ Chief Resident Immersion Training: Chief Resident Immersion Training: Reynolds at BUReynolds at BUààHartford national demoHartford national demo

ØØ Specialty Residents: Reynolds granteesSpecialty Residents: Reynolds granteesØØ Faculty development programs for Faculty development programs for

specialistsspecialistsHigh KP, et al. Amer J Med. 113:533-536; Levine SA et al. J Am Ger Soc. 2006; 54:S1

Medical Student EducationMedical Student EducationØØ AAMC Hartford grantsAAMC Hartford grantsØØ Reynolds GrantsReynolds Grants——30 30

programsprogramsØØ Hartford Home Care Hartford Home Care

grantsgrantsØØ AGS Student ChaptersAGS Student ChaptersØØ AGS/BU School of AGS/BU School of

Medicine Summer Medicine Summer Institute in Geriatrics: NIAInstitute in Geriatrics: NIA

Medical student geriatricsMedical student geriatrics curriculumcurriculumØØ 23% of medical schools require a geriatric 23% of medical schools require a geriatric

clerkship clerkship ØØ 48% integrated geriatrics into a required 48% integrated geriatrics into a required

clinical rotationclinical rotationØØ 34% said curriculum experience depended 34% said curriculum experience depended

on faculty interest in geriatricson faculty interest in geriatricsØØ 17% had some exposure, but no 17% had some exposure, but no

objectives objectives

Schools could report more than one type of experienceADGAP Survey of Geriatric Medicine Program Directors 2005.

Percent of graduating medical students who Percent of graduating medical students who agreed or strongly agreed that there was adequate agreed or strongly agreed that there was adequate

geriatrics/gerontology in their clerkship.geriatrics/gerontology in their clerkship.

59% 59% 52%52%Surgery Surgery

61%61%53%53%Psychiatry Psychiatry

39%39%34%34%OB/GYNOB/GYN

81%81%73%73%Internal medicineInternal medicine

73%73%65%65%Family medicineFamily medicine

2006200620032003ClerkshipClerkship

Source: AAMC, Medical School Graduation Questionnaire, All Schools Report

Percent of graduating medical students who Percent of graduating medical students who agreed or strongly agreed with the following agreed or strongly agreed with the following

statements.statements.

80%80%78%78%I am well prepared to care for older I am well prepared to care for older adult patients in ambulatory settings adult patients in ambulatory settings

72%72%69%69%I am well prepared to care for older I am well prepared to care for older adult patients in acute settingsadult patients in acute settings

87%87%77%77%I learned about the health care needs I learned about the health care needs of healthy older adults during my of healthy older adults during my medical training medical training

2006200620032003StatementStatement


Percent of graduating medical students who Percent of graduating medical students who agreed or strongly agreed with the following agreed or strongly agreed with the following

statements.statements.

61%61%53%53%Interdisciplinary approaches were Interdisciplinary approaches were used to increase my knowledge of used to increase my knowledge of geriatrics geriatrics

68%68%61%61%I was exposed to expert geriatric care I was exposed to expert geriatric care by the attending faculty of my medical by the attending faculty of my medical programprogram

59%59%55%55%I am well prepared to care for older I am well prepared to care for older adult patients in longadult patients in long--term health care term health care settings settings

2006200620032003StatementStatement


Possible SolutionsPossible Solutions

ØØ Care across sitesCare across sitesØØ NonNon--traditional sitestraditional sitesØØ Vertical and Vertical and

horizontal integration horizontal integration across all 4 yearsacross all 4 years

ØØ Role models in Role models in residents and facultyresidents and faculty

324 years of experience!!324 years of experience!!

117 years 109 years 98 years

SuggestionsSuggestionsØØ Start low; donStart low; don’’t go too slowt go too slowØØ Integrate, integrate, integrateIntegrate, integrate, integrateØØ Stealth geriatricsStealth geriatricsØØ Limit the number of competenciesLimit the number of competenciesØØ Mentorship is keyMentorship is keyØØ Effective teachers:Effective teachers: gerigeri and non geriatrics and non geriatrics ØØ Make it easy for everyone: carrots and sticksMake it easy for everyone: carrots and sticksØØ Find champions everywhere; stakeholdersFind champions everywhere; stakeholdersØØ Multiple modes; multiple sitesMultiple modes; multiple sitesØØ Get Get ““boomersboomers”” on the caseon the case

Rubin, C. D. et. al. Ann Intern Med 2003;139:615-620

Suggested Initiatives for Overcoming Barriers to Geriatrics-Oriented Faculty Development

Landefeld, C. S. et. al. Ann Intern Med 2003;139:609-614

Stakeholder Organizations Represented at 2 National Conferences on Planning for Sustained Improvement in the Training of General Internists in Geriatrics


Major Barriers to Improving Training in Geriatric Medicine, and Strategies To Overcome Those Barriers


Relationship between number of general internal medicine (GIM) faculty and knowledge of geriatrics

Simon, S. R. et. al. Ann Intern Med 2003;139:621-627

Geriatrics in General Internal Medicine Fellowship Programs: Key Summary Points


Suggested Initiatives for Overcoming Barriers to Geriatrics-Oriented Faculty Development

Programs

Fellows(All Years of

Training)

FellowsSecondYear &Beyond

& % of AllFellows

IMGs(All Years of

Training)

1993-1994

1994-1995

1995-1996

1996-1997

Geriatric Medicine Fellowship Programs, Family Medicine and Internal Medicine 1991/92-2006/07

AcademicYear

First YearPositionsAvailable

Fellows inFirst Year

Positions &% of FilledFirst YearPositions

FellowsCompleting

Program

1991-1992

1992-1993

1997-1998

1998-1999

1999-2000

92

97

98

99

99

103

107

198

215

225

220

223

242

305

--

--

--

--

106 (47.5%)

98 (40.5%)

100 (32.8%)

64 (32.3%)

88 (40.9%)

111 (49.3%)

115 (52.3%)

132 (59.2%)

145 (59.9%)

170 (55.7%)

--

--

163

192

206

222

226

--

--

--

--

117 (56.7%)

144 (64.9%)

205 (90.7%)

--

117

118

117

101

129

262

181

112 335 96 (28.7%) 209 (62.4%) 239 (91.2%) 222

114 368 99 (26.9%) 218 (59.2%) 307 269 (87.6%) 294

2000-2001 119 321 74 (23.1%) 187 (58.3%) 337 247 (73.3%) 276

2001-2002 120 338 79 (23.4%) 187 (55.3%) 373 259 (69.4%)

2002-2003 394

2003-2004

Source: AMA and AAMC data from the National Survey of GME Programs, JAMA 1992-2006.Abbreviation: IMG, International Medical Graduates

127 368 76 (20.7%) 190 (51.6%) 292 (74.1%)

295

321

129 352 62 (17.6%) 201 (57.1%) 430 290 (67.4%) 313

2004-2005 444 292298 (67.1%)184 (55.1%)36 (10.8%)334131

2005-2006 --442 296 (67.0%)230 (65.5%)55 (15.7%)351140

2006-2007 -- -- -- -- 468 -- --

IMGs in U.S. GME ProgramsIMGs in U.S. GME Programs

ØØ 27% of all Residents and Fellows are 27% of all Residents and Fellows are IMGs IMGs ØØ Endocrinology Endocrinology ---- 34%34%ØØ Cardiology Cardiology ---- 31%31%ØØ Ophthalmology Ophthalmology ---- 7%7%ØØ Emergency medicine Emergency medicine ---- 5%5%

Source: AMA and AAMC data from the National Survey of GME Programs, 2005-2006.

Note: IMGs do not include Canadians but do include U.S. citizen IMGs

IMGs in Geriatric Fellowship ProgramsIMGs in Geriatric Fellowship Programs

ØØ 66% of Geriatric Medicine fellows 66% of Geriatric Medicine fellows ØØ 63% of Geriatric Psychiatry fellows63% of Geriatric Psychiatry fellows

Source: AMA and AAMC data from the National Survey of GME Programs 2005/2006.

Note: IMGs do not include Canadians but do include U.S. citizen IMGs

Obstacles to Achieving Goals of U.S. Medical Schools Obstacles to Achieving Goals of U.S. Medical Schools

Geriatric Programs 2001 & 2005Geriatric Programs 2001 & 2005

28

33

39

53

58

71

21

26

27

45

60

63

74

61

65

50

Lack of clinical educator faculty

Lack of clinical fellows

Lack of access to MS's curricular time

Lack of institutional financial support

Lack of Junior research faculty

Lack of Senior research faculty

Lack of research fellows

Poor clinical reimbursement

2001 2005

ADGAP Survey of Geriatric Medicine Program Directors 2001 & 2005

Results Results

ØØ Practice of GeriatricsPractice of GeriatricsØØ Academic Geriatric MedicineAcademic Geriatric MedicineØØ Fellowship ProgramsFellowship ProgramsØØ Graduate Medical EducationGraduate Medical EducationØØMedical Student Education Medical Student Education


1010

3.153.152.452.45Flexible fellowshipsFlexible fellowships-- fellowships with out fellowships with out walls walls

99

3.283.282.152.15Required geriatrics clerkship in the 3Required geriatrics clerkship in the 3rdrd

year of medical schoolyear of medical school88

4.254.251.771.77Improve reimbursement for geriatrician Improve reimbursement for geriatrician servicesservices

77

2.062.062.382.38Advertise geriatrics as an attractive Advertise geriatrics as an attractive lifestylelifestyle

663.633.631.61.6Increase research funding Increase research funding 554.234.231.411.41Better pay for geriatriciansBetter pay for geriatricians44

1.891.891.821.82Resident initiatives geriatrics journal club, Resident initiatives geriatrics journal club, clinics interest groupclinics interest group

331.91.91.781.78Early mentoring of studentsEarly mentoring of students22

3.213.211.321.32Loan forgiveness for residents who want Loan forgiveness for residents who want to go into geriatricsto go into geriatrics



4.224.222.562.56More departments of geriatricsMore departments of geriatrics2020

332.642.64Techniques to enhance attitudes towards Techniques to enhance attitudes towards geriatricsgeriatrics

19193.733.732.882.88Increased compensation for fellowsIncreased compensation for fellows1818

1.711.713.323.32Business cards and immediate outreachBusiness cards and immediate outreach1717

3.693.693.773.77Require medical student applicants to Require medical student applicants to spend time in nursing homes (spend time in nursing homes (NHsNHs))

16163.43.43.173.17Funding to teach nonFunding to teach non--geriatriciansgeriatricians15152.62.62.232.23Better marketing/celebrity advocateBetter marketing/celebrity advocate1414

332.292.29Changing fellowship rules so practicing Changing fellowship rules so practicing doctors can become geriatricians (see #9)doctors can become geriatricians (see #9)

1313

2.322.322.622.62Clarification of role of geriatrician in market Clarification of role of geriatrician in market place place

12123.43.42.592.59Funding for second year fellowsFunding for second year fellows1111




Practice of Geriatric MedicinePractice of Geriatric Medicine

Academic Staff in U.S. Medical Schools Academic Staff in U.S. Medical Schools (FTEs, Mean(FTEs, Mean)

1.01.00.9PhD Postdoctoral staff

1.30.50.30.61.83.0

0.92.79.6

2005

1.40.60.50.72.04.2

1.22.89.6

2007

1.0Social Workers0.3Pharmacists0.3PA0.7CNS1.9Nurse Practitioners2.5Research faculty

0.9Second year fellows2.4First year fellows7.5MDs

2001Academic staff

ADGAP Survey of Geriatric Medicine Program Directors 2001, 2005, & 2007

0

10

20

30

40

50

60

<6 12<18 24<30 >36

2001 2005 2007

<6 6<12 12<18 18<24 24<30 30<36 >36

Distribution of Physician Faculty FTEs Among U.S. Medical School Geriatrics Programs in 2001, 2005 and 2007


PhysicianFaculty FTEs

Per

cent

Med

ical

Sch

ools

U.S. Medical School Geriatric Medicine Faculty and Staff U.S. Medical School Geriatric Medicine Faculty and Staff Time Allocated by Program Mission Time Allocated by Program Mission (% effort, mean (% effort, mean )

0.78.1

18.636.93.88.6

11.911.42007

0.44.4Other Other 8.4NAAdministrationAdministration

15.318.2Research/scholarshipResearch/scholarship36.936.6Clinical practice Clinical practice 4.43.9Continuing education Continuing education 9.910.7Fellowship training Fellowship training

11.612.6Residency education Residency education 13.113.6MS educationMS education2005 2001Category


Welcome Back to the Boston University Welcome Back to the Boston University Geriatrics SectionGeriatrics Section

• Longitudinal experience• Geriatrics Special Interest Group• Open to all students

BU Geriatrics OSCEBU Geriatrics OSCE

ØØ MidMid--rotation geriatrics OSCE rotation geriatrics OSCE instituted September 2004instituted September 2004

ØØ Goal: To provide practice and Goal: To provide practice and feedback on communication feedback on communication skills with older patientsskills with older patients

ØØ Assessment of interview: Assessment of interview: Master Interview Rating Scale Master Interview Rating Scale (MIRS) items(MIRS) items

Methods for Achieving Program Methods for Achieving Program ObjectivesObjectives

ØØModulesModulesll Geriatric ContentGeriatric Contentll EvidenceEvidence--based Medicinebased Medicinell Clinical TeachingClinical Teachingll Health Care SystemsHealth Care Systems

ØØ Precepted clinical visitsPrecepted clinical visitsØØ Scholarly projectsScholarly projectsØØ Individual mentoringIndividual mentoring

Percent of U.S. Medical Schools at which GM and Percent of U.S. Medical Schools at which GM and GP Faculty Teach Geriatrics to Residents in GP Faculty Teach Geriatrics to Residents in

Other SpecialtiesOther Specialties

75% 75% 20052005

87%87%20072007

ADGAP Status of Geriatric Workforce Study Surveys of US Academic Medical Schools. 2007 response rate = 75%, 2005 response rate = 68%

Percent of Geriatric Medicine and Geriatric Percent of Geriatric Medicine and Geriatric Psychiatry Programs that Teach Principles of Psychiatry Programs that Teach Principles of Geriatric Care to other Selected Specialties Geriatric Care to other Selected Specialties

50% 50% Emergency MedicineEmergency Medicine62%62%GynecologyGynecology

71%71%PsychiatryPsychiatryPercent Percent SpecialtySpecialty

2007 Specialties taught/medical school: median 5.0 (range 1-14)

ADGAP Status of Geriatric Workforce Study 2007 Survey of Academic Medical Schools

Percent of Medical Schools Where Faculty from Percent of Medical Schools Where Faculty from Other Selected Specialties Teach Principles of Other Selected Specialties Teach Principles of

Geriatric Care to their Own ResidentsGeriatric Care to their Own Residents

42% 42% PM & R PM & R 44%44%NeurologyNeurology

71%71%PsychiatryPsychiatryPercent Percent SpecialtySpecialty

2007 Specialties teaching their own residents/medical school: median 4.0 (range 1-11)

ADGAP Status of Geriatric Workforce Study 2007 Survey of Academic Medical Schools


Relationship between number of general internal medicine (GIM) faculty and knowledge of geriatrics


The internal medicine training cycle

FactsFacts

ØØ Fewer than 300 physicians entered Fewer than 300 physicians entered geri geri med fellowships in 2005med fellowships in 2005

ØØ Large and growing gap between available Large and growing gap between available geriatricians and numbers needed based geriatricians and numbers needed based on assumption that:on assumption that:ll Age 30 at original certificationAge 30 at original certificationll Between ages 40Between ages 40--62, 75% certify62, 75% certifyll Cohorts could recertify up to 3 timesCohorts could recertify up to 3 timesll 315 new geriatricians/year recertify315 new geriatricians/year recertify

recruitment and retention of physiciansiom.nationalacademies.org/~/media/files/activity...

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