Trends in Geriatrics Graduate Medical Education Programs and Positions, 2001 to 2018

INFLAMMATION's cognitive impact revealed by a novel "Line of Identity" approach

IMPORTANCE

Dementia is an "overdetermined" syndrome. Few individuals are demented by any single biomarker, while several may independently explain small fractions of dementia severity. It may be advantageous to identify individuals afflicted by a specific biomarker to guide individualized treatment.

OBJECTIVE

We aim to validate a psychometric classifier to identify persons adversely impacted by inflammation and replicate it in a second cohort.

DESIGN

Secondary analyses of data collected by the Texas Alzheimer's Research and Care Consortium (TARCC) (N = 3497) and the Alzheimer's Disease Neuroimaging Initiative (ADNI) (N = 1737).

SETTING

Two large, well-characterized multi-center convenience samples.

PARTICIPANTS

Volunteers with normal cognition (NC), Mild Cognitive Impairment (MCI) or clinical "Alzheimer's Disease (AD)".

EXPOSURE

Participants were assigned to "Afflicted" or "Resilient" classes on the basis of a psychometric classifier derived by confirmatory factor analysis.

MAIN OUTCOME(S) AND MEASURE(S)

The groups were contrasted on multiple assessments and biomarkers. The groups were also contrasted regarding 4-year prospective conversions to "AD" from non-demented baseline diagnoses (controls and MCI). The Afflicted groups were predicted to have adverse levels of inflammation-related blood-based biomarkers, greater dementia severity and greater risk of prospective conversion.

RESULTS

In ADNI /plasma, 47.1% of subjects were assigned to the Afflicted class. 44.6% of TARCC's subjects were afflicted, 49.5% of non-Hispanic Whites (NHW) and 37.2% of Mexican Americans (MA). There was greater dementia severity in the Afflicted class [by ANOVA: ADNI /F(1) = 686.99, p <0.001; TARCC /F(1) = 1544.01, p <0.001]. "INFLAMMATION" factor composite scores were significantly higher (adverse) in Afflicted subjects [by ANOVA in ADNI /plasma F(1) = 1642.64, p <0.001 and in TARCC /serum F(1) = 3059.96, p <0.001]. Afflicted cases were more likely to convert to AD in the next four years [by Cox's F, ADNI /plasma: F (252, 268) = 3.74 p < 0.001; TARCC /serum: F (160, 134) = 3.03, p < 0.001 (in TARCC's entire sample), F (110, 90) = 4.92, p <0.001 in NHW, and F(50, 44) = 2.13, p = 0.006 in MA]. The proportions converting were similar among afflicted NHW in both cohorts /biofluids but MA exhibited a lower risk (7% in TARCC /serum at 48 months).

CONCLUSIONS AND RELEVANCE

Our inflammation-specific psychometric classifier selects individuals with pre-specified biomarker profiles and predicts conversion to "AD" across cohorts, biofluids, and ethnicities. This algorithm might be applied to any dementia-related biomarker making the psychometric estimation of individual biomarker effects feasible without biomarker assessment. Our approach also distinguishes individuals resilient to individual biomarker effects allowing for more accurate prediction and precision intervention.

The Impact of Scholarly Concentration Programs on Graduates' Career Choices and Interest in the Care of Older Patients

BACKGROUND

More geriatricians are needed to care for the aging population. Geriatric scholarly concentration programs (GSCPs) may promote medical students' interest in this underserved field or careers working with older adults. Additionally, graduates of GSCPs may be more comfortable and competent in providing care for older adults. Surveys were administered to graduates of GSCPs to determine the role of these programs in shaping medical students' careers and views about caring for older adults.  Methods: The purpose of this study is to understand the impact of GSCPs on medical graduates' career choices and self-perceived skill and comfort in caring for older adults. A Qualtrics survey (Qualtrics International Inc., Seattle, Washington, United States) was developed and distributed to 83 graduates of four GSCPs in the United States. Data were analyzed using a significance level of p>0.05 for all tests. Descriptive statistics were calculated to summarize the data. Wilcoxon signed-rank tests were used to test for significant differences in interest in pursuing a career in geriatrics or working with older adults. Qualitative responses were coded and analyzed for themes.  Results: A total of 34 out of 83 surveyed graduates of GSCPs indicated a higher interest in geriatrics as a career as well as increased comfort and self-perceived skill in caring for older adults after completing the GSCP. The components of the GSCP that most strongly improved the participants' ability to care for older adults included the curriculum (n=31, 91%) and mentoring (n=28, 82%). An overwhelming majority of survey participants felt GSCPs should be offered as part of medical school programming (n=33, 97%).  Conclusion: This study suggests that GSCPs increase interest and competence in caring for older adults and increase interest in a career in geriatrics. GSCPs should be implemented across medical schools.

The Landscape of Geriatric Fellow Scholarly Activity Participation: Findings From a National Survey of Program Directors

Introduction As the US population continues to age, there is a critical need for geriatricians to be trained and engaged in research to inform high-quality care for older adults. Our objective was to understand the extent, type, barriers, and facilitators of research training and the attitudes toward research training and scholarly activity among Accreditation Council for Graduate Medical Education (ACGME)-accredited US geriatric fellowship programs. Methods We conducted a cross-sectional survey of geriatric fellowship program directors from September to November 2022. Surveys assessing program characteristics, requirements for scholarly activity, director demographics, and director attitudes toward scholarly activity were distributed via email. We used descriptive statistics to assess fellowship scholarly activity requirements, facilitators, and perceived barriers. Results The survey response rate was 35.3% (41/116 programs). Most programs (82.9%) required participation in scholarly activity and provided protected time (73.2%). Definitions of scholarly activities greatly differed among programs. The most common scholarly activity requirements included participation in a scholarly project (70.7%) or local presentation (46.3%). The short duration of fellowship was the most common major barrier, reported by 70.7% of directors. Lastly, 34.1% of directors indicated satisfaction with the quality of research training provided, while 65.9% of directors reported satisfaction with the opportunities provided to participate in scholarly activities. Conclusions Overall, program requirements, facilitators, and perceived barriers to scholarly activity were heterogeneous among US geriatric program directors. Additionally, only about one-third of directors were satisfied with the research training provided. Our future work will compare the attitudes and reported barriers/facilitators of program director and fellow participants toward participation in scholarly activity.

The perceived impact of physician shortages on human resource strategies in German hospitals - a resource dependency perspective

PURPOSE

Like other European countries, Germany is facing regional physician shortages, which have several consequences on patient care. This study analyzes how hospitals perceive physician shortages and which strategies they adopt to address them. As a theoretical framework, the resource dependency theory is chosen.

DESIGN/METHODOLOGY/APPROACH

The authors conducted 20 semi-structured expert interviews with human resource officers, human resource directors, and executive directors from hospitals in the northwest of Germany. Hospitals of different ownership types, of varying sizes and from rural and urban locations were included in the sample. The interviews were analyzed by using qualitative content analysis.

FINDINGS

The interviewees reported that human resource departments in hospitals expand their recruiting activities and no longer rely on one single recruiting instrument. In addition, they try to adapt their retaining measures to physicians' needs and offer a broad range of employment benefits (e.g. childcare) to increase attractiveness. The study also reveals that interviewees from small and rural hospitals report more difficulties with attracting new staff and therefore focus on recruiting physicians from abroad.

PRACTICAL IMPLICATIONS

Since the staffing situation in German hospitals will not change in the short term, the study provides suggestions for hospital managers and health policy decision-makers in dealing with physician shortages.

ORIGINALITY/VALUE

This study uses the resource dependency theory to explain hospitals' strategies for dealing with healthcare staff shortages for the first time.

The Wisconsin Alzheimer's Institute Dementia Diagnostic Clinic Network: A community of practice to improve dementia care

BACKGROUND

The Wisconsin Alzheimer's Institute (WAI) Dementia Diagnostic Clinic Network is a community of practice formed in 1998 as a collaboration of community-based clinics from various healthcare systems throughout the state. Its purpose is to promote the use of evidence-based strategies to provide high quality care throughout Wisconsin for people with dementia. The purpose of this study is to describe the use of a community of practice to facilitate education of healthcare providers on best practices in dementia care, and the implementation of an interprofessional approach to diagnose and manage dementia and related disorders.

METHODS

Cross-sectional study of the members of the WAI's Dementia Diagnosis Clinic Network. Characteristics of clinics and healthcare teams, learners' participation in educational events and educational outcomes were collected from evaluation forms. Number and characteristics of patients seen in the memory clinics were collected from de-identified data forms submitted by members to a centralized location for data analysis.

RESULTS

The clinic network currently has 38 clinics affiliated with 26 different healthcare systems or independent medical groups in 21 of 72 Wisconsin counties. Most (56%) are based in primary care, 15% in psychiatry, and 29% in neurology. Between 2018 and 2021, we received data on 4710 patients; 92% were ≥65 years old, 60% were female, and 92% were white. Network members meet in-person twice a year to learn about innovations in the field of dementia care and to share best practices. Educational events associated with the network are shown to be relevant, useful, and improve knowledge and skills of participants.

CONCLUSION

Communities of practice provide added value via shared best practices and educational resources, continuing education of the health workforce, continuous quality improvement of clinical practices, and adoption of new diagnostic and management approaches in dementia care.

Barriers and motivators to specializing in geriatrics and strategies for recruitment: scoping review

While the barriers to specializing in geriatrics are known, motivators behind why medical trainees choose geriatrics are not as well understood. It is also unknown if recruitment strategies in the literature address these barriers and motivators. The aim of this systematic scoping review is to examine the current literature on recruitment strategies alongside motivators and barriers for specializing in geriatrics. Eligible articles for this scoping review either focused on motivators or barriers among trainees (medical students, resident-physicians, fellows) or recruitment strategies. A scoping search was conducted in MEDLINE, Embase, CINAHL, and PsychINFO. Data was extracted on article characteristics and themes. 88 of 2064 articles were eligible and included. Personal fulfillment emerged as the most common theme for motivators, contrary to prior studies that cite positive role modeling. Financial disincentive remained the most common barrier, followed by limited exposure and "futile" practice. Promising interventions beyond financial compensation include defining geriatrics better, emphasizing the high job satisfaction rates, increasing clinical exposure for medical students, and additional funding for academic centers to recruit academic geriatricians. Policymakers and medical educators should consider multiple strategies that target the motivators, as well as the barriers to pursuing geriatrics.

An Interactive Workshop on Managing Dysphagia in Older Adults With Dementia

INTRODUCTION

Nearly six million American adults live with dementia, and dysphagia is a common comorbidity impacting their nutrition and quality of life. There is a shortfall in the number of geriatricians available to care for older adults. Thus, primary care physicians should be equipped with the knowledge to adequately care for the geriatric population. Modified diets are routinely prescribed for patients with dementia despite limited evidence that they protect patients from the sequelae of dysphagia and some suggestion of poor side-effect profiles.

METHODS

We created a onetime, interactive, case-based session to educate medical residents on how to evaluate and treat dementia-associated dysphagia and address the discrepancy between the limited evidence for dietary modifications and their routine use. The session had a mixture of small-group discussion and didactic learning as well as a participatory component during which learners were able to sample thickened liquids.

RESULTS

The session was implemented in an established primary care curriculum. Based on survey responses, which were obtained from 15 out of 17 participants, the session significantly improved participants' knowledge of dysphagia-associated dementia and increased their comfort with caring for patients with dysphagia.

DISCUSSION

Dementia-associated dysphagia, although an increasingly common clinical problem, remains an underexamined area of medicine. We successfully implemented a session on this topic for internal medicine residents on the primary care track. Limitations included generalizability due to the small number of residents in the course and inability to gather sufficient data to see if knowledge learned was sustained over time.

Using Non-Pharmaceutical Interventions and High Isolation of Asymptomatic Carriers to Contain the Spread of SARS-CoV-2 in Nursing Homes

More than 40% of the deaths recorded in the first wave of the SARS-CoV-2 pandemic were linked to nursing homes. Not only are the residents of long-term care facilities (LTCFs) typically older and more susceptible to endemic infections, the facilities’ high degree of connection to wider communities makes them especially vulnerable to local COVID-19 outbreaks. In 2008, in the wake of the SARS-CoV-1 and MERS epidemics and anticipating an influenza pandemic, we created a stochastic compartmental model to evaluate the deployment of non-pharmaceutical interventions (NPIs) in LTCFs during influenza epidemics. In that model, the most effective NPI by far was a staff schedule consisting of 5-day duty periods with onsite residence, followed by an 4-to-5 day off-duty period with a 3-day quarantine period just prior to the return to work. Unlike influenza, COVID-19 appears to have significant rates of pre-symptomatic transmission. In this study, we modified our prior modeling framework to include new parameters and a set of NPIs to identify and control the degree of pre-symptomatic transmission. We found that infections, deaths, hospitalizations, and ICU utilization were projected to be high and largely irreducible, even with rigorous application of all defined NPIs, unless pre-symptomatic carriers can be identified and isolated at high rates. We found that increasingly rigorous application of NPIs is likely to significantly decrease the peak of infections; but even with complete isolation of symptomatic persons, and a 50% reduction in silent transmission, the attack rate is projected to be nearly 95%.

Interprofessional student-led outreach to high-risk older adults during the COVID-19 pandemic

In response to a statewide stay-at-home order during the COVID-19 pandemic, the Seniors Clinic launched an interprofessional student-led, telephone-based outreach initiative targeting older adults deemed high risk for social isolation. The initiative primarily aimed to enhance students' geriatric and interprofessional education during a time when clinical learning opportunities were limited, as well as supporting geriatric patients and providers through outreach during the COVID-19 quarantine period. Nurse practitioner, medical, and pharmacy students participated in virtual patient contact, geriatric case-based learning, and team-based interprofessional development. We conducted pre-and post-outreach assessments with students and geriatric providers to determine the effects of this initiative. After participating in the 3-month outreach initiative, interprofessional students reported increased confidence in conducting outreach calls, participating in interdisciplinary team discussions, and reviewing geriatric cases. This student-led telephone-based outreach to older adults improved students' exposure to and confidence with interprofessional teamwork and geriatric medicine. Our experience can inform future interprofessional initiatives to improve outreach to populations affected by public health emergencies.

Advanced Practice Registered Nurse Transition to Practice in the Long-Term Care Setting: An Ethnography

Advanced practice registered nurses are successful in improving quality outcomes and filling provider care gaps in long-term care. However, little is known about the nurse’s transition to practice in this setting. A 12-month ethnography was conducted via participant-observation with nine advanced practice registered nurses in five long-term care facilities to understand practice environment influence on the nurses’ transition and on the reciprocal influence of the nurse on the practice environment. Transition was fraught with uncertainty as documented by five themes: where’s my authority, institutional acceptance, personal role fulfillment, provider relationships, and individual versus organizational care. These findings suggest that transition in this setting is complex, characterized by insecurity whether the individual is new to advanced practice or experienced. Transition in long-term care could be strengthened by formal programs that include clinical practice, reconceived mentorship for advanced practice registered nurses, and education designed to improve comfort and expertise with indirect care.

Assessing the Accessibility of Content for Geriatric Fellowship Programs

The information available on program websites concerning geriatric fellowships in internal medicine and family medicine is a crucial factor in generating applicants' interest in individual programs. Our study aimed to quantify the accessibility and quality of information available on accredited geriatric (family medicine and internal medicine) fellowship program websites and further analyze the implications of the results obtained. A list of geriatric (family medicine and internal medicine) fellowship programs was analyzed through quantified measures after being verified for accreditation. Certain criteria were evaluated for each of these programs, such as website accessibility and whether critical information was available on online program websites. These criteria were centered on academic, administrative, and application-based factors. Hundred and fifty eight Family Medicine and Internal Medicine geriatric fellowship programs were identified in total, of which only 150 were accredited by the Accreditation Council for Graduate Medical Education and considered for analysis. Of these, 20 (13.33%) programs had website links that were nonfunctional and only 145 programs had websites at all. On programs' websites, information regarding aspects such as contact information-including phone number or email for the program-were lacking. Other information regarding past and current fellows, research, and curriculum were also generally lacking. Geriatric Fellowship websites in Family Medicine and Internal Medicine can gain better traction from those interested in applying for their programs by updating information more often and providing more and better information concerning critical aspects of the programs themselves online.

Geriatrics Fellowship-Family Medicine: Evaluation of Fellowship Program Accessibility and Content for Family Medicine Applicants

Background: Website content and accessibility has the potential to influence the applicant’s decision whether to interview for the program or not. The objective of our study is to determine the content and accessibility of the American Academy of Family Physicians (AAFP) Directory and accredited geriatric (family medicine) fellowship program websites.

Methods: A list of geriatric (family medicine) fellowship programs was retrieved using the AAFP Directory and verified for accreditation. Contact information was compared between the directory and the fellowship websites. The programs’ website links from the directory were evaluated and compared with Google search. The websites’ accessibility and content were assessed for program, education, and application overview.

Results: Fifty programs were identified, but 43 programs were chosen for analysis. There was an incongruence of over 50% of contact information between the AAFP Directory and the website page. Regarding content, most websites were lacking in fellows’ profile information, previous research studies, and application ID.

Conclusion: AAFP Directory and fellowship websites can improve geriatric (family medicine) fellowship recruitment by updating their information and providing more accessible and accurate content.

Geriatrics Scholarly Concentration Programs Among U.S. Medical Schools

OBJECTIVES

To identify and describe geriatric scholarly concentration programs (GSCPs) among U.S. medical schools.

DESIGN

Survey and interview.

SETTING

Allopathic and osteopathic medical schools in the United States.

PARTICIPANTS AND METHODS

We used a systematic internet search, forum postings, and word of mouth to identify all U.S. allopathic and osteopathic medical schools with existing GSCPs. GSCP directors completed an online survey. We conducted interviews with key faculty of two representative programs.

MEASUREMENTS

GSCP size, goals, duration of activity, requirements, funding sources, and student outcomes.

RESULTS

Nine GSCPs were identified, and eight responded to the survey. The number of current medical student participants ranged from 0 to 28, with a mean cohort size of 23. All programs included the following components: formal mentoring, clinical experiences in geriatric medicine beyond the standard medical school curriculum, and research. Half required students to complete an independent research project. GSCPs reported challenges, including low student interest, lack of availability of faculty mentors, and budget constraints; however, student satisfaction was high. Among three programs that reported on the residency matches of their graduates, half matched into a residency with a geriatric subspecialty training option.

CONCLUSIONS

Among U.S. medical schools, there are few GSCPs. The GSCP model may help compensate for limited exposure to geriatric competencies in the standard medical school curriculum for a subset of interested students and may increase interest in geriatrics subspecialty training.

Identifying Palliative Care Champions to Promote High-Quality Care to Those with Serious Illness

Leading medical authorities advocate for routine integration of palliative care for all major causes of death in the United States. With rapid growth and acceptance, the field of palliative care is tasked with addressing a compelling question of its time: "Who will deliver timely, evidence-based palliative care to all who should benefit?" The current number of palliative care specialists will not suffice to meet the needs of persons with serious illness. In 2010, initial estimates quantified the shortage at 6000 to 18 000 additional palliative care physicians needed to fully staff existing programs. Unfortunately, the predicted number of specialty physicians in 2030 will likely not be larger than the workforce in existence today. These findings result in a physician-to-serious-illness-person ratio of about 1:28 000 in 2030.¹ To address the workforce shortage, stronger alignment is needed between intensity of patient needs and provision of palliative care services. Such an alignment better harnesses the talents of those in a position to deliver core palliative care services (such as discussing goals of care with patients or managing their symptoms) while engaging palliative care specialists to address more complex issues. We introduce the concept of "Palliative Care Champions," who sit at the nexus between specialty palliative care and the larger clinical workforce. Acknowledging that the needs of most patients can be met by clinicians who have received basic palliative care training, and that specialty palliative care is not always available for those with more complex needs, there exists an important opportunity for those with additional interest to scale training and quality improvement to fill this void. J Am Geriatr Soc 67:S461-S467, 2019.

2020 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the future challenges of meeting care demands for the growing number of people living with Alzheimer's dementia in the United States with a particular emphasis on primary care. By mid-century, the number of Americans age 65 and older with Alzheimer's dementia may grow to 13.8 million. This represents a steep increase from the estimated 5.8 million Americans age 65 and older who have Alzheimer's dementia today. Official death certificates recorded 122,019 deaths from AD in 2018, the latest year for which data are available, making Alzheimer's the sixth leading cause of death in the United States and the fifth leading cause of death among Americans age 65 and older. Between 2000 and 2018, deaths resulting from stroke, HIV and heart disease decreased, whereas reported deaths from Alzheimer's increased 146.2%. In 2019, more than 16 million family members and other unpaid caregivers provided an estimated 18.6 billion hours of care to people with Alzheimer's or other dementias. This care is valued at nearly $244 billion, but its costs extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2020 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $305 billion. As the population of Americans living with Alzheimer's dementia increases, the burden of caring for that population also increases. These challenges are exacerbated by a shortage of dementia care specialists, which places an increasing burden on primary care physicians (PCPs) to provide care for people living with dementia. Many PCPs feel underprepared and inadequately trained to handle dementia care responsibilities effectively. This report includes recommendations for maximizing quality care in the face of the shortage of specialists and training challenges in primary care.

Prescriber-Initiated Engagement of Pharmacists for Information and Intervention in Programs of All-Inclusive Care for the Elderly

Little is known about the types of drug information inquiries (DIIs) prescribers caring for older adults ask pharmacists during routine practice. The objective of this research was to analyze the types of DIIs prescribing clinicians of Programs of All-Inclusive Care for the Elderly (PACE) made to clinical pharmacists during routine patient care. This was a retrospective analysis of documented pharmacists' encounters with PACE prescribers between March through December, 2018. DIIs were classified using a developed taxonomy that describes prescribers' motivations for consulting with pharmacists and their drug information needs. Prescribers made 414 DIIs during the study period. Medication safety concerns motivated the majority of prescribers' inquiries (223, 53.9%). Inquiries received frequently involved modifying drug therapy (94, 22.7%), identifying or resolving adverse drug events (75, 18.1%), selecting or adjusting doses (61, 14.7%), selecting new drug therapies (57, 13.8%), and identifying or resolving drug interactions (52, 12.6%). Central nervous system medications (e.g., antidepressants and opioids), were involved in 38.6% (n = 160) of all DIIs. When answering DIIs, pharmacists made 389 recommendations. Start alternative medications (18.0%), start new medications (16.7%), and change doses (12.1%) were the most frequent recommendations rendered. Prescribers implemented at least 79.3% (n = 268) of recommendations based on pharmacy records (n = 338 verifiable recommendations). During clinical practice, PACE prescribers commonly ask pharmacists a variety of DIIs, largely related to medication safety concerns. In response to these DIIs, pharmacists provide medication management recommendations, which are largely implemented by prescribers.