Evolution of Geriatric Medicine: Mid-career Faculty Continuing the Dialogue

Never believe that a few caring people cannot change the world. For, indeed, that's all who ever have.

Margaret Mead, Cultural Anthropologist

Dear Dr. Applegate

We read the July 16, 2016 article by Dr. Mary Tinetti and accompanying editorial by Drs. Robert Kane, Christopher Callahan, John Morley, and Jim Pacala in Journal of the American Geriatrics Society with great interest.^1,2 During our careers as geriatricians, we have been inspired by these remarkable physicians (and others) whose work drew us into this challenging field, and who continue to motivate us as clinicians, educators, mentors, and scientists. Close colleagues and friends for almost two decades since we met through the American Geriatrics Society's Junior Faculty Research Career Development Special Interest Group, the four of us meet at the annual meeting of the American Geriatrics Society (AGS), doggedly united in our hope that when we retire we will be able to say that the lives of older people have improved because of the work we did. So when Dr. Tinetti generated an article telling us to “stop whining,” it caught our attention. We were reminded of a quote by James Macgregor Burns, a historian and political scientist: ‘Transformational leadership occurs when one or more persons engage with others in such a way that leaders and followers raise one another to higher levels of motivation and morality.’ After many heartfelt email and telephone conversations among ourselves and with other colleagues, we feel compelled to contribute our thoughts from “mid-career.”

We agree with Dr. Tinetti that geriatrics can be considered a ‘metadiscipline,’ that we do not market ourselves well, and that we are an elite workforce; however, we disagree with the notion that our field should be narrowed to be considered experts in multi-morbidity and complex medicine.

Geriatrics as ‘Metadiscipline’

We love the concept of geriatric medicine as a “metadiscipline.” Core principles of geriatrics are now applicable to all areas of clinical, research and training enterprise. Numerous leaders have been rapidly “Geriatricizing” both the health care delivery systems and the health care policy systems³ by first, designing innovative, scalable, and sustainable models of care such as Care Transitions Program,⁴ Hospital-at-home Program⁵; second, developing tools, processes and strategies to rapidly implement evidence based health care solutions into the local community such as INTERACT tools⁶; third, leading major healthcare delivery and health insurance organizations as effective health care administrators; and fourth, guiding national healthcare policy agenda at both the federal and state levels such as the Centers for Medicare and Medicaid.

Several other medical and surgical specialties have infused their fields with innovative models to enhance safety and quality of the aging population that they serve. ‘Geriatric Emergency Departments’ is a testament. With a rapidly growing aging population and the impact of healthcare reform, emergency care has been challenged by a complex patient population, expedited decision making, and the need to coordinate care with surrogate decision makers. Geriatric Emergency Departments, supported by research led by collaborative teams including emergency physicians, geriatricians, educators, social workers, palliative care and advanced nursing practitioners have started to revolutionize urgent care.^7,8 In collaboration with Infectious Diseases physicians, research and guidelines have fundamentally changed the approach to infectious diseases in aging populations.^9-12 New research has revolutionized our approach to managing chronic diseases such as hypertension and dementia in primary care.^13,14 Seminal studies by multidisciplinary research teams have led the way in identifying and reducing adverse events such as delirium,¹⁵ functional decline,^16,17 frailty,¹⁸ falls,¹⁹ infections, polypharmacy²⁰ and pressure ulcers. Geriatricians have either led or been a major partner in each of these initiatives.

These successes have inspired a generation of junior physicians in various medical and surgical subspecialties to pursue a career of research and program development that enhances quality of care and improves health outcomes within their clinical practices. Geriatricians mentor young, energetic physicians brimming with ideas about how to better serve aging adults in their practices.^21-24 Numerous medical and surgical subspecialists now attend the annual AGS meeting and consider the meeting a vibrant venue at which to present their key research findings and to receive peer review and mentorship from a broad range of expertise. We, as mentors, have to be able to promote not only geriatrics fellows and junior faculty but also subspecialists engaged in clinical care, research, training and policy development for an aging population. In order to accomplish these goals and for geriatrics to be considered a metadiscipline, it is critical that we accelerate the pace with which we develop, enhance and sustain connections with other specialty and subspecialty societies, both at an individual level, from the national society and funding perspectives.

Enhancing Our Visibility

Aging is often viewed in a negative manner, thus short- and long-term marketing measures need to be designed and implemented to change engendered societal and cultural mores. We strongly agree with Drs. Kane, Callahan, Morley, and Pacala that rather than “rebranding” our field for ourselves, we need to extend our impact through collaborative partnerships with businesses and policymakers.² We understand Dr. Tinetti's frustration that her fellow geriatricians are being rather timid about taking credit for our accomplishments. Just as Sheryl Sandberg, Chief Operating Officer of Facebook, is justified in urging women to “lean in”²⁵ and change the conversation from what women can't do to what they can do, Dr. Tinetti is equally justified in encouraging us to focus career discussions on the impact our elite field is having on clinical care, health system transformation, healthcare policy, and improving the lives of older adults – be more active in promoting our work. Thus, it is critically important that the AGS engage in: first, rebranding geriatric medicine as a meta-discipline; second, developing a broad-based marketing strategy deployable to a wide audience; and, third, partnering with companies like Google and other geriatrics-supportive organizations to raise the intellectual and financial capital necessary to enhance societal awareness and aggressively market our brand. Equally important is to engage social media in promoting research. With 34,550 scholarly journals publishing 2.5 million articles every year, obtaining recognition of a research article requires careful crafting of the article's message and promotion in social media. While Impact Factor measures citations of a particular journal over the previous 2 years, Altmetrics provides a new way for an individual article tracked in social media promotion and the attention it receives in real time. These emerging tools are critical to promote research to our peers, translating the incredible progress made into practice and being recognized for these contributions.

Narrowing our field will trim our impact

We respectfully disagree, however, with Dr. Tinetti's suggestion to endorse multimorbidity as our defining condition. Multimorbidity should be one condition we are known for being expert at addressing, but if we focus on this single “defining condition” not only will we risk burnout and drive away potential geriatricians who are drawn to the field out of a passion to promote “healthy aging,” but we will also miss out on our unique opportunity to improve the lives of older adults in other domains who may not have multimorbidity.²⁶ Individually and collectively, we need to relentlessly disseminate scientific knowledge about the best ways to prevent physical and cognitive decline.

Besides teaching and promoting principle of geriatrics to all health professionals, our expertise as clinicians, educators, and scientists committed to caring for older adults positions us to have a tremendous impact across virtually every sector of society. We need to engage with the community-at-large, educators and policy-makers to improve educational attainment as well as physical health in under-resourced communities. Entrepreneurs and engineers need our expertise to create the most relevant age-friendly products to allow ‘aging in place’ safely. The television and movie industries need our expertise on how to create and deploy entertainment products that are relevant to older audiences and promote healthy aging. As experts in geriatric medicine, it is our responsibility to have a loud voice in the “anti-aging” world. We are not concerned about the described need to “achieve consensus on a concise description of geriatrics;” instead, we embrace a broad and encompassing description of geriatrics that not only allows but encourages diverse career paths and interdisciplinary collaborations to expand our impact far beyond our small community.

Way Forward

We should take on this challenge and break it into practical applications. First, we should ask ourselves: Do we want to promote the field of aging, promote ourselves as geriatricians, or both? The answer is “both.” Promoting the field of aging is perhaps intuitive — all of us are aging. Making the case to devote resources to educate and train future experts in geriatric medicine is more difficult. Indeed, making the case that expertise in aging should be represented in all aspects of healthcare is the challenge. If we, as a community, agree, let us devote our energy and resources toward developing and implementing practical strategies.

The competencies of our current ‘influencers’ need to be translated into an effective and scalable mentorship programs sponsored and nurtured by the American Geriatrics Society and its partner organizations such as but not limited to the Hartford Foundation. The Aging and Healthcare Policy fellowship is a salient example of such a national mentorship program. The impact of this fellowship can be magnified by having clinical executive leadership coaching track embedded within the annual American Geriatrics Society offered for both early and mid-career geriatric clinicians who are interested in becoming the next generation of influencers. It is critical that geriatricians are engaged in hospital administration as members and leaders of committees to ensure that the healthcare systems are designed to meet an aging population. Furthermore, while developing and evaluating new models of care is complex, it behooves us to strive for simplicity in programs and tools used by frontline clinicians to enable faster and broader adoption.²⁷

In order to achieve these goals, it is critical that our fellowship programs are redesigned to prepare our fellows to be local and national leaders, be clinical and research mentors to other specialists, be disruptors of today's healthcare system and innovators in redesigning for tomorrow's. It is crucial that our training incorporates research, quality improvement, dissemination, public policy, advocacy, and leadership development.

The personality of our entire field can be summarized in a single word: patience. Geriatricians are elite because of our patience, understanding, bandwidth and passion to be able to discuss the complexities of what it means to grow old and to be able to view each patient as an individual with a story to tell. Let us be passionate and not patient in defining ourselves within this rapidly evolving healthcare landscape.