March/April 2013

5 Noteworthy Geriatricians

By Barbara Worthington
Aging Well
Vol. 6 No. 2 P. 10

Nominated by their colleagues, our readers, these geriatricians’ decades of dedication to treating older adults have resulted in productive and fulfilling aging experiences for countless patients.

Geriatricians appear to be in universal agreement that although financial compensation for their time and efforts in treating older patients could be termed less than adequate, the satisfaction derived from interaction with patients contributes to the extraordinary personal reward found in the practice of geriatrics.

These dedicated physicians share a deep commitment to compassionate caring and comprehensive treatment for older patients, recognizing the extra time, additional guidance, extraordinary empathy, and often complex disease management necessary to shepherd patients on their aging journeys.

Peter H. Cheng, MD, AGSF, CMD

Physician Lead, Palo Alto Division of Geriatric Medicine, Palo Alto Medical Foundation, California

Eager to arrive at work each day, Peter Cheng likens himself to a Swiss army knife and its many functions, with his including involvement in consulting, a skilled nursing facility, and clinical work. He finds it’s a “very cool time to be a geriatrician” because people are beginning to pay attention to the field of geriatrics.

Cheng’s early interest in geriatrics originated as he grew up in Taiwan, where his grandmother’s courage, wisdom, and insight influenced his understanding of the mindset of elders. His first rotation in medical school likewise enhanced the attraction geriatric medicine held for him. Citing mentors who inspired him to “dream big,” he says he has “stood on the shoulders of some giants” who have done great things for geriatrics.

As a practitioner, Cheng has promoted Successful Aging Shared Medical Appointments, a new way of caring for older patients. The model features a physician and a behavioralist who interact with small groups of up to eight patients during three 90-minute sessions. Designed to be inclusive, the sessions are open to healthcare system patients aged 65 and older who want to take a proactive approach to their own health, seeking guidance from geriatricians on aging well. Patients are provided with resources that assist them in implementing the recommendations they’re provided.

The sessions, focusing on mind, body, and soul, promote the discussion of topics ranging from cognitive decline to fall prevention. The final session examines individuals’ perception of and attitudes toward aging, evaluating risks for isolation and depression. Amid the group’s shared stories, elders bond through their experiences and shared prospects for the aging journey.

Cheng was instrumental in planning and implementing the first Successful Aging Celebration last July. With a community-based sponsor, the medical group presented a celebration to highlight the positive aspects of aging. Offering the community glimpses of what growing older in America can mean, the event showcased the musical and artistic talents of older adults, enjoyed by 92 volunteers of all ages, 39 community partners, and nearly 500 attendees. The event’s educational component featured well-received informational lectures that were sold out weeks in advance.

Successful aging doesn’t happen by accident, and Cheng recognizes that education plays a key role in putting the pieces together to make the experience positive and rewarding. He finds satisfaction in developing effective programs like the Successful Aging Shared Medical Appointments model and in cultivating relationships with community-based organizations that are passionate about promoting positive aging.

Although the field of geriatric medicine suffers from a shortage of practitioners, Cheng believes geriatricians can meaningfully help to reform the current healthcare system. Moving from a fee-for-service model to a total cost-of-care model seems to him to be an ideal place to start. He sees significant promise in improving ways geriatricians can effectively impact the system via methods beneficial to patients and additional strategies to positively influence patients’ quality of life.

Harry S. Strothers III, MD

Chairman and Professor of Family Medicine, Department of Family Medicine, Morehouse School of Medicine, Atlanta

Special relationships with older family and extended family members early in his life sparked an interest in older adults for Harry Strothers. In medical school, he recalls, faculty members created additional interest in geriatrics by including him on particular cases even prior to his clinical experience. That early exposure proved so attractive that it has led to a gratifying career in geriatrics.

Strothers notes that high-functioning teamwork forms the cornerstone of patient care. He finds that teaming with other skillful professionals increases the likelihood of optimal outcomes. Placing the focus of outpatient care on patients rather than on physicians results in improved effectiveness, higher office staff morale, and physician interest in the patients. Having adopted the team approach years ago, he says he’s gratified to now see literature supporting validation of teamwork with respect to outcomes.

Using understandable analogies works best as Strothers attempts to educate older patients on the importance of the proactive role they can take in their own healthcare. He often uses the car maintenance TV ad in which the mechanic told motorists, “You can pay me now or pay me later.” He emphasizes his point by reminding patients that the body requires maintenance, urging patients to take charge of their own health by checking their blood sugar or monitoring their salt intake, for example.

Relationships with patients and their families keep him engaged and his practice vital. And although he acknowledges that finding a cure often is not a realistic expectation, knowing he’s made a life better, made a patient more comfortable or more functional, or helping patients achieve something they want to accomplish at the end of life provides substantial reward.

Strothers embraced a leadership role in Georgia, a state that lagged behind in adopting the patient-centered medical home concept. Three years ago, only four practices had obtained National Committee for Quality Assurance (NCQA) recognition. As a member of the executive board of the Georgia Academy of Family Physicians, he helped to initiate the institutional process that launched the Patient-Centered Medical Home University, a collaboration of 27 practices that underwent the transformational process to become NCQA-recognized patient-centered medical homes with the help of funding from the family physicians academy. Twenty-four of the 27 practices have received the recognition, and the academy began another cycle in November.

Strothers expresses concern related to the number of physicians he expects to retire in the next 10 to 15 years, with few “replacements” ready to fill the ranks. He suggests that passing on to the next generation of medical students the knowledge necessary to adequately care for older adults presents an enormous challenge. He’s doing his part through his teaching role, recruiting medical students to family medicine, and encouraging them to accept geriatric fellowships.

Stephanie Trifoglio, MD, FACP

Partner, Maryland Geriatric Medicine, Greenbelt, Maryland

Trained in internal medicine, Stephanie Trifoglio met her current partners who, as trained geriatricians, had become involved in nursing home care and caring for elders in the community. During a geriatric elective at George Washington University, a mentor who created a “dynamic training” experience and promoted advocacy for patients’ ability to age well and die gracefully made a lasting impression on her professional development. Now she and her partners operate a practice with the distinction of being the county’s only practice in which all three internists are board certified in geriatrics.

Empathy plays a huge role in dealing with her patients, many of whom suffer from dementia, and their families. Recognizing dementia as a “long, long journey,” Trifoglio professes her “amazing respect” for family members who commit to the long-term care of loved ones with dementia. She notes that although providing such care can be gratifying, it’s exhausting both physically and emotionally. She recognizes that without opportunities to network, receive support, and take time to rejuvenate themselves, caregivers will find it impossible to sustain their efforts. For that reason, she has become an advocate for caregivers, reminding them of the importance of caring for themselves—keeping medical appointments, scheduling appropriate tests, maintaining relationships, and reaching out to others.

Referring to her patients as her “everyday heroes,” Trifoglio laments the fact that medical students often equate the practice of geriatrics with treating unresponsive older patients in the ICU and never seeing “the fun people.” She derives pleasure from interaction with her older patients who “just love life” and notes that they’re spunky and funny, and have an amazing sense of life and verve.

As a hands-on physician who takes thorough case histories herself, she recalls a notable case in which a retired scientist brought his retired biologist wife to her, expressing concern regarding a diagnosis of Alzheimer’s disease and Parkinson’s disease confirmed by two neurologists. While her symptoms of confusion, tremors, unsteady gait, and colitis seemed to fit, a medication check revealed that the patient had been taking two Pepto-Bismol tablets three times per day for five years. Trifoglio stopped in the middle of the intake history, on a hunch consulting a reference text to confirm her suspicion. The symptoms perfectly fit bismuth toxicity. Trifoglio told the patient to stop the bismuth, which reversed the symptoms and restored the woman’s cognition. The diagnosis and treatment changed her patient’s life, the result of analyzing each patient anew, “understanding what could be,” and “taking patients seriously.”

Trifoglio practices geriatrics with a realistic perspective, often surprised at the mistaken expectations of patients’ family members. Treating patients from the realistic perspective that accepts death as a part of life, she attempts to help patients and their families understand “how fragile life is,” particularly as aging limits patients’ homeostatic reserve. She commits herself to helping patients live as well as they can for as long as they can, noting that “death is not the enemy; dying badly is.”

Of course, analyzing medications, speaking with families, and providing specialized care require time. Receiving proper reimbursement for services geriatricians provide would prove cost-effective, Trifoglio believes. Politicians’ and insurance companies’ support for adequate time and appropriate treatments would enable clinicians to save money and eliminate a lot of unnecessary care, Trifoglio explains. On the other end of the spectrum, she shares with her 50-something patients her vision of their future, encouraging exercise, diet vigilance, cholesterol monitoring, and getting diabetes under control. She knows it’s an investment in protecting patients’ health and saving healthcare dollars down the road.

T. S. Dharmarajan, MD, FACP, AGSF

Vice Chairman, Department of Medicine and Clinical Director of Geriatrics, Montefiore Medical Center, Bronx, New York; Professor of Medicine and Associate Dean, New York Medical College, Valhalla, New York

In the early 1990s, before the field of geriatrics was widely recognized, T. S. Dharmarajan was recruited to establish a geriatric program within a New York university hospital. He admits he reluctantly left behind his nephrology specialty, choosing to embark on a unique pioneering effort.

Teaming with a psychiatrist and a physiatrist, Dharmarajan launched a pilot program that included geriatrics components that “made sense.” After one successful year, the hospital extended the program and requested that he develop a fellowship to enhance the program. The endeavor snowballed; the 17-bed pilot program grew to 43 beds. It has now expanded into two large hospital units encompassing 69 beds. And the fellowship program that began with a single fellow is now fully accredited for 10 fellows.

Dharmarajan readily admits that practicing geriatrics is an extremely time-consuming proposition that’s poorly reimbursed, making it sometimes a less-than-attractive field for younger doctors. But at the same time, he finds patients to be grateful for the ways in which he improves their lives. With older patients, he notes, doing even a little for them results in high levels of patient satisfaction. He emphasizes the importance of caring despite the knowledge that curing is often not an option.

With geriatricians in short supply, by the time many patients are referred to them, it’s often rather late in the game, Dharmarajan says. He expressed serious misgivings about the future of geriatrics and the difficulties surrounding the ability to meet older patients’ medical needs over the coming years. He suggests that medical school curricula require “radical change,” including more geriatrics-specific exposure to prepare for the huge numbers of older adults and their healthcare.

His prolific writing has produced more than 150 works, including scientific articles and textbook chapters. Two of his major writing efforts resulted in the 2003 publication of Clinical Geriatrics and authorship of 17 of the 72 chapters in the 2012 publication of Geriatric Gastroenterology, addressing topics such as nutrition, abdominal pain, aging physiology, and comprehensive geriatric assessment.

In April he will be recognized as a master by the American College of Physicians. Those receiving the designation are distinguished physicians selected from the organization’s fellows, who have achieved recognition in medicine by exhibiting preeminence in practice or medical research, holding positions of high honor, or making significant contributions to medical science or the art of medicine.

Although Dharmarajan finds the present healthcare system to be “in a huge mess,” he believes in the possibility of change. An element that may contribute to such change lies in rewarding good care, he says. And the need to educate future generations of medical professionals continues. He acknowledges that teaching is his passion, and he yearns to share his knowledge and skills with young residents and fellows. He also entertains thoughts about writing a book aimed at consumer readers that would focus on the positive aspects of aging.

Steven R. Counsell, MD, FACP, AGSF

Mary Elizabeth Mitchell Professor and Director, Indiana University Geriatrics Program, Indiana University School of Medicine, Indianapolis

Following his internal medicine residency, Steven Counsell observed the demographic shift and identified geriatrics as the wave of the future. Having later completed a geriatric medicine fellowship, he focused on older patients—”and the older the better.” His approach involved treating the whole patient, developing treatment plans to optimize patients’ function and quality of life. Additionally, he adopted a team approach, including nurse practitioners, social workers, physical therapists, occupational therapists, pharmacists, and mental health professionals who worked together. His geriatric care encompassed the healthcare continuum, including not only the clinic and hospital but also rehabilitation, home healthcare, assisted living, and long term care. He became adept at helping people navigate transitions and advocating for patients receiving care in various healthcare environments.

Among his hallmark achievements is the development of the GRACE (Geriatric Resources for Assessment and Care of Elders) team care program, designed to provide resources to primary care physicians caring for complex older patients and to help coordinate their care, assist with transitions of care, and integrate care with community resources. Utilizing a team approach, the program initially provides home assessment of patients by a nurse practitioner and a social worker who assess vision, hearing, depression, cognitive impairment, fall risk, mobility, and home safety. Considering the information reported by the evaluating team, a broader geriatrics team, including a geriatrician, mental health liaison, and pharmacist, develops a care and treatment plan. Then the nurse practitioner and social worker meet with the primary care physician to report the home visit findings and provide the GRACE team’s recommendations.

Collaboratively with the physician, they prioritize patient needs, determine how to implement the care plan, and meet again with the patient to align the care plan with the patient’s goals. The team works with the primary care physician to ensure patients keep appointments with specialists, assist patients with medications, coordinate care in the case of hospitalization, and help with discharge planning.

After two years of the program’s operation, analysis has determined that general health, mental health, and quality of life for elders in the GRACE program surpass the corresponding conditions of elders who did not participate in the program. The program’s success extended to a reduction in hospitalizations, improved quality of care, and reduced costs. It works particularly well for vulnerable and low-income older adults and dual eligible populations. Because of its efficacy and success in avoiding unnecessary costs of care, other health systems are working to replicate the program.

Counsell believes it’s an exciting time for geriatrics as it continues to catch on with accountable care organizations, where evidence demonstrates the value geriatrics delivers in improving the quality of care to older patients. Reducing hospitalizations and readmissions favorably impacts the bottom line and reinforces the positive and productive aspects of geriatric medicine.

But he acknowledges that nationally geriatrics remains “fragmented,” what with primary care, wellness, consultations, research, and training. It’s critical for geriatricians to continue to advance the clinical care of older adults, he says, and it’s necessary to define geriatricians’ roles in patient care so that they can make meaningful contributions and receive acknowledgement from their colleagues.

— Barbara Worthington is the editor of Aging Well.