Hayka Hovsepyan, MD, had been an attending internist for two years when she decided to leave her position as associate director of an internal medicine residency program to apply for a geriatric fellowship. “I was deeply influenced by a mentor in my residency program, who was the only geriatrician among internists and subspecialists,” she says. “And I knew I could be a better doctor for elderly, vulnerable patients by becoming a geriatrician myself.”
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The fellowship has made her a better physician, she says. That is what Ronan Factora, MD, wants to hear. As program director for the Geriatric Fellowship at Cleveland Clinic, the nation’s No. 2 hospital, Dr. Factora says the program aims to enhance the skills of board-certified physicians who have developed an affinity for caring for older patients.
Two fellows are accepted every year into the one-year program. The first part of the year centers on core rotations. This is followed by a choice of curricula that provide stewardship in an area of interest. “We adjust the curriculum to allow our fellows to focus on the area they choose: inpatient, outpatient or nursing home,” says Dr. Factora.
The training emphasizes preventing decline and preserving function for patients over age 65 as well as treating chronic illness.
“We aim to reduce issues that lead to hospitalization, such as falls and medication noncompliance,” says Dr. Factora. “Often, these issues are avoidable by asking the right questions. We help the fellows improve their interpersonal communication skills and encourage them to take time investigating problems and explaining findings and plans with patients and families.”
The outpatient geriatric service primarily serves patients with multiple medical conditions or memory disorders. “We are often consulted for geriatric syndrome management, patients admitted to the hospital who also have weight loss, malnutrition, falls, incontinence, memory loss, delirium—lots of things considered a part of aging, but often are not,” Dr. Hovsepyan says. “These are symptoms that increase length of stay.
“A typical patient may have pneumonia, be taking multiple medications, gets dizzy, falls, breaks a hip and cannot be discharged home,” she continues. “We review the medications and determine why they fell. We may recommend physical therapy and a change in medications. If the patient cannot return home, we help the patient transition to a nursing home or assisted living, so we learn about the community resources that are available.”
The goal is always to decrease length of stay and prevent readmission.
Another aspect of the program involves learning how to pass along the skills needed to care for older patients to other health personnel. The fellows are taught the essentials of teaching and hone their skills by mentoring residents on a regular basis.
“Everyone should be aware of the effects of chronic illness on mobility and cognition, and how these affect function. They also need to be alert to the effects of medications on these areas and how to appropriately dose them for older adults,” says Dr. Factora. “You can’t prescribe a medication that patients cannot afford to buy, administer themselves or remember to take.”
To teach fellows the various steps involved in solving problems and measuring improvement, they are required to lead and implement a quality improvement project. Broadly, quality projects have involved strengthening communications at key points, looking at ways to reduce length of stay/rehospitalizations and adjusting interventions to improve care. “They get used to a sequence of thought that can be applied wherever they are going to work,” Dr. Factora explains.
Leadership is cultivated by encouraging fellows to take specific leadership courses offered through Cleveland Clinic’s Education Institute. They also assume medical directorship activities in a long-term care setting, where they can help develop protocols for falls prevention, infection control and other problems. “The fellows learn what is required in these roles and how to interact with administration and staff to achieve a specific goal,” says Dr. Factora.
For all the value geriatricians provide, their efforts are not fairly compensated by Medicare. Dr. Factora is confident this will change when the country moves to a value-based system. When this time comes, he hopes Cleveland Clinic-trained geriatricians will lead the way. “They will show what geriatricians can bring to the table,” he says.
Dr. Hovsepyan says she was surprised to find out how different caring for geriatric patients was. “We assume responsibility for ensuring that a patient is mentally and physically able to comply with medications and instructions, has a safe home environment, is not being abused, and has social support and money for medications.”
After she finishes her fellowship, she hopes to join a practice that understands the importance of geriatric patient-directed care and the time commitment it requires. “Many practices that call themselves geriatric-oriented want a physician to see 20-25 patients a day. This is impossible,” she says. “The assessment of a new geriatric patient takes one hour or more, and we need 30 minute follow-up appointments to address patients’ needs properly.”
Dr. Hovsepyan says the fellowship has given her the skills to provide excellent care for aging adults. “I would not be able to assess geriatric syndrome as thoroughly without this training. It has been so rewarding to do the right thing for these patients.”