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March/April 2012
Dynamic DoctorsBy Barbara Worthington Aging Well features its 2012 Professionals of Note in Geriatric Medicine. Geriatricians readily admit their specialty may lack the allure, fascination, and prestige careers in cardiology, radiology, or other specialties might offer. Although adequate recognition of their capabilities and expertise may sometimes fall short, geriatricians find a special satisfaction in treating the most fragile and often most vulnerable of patients. With more than 100 years of geriatrics practice experience among them, Aging Well’s honorees have taken bold and innovative actions that have allowed them to excel in their specialty despite insufficient funding, limited research, and decision makers who fail to recognize the far-reaching implications of promoting and supporting the field of geriatrics. Each of these physicians has mapped out a unique game plan, identifying a particular niche in which, over the course of a career, he or she can exert a meaningful impact on patients, their families, and caregivers. Charles E. Driscoll, MD Driscoll has developed an appreciation for the special needs of older patients. He’s a seasoned practitioner with a knack for establishing goals of care and addressing end-of-life decisions. He’s also experienced the myriad challenges all geriatricians face. Among them he points to limitations on community and financial resources as significant barriers to improving geriatric practice. “There are things you know your patients could benefit from, but they’re just not available,” he says. Identifying a community need some years ago, Driscoll helped launch the region’s first Lewy body dementia support group as its cofounder and cofacilitator. He recalls, “In 1971 nobody knew about Lewy body dementia. It got a CPT code in 2001.” Intrigued by the disease, he devoured the available literature and discovered that “these people are everywhere.” He has worked to raise awareness among practitioners about the nuances of Lewy body dementia. With the vast number of current geriatric patients and those who will flood healthcare systems in years to come, Driscoll expresses concern about the shortage of geriatricians to treat aging patients. To play a part in remedying the situation, he has started a fellowship program within the Centra Health System in Lynchburg. As the program’s director, he has now trained two geriatric fellows. It’s a source of considerable pride, as Driscoll notes, “It’s taken me 10 years to get enough capital and momentum going. But we created the fellowship two years ago, and I really feel that might be my legacy for this community.” He feels quite positive about the accomplishment of “training a geriatrician a year.” Additionally, he donates his services as an educator for Lynchburg College’s annual conference, “Aging Well in Mind, Body and Spirit,” as well as volunteering monthly at the local free clinic. In light of the huge number of aging baby boomers, Driscoll sees the future of geriatrics requiring “some kind of mandate to produce better training and more geriatricians,” but his expectation is that the mandate will originate outside medicine. Equally likely, he believes, is some “pull back in technology.” He says not all sophisticated technology is appropriate for geriatric patients. Consuelo Alvarez, MD In her geriatrics practice, Alvarez works to inform patients that “as you go on with life, you can embrace the changes that are happening to you physically and mentally.” Adopting such a philosophy is key to navigating the aging process. She says that in light of the significant negativity surrounding aging patients, “I try to put a positive spin on aging.” She focuses her practice by looking at patients as individuals and modifying medical care based on that individuality. She teaches patients about the changes to expect as they get older, explaining that such changes aren’t necessarily bad. “They sometimes have to do things differently,” she explains, adding that she urges patients to adapt to change and “look at it as an opportunity that arises.” Making modifications that enable patients to function and feel good about themselves without viewing themselves negatively is just one aspect of her role. Alvarez has earned the Certified Medical Director in Long Term Medicine designation from the American Medical Directors Association (AMDA). Despite her status as a skilled clinician, she recognizes there is more to patients’ health and well being than taking medical histories and tracking lab results. She has embraced the concept of culture change, educating other geriatrics professionals, elder patients themselves, and long term care facilities’ staff. She has served as a member of the Elliot Health System’s Falls Committee and Investigational Review Board. She participates in quality management activities as a member of the state chapter of AMDA’s Board of Directors. She derives particular satisfaction from helping patients solve problems, enabling them “to feel good about themselves and function at the level where they want to be functioning,” she says. “When they say ‘Thank you, you’ve helped me,’ that means a lot.” One such thank you from a patient came in the form of a painting he created and presented to Alvarez. That prompted her thoughts that if one artistically talented patient had such impressive capabilities, there certainly must be other similarly talented elders. So she launched an all-media, juried art show for artists aged 65 and older to display their creations. The event that’s now conducted annually offers a venue for elders to showcase their work. “It’s growing more every year,” she says. Alvarez expects the baby boomers’ mindset to exert an influence on modifying the philosophy on aging. She anticipates boomers will seek alternatives rather than traditional medicine. Recognizing boomers’ interest in options that often depart from the conventional, she seeks to integrate aspects of complementary and alternative approaches such as acupuncture and herbals in treating patients. “Boomers want to keep going,” she says. “They’re often in better shape than a lot of their parents, and they’re looking for alternatives.” While gratified that the geriatrics profession is growing, Alvarez suggests the need to expend significant efforts toward higher visibility and recognition. “It’s not a glamour field,” she admits, adding that with the coming age boom, the profession is going to be overwhelmed. Expansion of the field that will invite more geriatricians will require more funding, she says, adding, “It’s going to get bigger and bigger while the government is cutting back payments for physicians. Decision makers need to support geriatricians or they’ll be unable to meet the demand.” Lanyard K. Dial, MD Following up on his own geriatrics education and experience, Dial immersed himself in the education of others. He became involved in local and national education programs designed to present various topics related to elder healthcare concerns to inform other professionals about significant elder issues, including dementia, Alzheimer’s disease, end-of-life care, hospice vs. palliative care, and prostate disease in older men. “I was generally trying to educate other doctors about senior medical issues,” he says. Dial found special motivation in end-of-life care, an area in which he believes many physicians are uncomfortable being involved. He found that “when you step in, patients and families are so grateful they have someone who cares about helping them.” His focus, he says, tends away from simply improving a patient’s blood pressure or blood sugar. “I love the concept that function is a key part of seniors and focusing on helping somebody function better and be more active,” he adds. For his patients, Dial says he places the emphasis on important functional aspects such as their ability to drive, walk, or prepare their own meals. “To me that’s more globally important than establishing good blood pressure numbers on medication,” he says. He derives a sense of personal reward from the positive impact he has on patients’ and caregivers’ lives. As Dial’s career progressed, he fulfilled his desire to impact the medical community on both local and national levels. He promoted the education of geriatricians to a residency program in the local area. Eventually he took the program nationwide via the development of geriatric education for family physicians across the country. When the American Academy of Family Physicians created the materials and review course for geriatric training, Dial served as the lead and chair, delivering the curriculum to family physicians throughout the United States to improve communities’ elder care. “I’ve spent a lot of my career in the belief that rather than taking care of 50 to 100 patients at a time, I could take care of thousands by teaching their doctors how to do this better,” he says. The field of geriatric medicine faces huge challenges, according to Dial, not the least of which involves financial reform. He says elder healthcare issues require careful analysis of concerns such as the amount of money spent at the end of life and changes in services that will make chronic disease management more effective. He says the current funding system designed around hospital systems and acute procedure care is incompatible with the practice of geriatrics in which there’s “less and less of that.” Joseph Ouslander, MD Many of the challenges geriatrics professionals faced at that time remain pervasive today. Geriatric patients require significantly more time, and reimbursement is inadequate. Ouslander explains that he’s “been fighting for 30 years” to support “adequate reimbursement for the kinds of complicated things we do.” He explains, “[Geriatric] patients are complex and fragile. You have to be very careful what you do with them. They don’t have the physiological reserve other patients have, and they usually have multiple problems.” Additionally, he says, “There’s not enough research to guide exactly what to do in older people” due to the complex nature of their conditions. “Using standard evidence-based medicine can be dangerous as it’s limited by definitive research studies.” And he laments that the geriatric specialty itself suffers from a lack of respect. “People in academics don’t understand what we do and don’t put resources into it,” he says, adding that geriatricians should clearly articulate what sets the specialty apart from others. Many meaningful milestones punctuate Ouslander’s long career as a geriatrician. He was instrumental in bringing attention to incontinence science and management in nursing homes, along with efforts to improve overall care of nursing home residents. He developed a program called the INTERACT (Interventions to Reduce Acute Care Transfers) Quality Improvement program to identify changes in residents’ health status in skilled nursing facilities, improve care, and reduce unnecessary transfers to acute hospitals. He has served as a past president of the American Geriatrics Society and currently serves as the executive editor of the Journal of the American Geriatrics Society. His article “Reducing Unnecessary Hospitalizations of Nursing Home Residents” was published in the September issue of The New England Journal of Medicine. In his current academic role, he is an advisor to 16 medical students. In treating patients, Ouslander has found their experience and wisdom rewarding. There’s genuine satisfaction in identifying and carefully managing patients’ medical problems, seeing that they’re safe, and ensuring preventive measures are taken to minimize complications. “You can do something very small and make a huge difference in somebody’s life,” he says. But he believes the field of geriatrics is approaching a crossroads, partially due to reimbursement. He believes the future holds new practice opportunity with all the new models of care focused on coordinating care and preventing hospital readmissions. “Geriatricians will work in systems of care where care is being vertically integrated and coordinated for older people in a variety of settings,” he predicts. “Geriatricians have to become medical administrative leaders in those kinds of systems to guide quality of care.” Janice A. Knebl, DO However, the intervening decades have found Knebl making her mark in the field, enhancing the quality of life for the patients she treats. As a geriatrician, she takes a team approach designed to enhance total patient care: owning the patient, coordinating care, and vigilantly managing chronic disease. And her academic role promotes far-reaching benefits that exert “an exponential influence because of the training we do with medical students, other members of the interdisciplinary team, and even researchers.” With such training, Knebl says she can extend her influence to affect many more. Despite the often limited funding for geriatric care, specifically the traditional fee-for-service model “that tends to reward procedure-based specialties,” Knebl says it’s important to encourage young physicians to enter the geriatrics field. “Unfortunately, we haven’t moved toward funding geriatric care appropriately,” she says. But for her, “It wasn’t ever about the finances at all.” She eagerly admits, “There are those of us who would do it no matter what.” Though the financial rewards may not equal the intangible ones, geriatricians find personal satisfaction in their careers. Knebl says a survey of physicians done some time ago to identify the happiest and most satisfied doctors put geriatricians in the No. 2 spot—and she’s not surprised. Knebl, the Dallas Southwest Osteopathic Physicians Endowed Chair in Clinical Geriatrics and professor of medicine at the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center, finds that making small changes for her patients, such as tweaking a medication dosage or stopping a particular medication, can make a huge difference in a patient’s functionality and quality of life. “I may not cure by a traditional definition of cure,” she says. “A patient will still have Alzheimer’s disease, high blood pressure, or diabetes, but if I can manipulate medications they’re on, focus on the quality of life, and have them remain independent in their homes, that’s what really floats my boat. It’s a wonderful thing to see that.” In 1992, Knebl started a geriatric fellowship at the University of North Texas that has been in existence ever since. She was also instrumental in procuring a four-year $2 million grant to infuse geriatric education into all undergraduate medical school curricula at the university, resident training programs, and for practicing physicians. She explains that for many doctors, geriatric training was unavailable because they trained before a dedicated geriatric curriculum was widely available. Additionally, she was involved in the creation of the successful SAGE (Seniors Assisting in Geriatric Education) program, a mentoring program in conjunction with Meals on Wheels in which clients are paired with two medical students who make eight home visits. The program enables the students to hone their physical exam and history-taking skills. Knebl envisions the future of geriatrics as more integrated, resulting in, for example, better coordination of care for hospitalized patients. She says there’s a huge role for geriatricians in transitions of care to manage them effectively with the necessary quality. She’s optimistic that coordination will “break down the silos of sites of care and move toward an integrated system so that funds can flow with older adults rather than flowing to a site of care. That will give older adults more choices about where they want to be,” she says. She also expects new technology allowing for continuous evaluation and monitoring will be used more in maintaining older adults’ independence. She feels a personal responsibility to help shape the future of geriatrics practice. She’s committed to playing a huge role in “making sure that in 20, 30, or 40 years from now it will be great to be old in America,” she says. “We’ll all reap the benefits of that.” — Barbara Worthington is the editor of Aging Well.
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