UCSF
Newsletter on
Aging
November 2005 Volume 4, Issue 2
Also in this Issue:
Burton Gives Lieberman Lecture HCGNE Receives Five-Year Renewal Honors and Awards Selected Publications Upcoming Geriatrics Grand Rounds 5 5 6 7 8
Training Providers to Meet an Aging Population’s Complex Needs
In the United States, adults age 65 and older now make up 13 percent of the entire US population; experts expect that by 2030 it will be 20 percent. These older adults account for a huge percentage of all hospitalizations, prescription drug costs, and medical care. “You would think the demographic imperative would be overwhelming evidence that we ought to be training all physicians to be aware of older people’s needs, and giving them the skills to provide quality, cost effective, sensitive care to a frail population,” says Mike Harper, MD, Associate Professor of Medicine, and Staff Physician at San Francisco VA Medical Center (SFVAMC). Yet many physicians still lack such training. In response, the UCSF Division of Geriatrics has overseen a substantial infusion of geriatrics content for medical students and residents at UCSF, provided geriatric training in surgical sub-specialties, created fellowships that have developed a corps of national leaders in academic geriatrics, and created a range of resources for any clinician or educator interested in treating older adults. As it has done so, it’s become a leader in the effort to enhance geriatric education nationwide. Working with Medical Students and Residents In 2001, the UCSF School of Medicine initiated a revolutionary new curriculum. Funding from the John A. Hartford Foundation and the Association of American Medical Colleges assured geriatrics a more prominent role than it had in the past. “There’s a geriatric thread throughout, especially during the didactic part of students’ training,” says Bree Johnston, MD, who has spearheaded many of the division’s educational initiatives over the last nine years. Johnston is Associate Professor of Medicine and Geriatric Clinic Director at the SFVAMC. She’s also a member of the Haile T. Debas Academy of Medical Educators. She was instrumental in developing and overseeing the geriatrics piece of what is known as the Life Cycle block in the new medical curriculum – and continues to push for more geriatrics during students’ clinical training.
University of California San Francisco
UCSF Mount Zion Center on Aging San Francisco Veterans Affairs Medical Center
As part of that effort, Johnston and colleagues in hospital medicine recently initiated a new program called “Going Home.” In the program, medical, nursing, and social work students choose a patient to work with at home after his or her discharge from the hospital. The project involves an interdisciplinary team of clinician educators to supervise the students’ work. “It helps each student see their patient as a whole person and understand how the hospital fits into the entire medical system,” says Johnston. “(In doing so) it enhances continuity and helps ensure balls aren’t dropped when patients are discharged to home…. It’s a powerful activity and it’s had a wonderful student response.” Fostering Expertise in the Surgical Specialties The Division of Geriatrics is also engaged in joint educational initiatives with various surgical subspecialties, including the Department of Urology, whose patient mix is dominated by older adults. “Among urologists, there’s been a lot of attention paid lately to the complex therapeutic decisions involved with treating older patients,” says Badrinath Konety, MD, Associate Professor of Urology and a 2004 American Geriatrics Society Dennis W. Jahnigen Career Development Scholar. Last year, Konety and the urology department, with Johnston’s help, won a competitive grant from the American Geriatrics Society/John A. Hartford Foundation. This fall she and Konety began creating a geriatric training module. The two-year program includes a Grand Rounds lecture series on geriatric topics, including polypharmacy, evaluating functional status in preoperative patients, assessing and averting delirium in post-operative patients, and post-discharge care. The program also might involve geriatricians in urological pre-operative conferences and in consulting on other urological cases. In addition, during each rotation, urology residents will attend at least one Geriatrics Grand Rounds or make a presentation of their own – as well as hear a lecture from a nationally known geriatrician from outside UCSF.
Stephen J. Bonasera gives the main talk at Geriatrics Grand Rounds. Bonasera completed a geriatric fellowship in 2003 and subsequently joined the Geriatrics faculty with support from a K08 award from the National Institutes of Health.
Refining Grand Rounds In an effort to create livelier sessions that give more people opportunities to present, Geriatrics Grand Rounds has adopted a new approach; now, the hour-long sessions are broken into three components. Sessions begin with a ten minute “invocation,” where a speaker addresses a subject of personal career importance. A 1520 minute case presentation comes next, and a central talk covering a prominent research topic takes up the last half-hour. “We expect to do more interdisciplinary presentations this way,” says Mike Harper, who coordinates the sessions.
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“We expect that after the grant period, we will have developed content that the urology department can continue to use,” says Konety. Training Academic Geriatric Leaders When Mike Harper assumed leadership of the Division’s fellowship programs, he was determined to continue a tradition of training a cadre of national leaders in academic geriatric medicine. Many fellows have subsequently joined the UCSF faculty; many others teach at prominent institutions nationwide. Helen Chen is a current fellow who chose to undertake fellowship training, despite already being Associate Professor of Medicine at UCSF and a longtime member of the General Medicine faculty at San Francisco General Hospital. “It’s been an incredible opportunity,” she says. It’s helped her understand much more deeply what she and her colleagues need to succeed in treating geriatric patients – and what she can do to facilitate that process. The Division of Geriatrics also has training grants from the National Institute on Aging (NIA) for research training; the Department of Veterans Affairs for training in healthcare improvement; and the Health Resources and Services Administration (HRSA) to train physicians, dentists and psychiatrists to address geriatric concerns in underserved populations. “Recruiting dentists and psychiatrists can be difficult,” says Harper. “Unlike a lot of other advanced training, a geriatrics fellowship doesn’t necessarily enhance your income and dentists need to have had some advanced training prior to their fellowship.”
New Pathways to Geriatric Training: The Mid-Career Fellowship Helen Chen, MD, has long had an interest in and affection for older patients. During her tenure heading the adult medical clinic at San Francisco General Hospital, she became one of the key physicians for teaching and practicing geriatrics. As she did, she realized she needed help.
Helen Chen “Geriatrics is a team sport,” she says. “It demands someone who can marshal resources and assemble a team, but I didn’t have the time, training, or technical expertise I needed to make that happen.” In January 2005, she began a one-year clinical fellowship.
For someone in her position it was an unusual move – and not just because of the sacrifice in salary. “You have to be willing to be a trainee,” she says. “But it’s an incredible opportunity.” That opportunity included recognizing bad habits she’d developed and incorporating advances in clinical knowledge she’d missed, especially around the demands geriatrics imposes to treat “the whole patient.” “I’ll read other people’s charts and, like me, they write pages and pages about conditions like heart and lung disease – but there’s not one word of how a patient is doing at home or how they’re functioning. Can they walk? What’s their relationship with their caregiver?” The fellowship has given her time to talk with her geriatric patients and let their stories unfold. In turn, she can assess whether it’s reasonable to do things like prescribe eight or nine medications at once. Chen believes the clinical understanding her older patients’ stories enable is extremely important for anyone treating seniors. “My hope is we can get to the point where all general internists can practice great geriatric medicine,” she says. In 2006, Chen will rejoin the faculty as Associate Professor of Medicine at the San Francisco VA Medical Center.
A Wealth of Educational Resources The Division of Geriatrics has been instrumental in developing a number of educational resources that have had a national impact. These include:
Michael Harper
Challenges and Opportunities Unfortunately, recruiting fellows is but one of the barriers that remain to extending adequate geriatric training to all health professionals. “We are still a relatively small faculty trying to reach the thousands of trainees UCSF works with each year. We get a lot of requests for small activities, but then have a difficult time getting medical students and residents to spend more time with us, particularly in their clinical training,” says Johnston. Harper believes that part of the reason those struggles continue is that “Among health care professionals nationally, we (geriatricians) have not always done a good job of demonstrating or articulating our value… It’s getting better, but we’ve not solved the problem entirely.” Nevertheless, the growing awareness of the demographic imperative nationwide, and the growth of the division at UCSF – its ever-broadening impact on a range of educational pursuits as well as its frequent presentations at national conferences – have to be taken as encouraging signs. “My hope is that if we’re successful enough, we will put ourselves out of business,” says Harper.
· Current Geriatric Diagnosis and Treatment: A textbook authored by Seth Landefeld, MD, Professor and Chief in the Division of Geriatrics, UCSF, and Associate Chief of Staff for Geriatrics and Extended Care (SFVAMC), faculty in the Division of Geriatrics and others, published by Lange. · UCSF Academic Geriatric Resource Center Online Curriculum in Geriatrics and Gerontology (www.ucsfagrc.org): A web-based core curriculum in geriatrics for health professionals, developed by a multidisciplinary committee of UCSF faculty. · Northern California Geriatric Education Center Geriatrics Faculty Scholars Program: An interdisciplinary faculty development program in geriatrics directed by Joan B. Wood, PhD, Professor of Social and Behavioral Sciences and Medicine. · National Online Geriatric Education Center Resource Directory (bhpr.hrsa.gov/ interdisciplinary/gec.html): A clearinghouse for educational products and resources on aging created by the Geriatric Education Centers through a contract with the Health Resources and Services Administration. · Increasing Education and Research Capacity to Improve the Health of Older Americans: This national initiative of the Society of General Internal Medicine is led by Seth Landefeld, MD. The project will undertake the initial steps to provide the physician workforce an enhanced knowledge base essential for delivering excellent medical care to all older Americans.
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Burton Delivers Lieberman Lecture on Hospital at Home
On October 11, John R. Burton, MD, one of the founding fathers of modern geriatrics, delivered this year’s Benjamin Lieberman Memorial Lecture. His topic was the Hospital at Home initiative, an alternative way of administering hospitallevel care for acutely ill geriatric patients. Burton John Burton and his colleagues at Johns Hopkins have completed a five-year study and are poised to publish the results. The initiative is a direct response to the high rate of complications seniors experience after a hospital stay, as well as to a worsening shortage of hospital beds. In Burton’s study, researchers identified four common conditions that today require hospitalization, but that caregivers might effectively treat at home. They then developed protocols to deliver such treatment. “We found patients got better as quick as or quicker than people with the same conditions in the hospital. Length of stay was shorter, our patients had significantly fewer complications, families liked it – so did doctors and nurses – and the costs were a third less,” says Burton. But, he warns that it’s not yet clear patients would do as well in a less self-selecting environment. In addition, the initiative could be difficult to implement under a fee-for-service financing arrangement. “Nevertheless, it’s an idea whose time has arrived,” says Mike Harper. Burton agrees and is already creating programs to teach other hospitals and providers how they might implement Hospital at Home. “If done carefully, with the proper protocols and strict criteria for admission and discharge, it’s a much better way to do things for older people,” says Burton.
Hartford Center for Geriatric Nursing Excellence Receives Five-Year Renewal Grant
In recognition of five years spent preparing an exceptional cadre of gerontological nurse leaders – and in support of proposed new directions – the UCSF/John A. Hartford Center of Geriatric Nursing Excellence recently received a renewal grant from the John A. Hartford Foundation: $1,050,000 over five years. Under the direction of Dr. Jeanie KayserJones, “The center has created a critical Margaret Wallhagen mass of students who feel connected to a cause, and who are able to grow together as they share research and practice ideas,” says Margaret Wallhagen, who wrote the renewal grant. Wallhagen will take over as director in January 2006. One of her objectives is to build on the center’s success to date by continuing to recruit students into its doctoral and masters programs. In addition, the center will develop two initiatives that will improve content and research in the areas of palliative care and gerontological psychiatry. “I’d also like to continue to enhance the interdisciplinary nature of the center, working closely with programs in medicine, dentistry, and pharmacy,” says Wallhagen. Finally, Wallhagen wants to work on development. “It will be a major focus for us to promote the sustainability of the center and to obtain designated funds that provide student scholarships and could support faculty so we have more time and resources to give to students,” she says.
HONORS AND AWARDS
Rebecca E. Conant, MD, Assistant Professor of Medicine; G. Michael Harper, MD, Associate Professor of Medicine and Staff Physician SFVAMC, Sandra Moody-Ayers MD, Assistant Professor of Medicine and Staff Physician SFVAMC; and Louise C. Walter, MD, Assistant Professor of Medicine and Staff Physician SFVAMC, were all recipients of the 2005 Excellence in Direct Teaching Award from the UCSF Haile T. Debas Academy of Medical Educators. In July 2005, Mary-Margaret Chren, MD, Associate Professor of Dermatology and Director of the REAP Program for Health Services Research and Development SFVAMC, received a five-year Midcareer Investigator Award (K24) from the National Institute of Arthritis, Musculoskeletal, and Skin Diseases entitled “Patient-Oriented Research in Skin Diseases” and a three-year Investigator Initiated Research (IIR) award from the Department of Veterans Affairs entitled “Recurrence after Treatments for Nonmelanoma Skin Cancer.” Margaret C. Fang, MD, MPH, Assistant Professor of Medicine, was the recipient of the California Clinician-Investigator of the Year Award and the Milton W. Hamolsky Award in 2005 from the Society of General Internal Medicine. She also received a twoyear American Geriatrics Society/Hartford Geriatrics Health Outcomes Research Scholars Award for her project entitled “Use and Outcomes of Warfarin for Older Adults with Atrial Fibrillation.” Patrick J. Fox, MSW, PhD, Professor of Sociology, was the recipient of the 25th Helen Nahm Research Lecturer Award, School of Nursing, UCSF in 2005. The award recognizes a UCSF School of Nursing faculty member or graduate who has made an outstanding contribution to nursing science and research. Fox was also elected a Fellow of the Gerontological Society of America, Social Research, Policy and Practice Section. Charlene Harrington, PhD, RN, FAAN, Professor of Sociology and Nursing, was chosen as the recipient of the 2005 Doris Schwartz Gerontological Nursing Research Award by the Gerontological Society of America. The Schwartz Award is given to a member of the Society in recognition of outstanding and sustained contribution to geriatric nursing research. Hal S. Luft, PhD, Caldwell B. Esselstyn Professor of Health Policy and Health Economics and Director, Institute for Health Policy Studies, UCSF, received an Investigator Award in Health Policy Research grant from the Robert Wood Johnson Foundation for a project entitled, “Reconfiguring the U.S. Health Care System.” Jay S. Luxenberg, MD, Professor of Medicine, was recently elected to the Board of Directors of the International Psychogeriatric Association. He was the only American elected in this election cycle. In 2005, Kala Mehta, DSc, Assistant Professor of Medicine, was awarded a fiveyear Research Scientist Career Development Award (K01) from the National Institute on Aging entitled “Racial Disparities in Cognitive Impairment and Impact on Poor Health Outcomes.” She also received a Junior Investigator Award from the National Alzheimer’s Coordinating Center for a oneyear research project to examine “Ethnic Differences in Alzheimer’s Disease Survival and Pathology.” In March 2005, Steven Z. Pantilat, MD, FACP, Associate Professor of Medicine, received a teaching award from the UCSF School of Medicine Class of 2007 for Outstanding Lecture for his presentation on palliative care. Louise C. Walter, MD, was awarded an Investigator Initiated Research (IIR) grant from the Department of Veterans Affairs entitled “Impact of Health Status on Colorectal Cancer Screening in Older Adults.”
SELECTED PUBLICATIONS
Chan J, Kayser-Jones J. The experience of dying for Chinese nursing home residents: cultural considerations. J Gerontol Nurs. Aug 2005;31(8):26-32; quiz 52-23. Fang MC, Singer DE, Chang Y, Hylek EM, Henault LE, Jensvold NG, Go AS. Gender differences in the risk of ischemic stroke and peripheral embolism in atrial fibrillation: the AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA) study. Circulation. Sep 20 2005;112(12):1687-1691. Haas AL, Eng C, Dowling G, Schmitt E, Hall SM. The relationship between smoking history and current functioning in disabled communityliving older adults. Ann Behav Med. Jun 2005;29(3):166-173. Harrington C, Chapman S, Miller E, Miller N, Newcomer R. Trends in the Supply of Long Term Care Facilities and Beds in the United States. J Appl Gerontol. Aug 2005;24(4):265-282. Kerlikowske K, Shepherd J, Creasman J, Tice JA, Ziv E, Cummings SR. Are breast density and bone mineral density independent risk factors for breast cancer? J Natl Cancer Inst. Mar 2 2005;97(5):368-374. Kurella M, Chertow GM, Fried LF, Cummings, SR, Harris T, Simonsick E, Satterfield S, Ayonayon H, Yaffe K. Chronic kidney disease and cognitive impairment in the elderly: the health, aging, and body composition study. J Am Soc Nephrol. Jul 2005;16(7):21272133. Mehling WE, Hamel KA, Acree M, Byl N, Hecht FM. Randomized, controlled trial of breath therapy for patients with chronic lowback pain. Altern Ther Health Med. Jul-Aug 2005;11(4):44-52. Mehta KM, Yin M, Resendez C, Yaffe K. Ethnic differences in acetylcholinesterase inhibitor use for Alzheimer disease. Neurology. Jul 12 2005;65(1):159-162. Moody-Ayers SY, Mehta KM, Lindquist K, Sands L, Covinsky KE. Black-white disparities in functional decline in older persons: the role of cognitive function. J Gerontol A Biol Sci Med Sci. Jul 2005;60(7):933-939. Newcomer R, Kang T, Laplante M, Kaye S. Living quarters and unmet need for personal care assistance among adults with disabilities. J Gerontol B Psychol Sci Soc Sci. Jul 2005;60(4): S205-213. Sands LP, Landefeld CS, Moody-Ayers SY, Yaffe K, Palmer R, Fortinsky R, Counsell SR, Covinsky KE. Disparities between black and white patients in functional improvement after hospitalization for an acute illness. J Am Geriatr Soc. Oct 2005;53(10):1811-1816. Sheikh AY, Rollins MD, Hopf HW, Hunt TK. Hyperoxia improves microvascular perfusion in a murine wound model. Wound Repair Regen. MayJun 2005;13(3):303-308. Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. Weight Loss: A novel and effective treatment for urinary incontinence. J Urol July 2005; 174: 190-195. Walter LC, Lewis CL, Barton MB. Screening for colorectal, breast, and cervical cancer in the elderly: A review of the evidence. Am J Med. Oct 2005;118(10):1078-1086. Zipkin DA, Steinman MA. Interactions between pharmaceutical representatives and doctors in training. A thematic review. J Gen Intern Med. Aug 2005;20(8):777-786.
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UCSF GERIATRICS GRAND ROUNDS
Geriatrics Grand Rounds are presented on the first Wednesday of each month from 8:00am9:00am on the Parnassus Campus. Topics and speakers are targeted to appeal to the multiple health sciences disciplines on the UCSF campus. Upcoming featured speakers and their topics are listed below. In addition to the main talk, Grand Rounds sessions also include shorter introductory talks and case presentations on topics of interest to our multidisciplinary audience. For more information about Geriatrics Grand Rounds, contact Matthew Case at mcase@medicine.ucsf.edu or visit http://agrc.ucsf.edu/GrandRounds.htm. DATE December 7, 2005 January 4, 2006 February 2, 2006 SPEAKER Laura Mosqueda, MD C. Seth Landefeld, MD Claudia Beverly, PhD, RN, FAAN Jeanie Kayser-Jones, PhD, RN, FAAN MAIN TOPIC Elder Abuse: Medical Aspects and Interdisciplinary Teams Hospital Care of Older Persons: Is It Safe and Effective? Improving the Health Outcomes of Older Rural Arkansans through Specialized Geriatric Health Care and Education The Significance of Food and Water at the End of Life
March 1, 2006
UCSF Newsletter on
University of California San Francisco UCSF Mount Zion Center on Aging
Aging
NONPROFIT ORG. U.S. POSTAGE PAID UNIVERSITY OF CALIFORNIA SAN FRANCISCO
San Francisco, CA 94143-1265
The Newsletter on Aging is partially supported by the UCSF Academic Geriatric Resource Program.
UCSF Mt. Zion Center on Aging C. Seth Landefeld, MD, Director Joan B. Wood, PhD, Assoc. Director UCSF Newsletter on Aging Matthew Case, Editor Andrew Schwartz, Writer