September 8, 2011

Geriatrics training efforts grow to meet rising demand

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Patient Harold McDermott, 77, is seen by a geriatrics team consisting of, from left, Parul Goyal, M.D., Amber Velasquez, MSN, Kiffany Peggs, M.D., and Piotr Pilarsky, M.D. (photo by Susan Urmy)

Geriatrics training efforts grow to meet rising demand

Through its Geriatric Fellowship Program, Vanderbilt University Medical Center is well positioned to help guide the care of the fastest growing segment of the U.S. population — people over age 85.

James Powers, M.D., director of the program, said the mounting “silver tsunami” is sure to profoundly influence future health services and delivery models, and Vanderbilt is rising to the challenge.

“Our fellowship positions here are filled and we have doubled our faculty since we began in 1999. We now have three endowed chairs in Geriatrics, two in Medicine and one in Psychiatry. Two of these chairs are new and searches are under way to fill them,” Powers said.

Recent statistics are eye opening. A report from the Geriatric Workforce Policy Studies Center shows only about half of first-year fellowship positions are filled, and fellowships declined from 167 in 2002 to 86 in 2009. This despite a growing national shortage of geriatricians. In Tennessee, there are 4,700 patients for every geriatrician

But Vanderbilt’s Geriatric fellowship is filled. Powers credits a novel approach to training combined with the enthusiasm of young physician fellows like Kiffany Peggs, M.D., and Ryan Kalinsky, M.D.

Peggs said the idea held by many young physicians that geriatrics is somehow less exciting than other specialties is simply not true.

“Geriatrics patients are often complicated cases. You might have a patient experiencing falls and the reasons they might be falling can involve medications, the environment or other medical problems. Older people are just more interesting. It is not like treating a 20-year-old with a head cold,” Peggs said.

Geriatrics, a section within the Division of Internal Medicine and Public Health in the Department of Medicine, began fellowship training with a Veterans Health Administration Geriatric Research Education and Clinical Centers (GRECC) award in 1999.

Since then the program has experienced key successes. In 2010, U.S. News and World Report ranked Vanderbilt geriatrics 49th in the nation and they remained “high performing with regional recognition” in 2011.

The program takes a three-prong approach — excellence in training the next geriatric leaders in medicine, offering top level research and clinical opportunities and collaborative training of many disciplines within the Medical Center and with external hospital partners like the VA and the community.

“Each health care discipline has principals they can apply to the care of the older person. Our goal is that all doctors should be good geriatricians for their own patients,” Powers said.

Geriatric Fellowship Program members, from left, Kiffany Peggs, M.D., Piotr Pilarsky, M.D., and Parul Goyal, M.D., talk with patient Sarah Joe Winn during rounds. (photo by Susan Urmy)

Geriatric Fellowship Program members, from left, Kiffany Peggs, M.D., Piotr Pilarsky, M.D., and Parul Goyal, M.D., talk with patient Sarah Joe Winn during rounds. (photo by Susan Urmy)

Peggs said she could find a job almost anywhere because of the demand. That and the wide-open nature of research questions are draws.

On recent rounds, her team reviewed the care of an elderly dementia patient who had fallen with such force he broke his jaw. This patient could be difficult to keep safe after discharge, a common concern and, despite common assumptions, not a normal part of aging.

“I have a special interest in syncope (fainting) and orthostatic hypotension (blood pressure drops as someone stands). We see plenty of that here. There are lots of places around the country with fall centers, so it would be great to see a geriatric assessment center at Vanderbilt,” Peggs said.

Kalinsky plans to use his geriatrics training to enter the field of Oncology. Combined interest in aging within other specialties such as Cardiology or Surgery is common among Geriatrics trainees.

Powers said Geriatricians consistently report higher job satisfaction than other medical specialists despite the emotional challenges inherent in caring for both patients and families faced with serious life changes and stresses. Colleagues like Laurence Solberg, M.D., assistant professor of Medicine and director of the Geriatric Consultation Program at Vanderbilt, agree.

“If you invest a lot in the relationship with the family and the patient, it really pays off. I don’t know many other specialties where families often give a hug and a kiss,” Solberg said.

Solberg’s Geriatrics Consult Service is continually inundated with requests. Powers said the demand is even greater in outpatient care.

“We probably turn down 10 new patient requests a week because we don’t have enough Geriatricians. The most common request is to see us about dementia or agitation, and these patients need help now,” Powers said.

Peggs is undaunted by the current and future challenges. She says patients and families reinforce how much they appreciate her.

“Family members can see the difference. I go in and fix a problem that may have developed with their primary care provider and they notice the improvement in their loved one. I’ll tell them that’s what geriatricians do. The fix usually means taking (a medication) away and not adding back,” Peggs said.

Powers said he hopes to see even more physicians choose geriatric training to meet the challenges of the growing senior population.

“We could easily triple our faculty and keep them busy. We are not even scratching the surface regarding clinical needs. And yet it is a joyful employment, very meaningful and fulfilling. Each day is very full.”