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Geriatrics and Gerontology Education

Introduction


The University of Wisconsin (UW) Division of Geriatrics and Gerontology and the Madison Veterans Affairs (VA) Geriatric Research, Education and Clinical Center (GRECC) have worked collaboratively for over 18 years to promote excellence in education, clinical care, and research to improve the health of older adults. The following sections describe the programs sponsored by the UW and VA to accomplish the major goals of the Division of Geriatrics.


Education


The UW Division of Geriatrics and the Madison VA GRECC faculty sponsor educational programs at the UW School of Medicine and Public Health that integrate interdisciplinary principles of Geriatric Medicine into undergraduate, graduate, and continuing medical education. These educational programs are designed to improve the health of older adults by providing training in 1) the approach and care of older adults, 2) the identification of unique presentations of disease in older persons, 3) differentiating disease states from "normal aging", 4) managing geriatric syndromes, and 5) clinical research in aging and aging-related diseases. In addition, our faculty members work closely with undergraduate students as well as advanced practice trainees in social work, nursing, physician's assistant training, and physical therapy. Our educational focus is to provide innovative and effective means for clinicians of all disciplines to be competent in the care of older persons. Acknowledging that only a small percentage of all health professionals will specialize in geriatrics, we look to infiltrate geriatric principles across different levels of training and within multiple care settings. In most cases this is accomplished by integrating teaching into existing educational programs and into the context of practice as appropriate to the learner. We also recognize the need to expose students to those older adults who are aging well and remaining functional in the community. Meeting learner needs and providing for learner choice are key ingredients in maximizing utilization and program success.


Medical Student Training in Geriatrics
There is a continuum of professional growth between medical school, residency and practice in which the evolving physician achieves progressively more sophisticated competencies. In order to influence the attitudes of physicians-in-training, we have created a number of experiences that span the four years of the medical school curriculum.

These offerings include:


The Geriatric Interest Group (GIG): Creation of this group four in the 1990's gave students in all four years of medical school a formal framework in which to collaborate, develop, and validate their interest in geriatrics as an area of medical practice. The GIG continues to be a forum for interprofessional education and is comprised of between 15 to 20 active members across 4 health disciplines (medicine, nursing, pharmacy and PAs) who serve as geriatric champions amongst their peer groups, and develop a number of class-wide initiatives that relate to seniors. Dr. Barczi and Dr. Irene Hamrick supervise and advise the student leaders of this group.

Women in Medicine Mentoring Forum: Molly Carnes, MD, MS, has created this forum for first- and second-year women medical students to discuss and consider career options for women faculty in academic medicine.
Geriatrics in the Hospital Setting on the Acute Care for Elders Consult Team: Dr. Elizabeth Chapman oversees this 2-4 week experience for 3rd and 4th year medical students. This may occur during the 3rd year Medicine Clerkship or as part of the 4th year. This interdisciplinary team provides consultation to the entire University of Wisconsin hospital serving a population of vulnerable and medical complex hospitalized older persons. It incorporates a proactive approach that emphasizes patient safety, deprescribing and strategies to minimize functional losses.
Geriatrics Fourth-Year Elective: A four-week ambulatory and community-based experience exists for medical students with a specific interest in geriatrics. This rotation is directed by Dr. Barczi and includes involvement in UW and VA clinics in both geriatrics primary care, and geriatrics specialty clinics (12 different options) as well as visits to area assisted-living sites, nursing homes, and patient homes.

Research Mentoring for Medical Students: The VA GRECC and the UW Division of Geriatrics have supervised MD-PhD students for over 10 years. Additionally, the UW Clinical and Translational Research Core (formerly known as GCRC) and other university-based summer fellowship programs have sponsored medical students to work in laboratories within the Division of Geriatrics, such as: Dr. Carnes (National Center for Excellence in Women's Health), Cindy Carlsson, MD, MS, (Alzheimer's disease prevention), Sanjay Asthana, MD (treatment of Alzheimer's disease) and many other investigators within the Wisconsin Alzheimer's Disease Research Center. Drs Carlsson and Mahoney offer a medical student Summer Externship for research at the Wisconsin Alzheimer's Institute.

Residency Training in Geriatrics


Geriatrics Ambulatory Rotation for Internal Medicine (IM) Residents: Two to three residents rotate through this experience per month. This experience provides an exposure to the continuum of geriatric care services within the clinic, hospital, nursing home and community. Based at the VA Hospital, University of Wisconsin Hospital and Clinics and Madison Community, this rotation balances a primary care and specialty focus with a strong emphasis on interdisciplinary teams. Housestaff rotate through the following specialty clinics: Osteoporosis, Geropsychiatry, Geriatrics Evaluation and Management (GEM), Memory Assessment, Geriatric Sleep, Geriatrics Palliative Care and GRECC Connect (a geriatric telemedicine program). They are mentored in geriatric primary care clinics at 3 sites. They also spend time at the teaching nursing home at Capitol Lakes Continuing Care Retirement Community and on the Acute Care for Elders (ACE) team at the UW Hospital. Housestaff all particpate in Observed Structured Clinical Exams that use standardized patients with faculty observation and feedback to hone their skills in addressing cognitive impairment, late life depression and falls/ immobility. The Wisconsin STAR method, an educational tool promoting a systematic approach to complex geriatric patients, is introduced as an evaluation method for older patients.
Continuity Clinics in Geriatric Medicine: A select number of IM residents choose to have two-year continuity clinics within the UW and VA primary care geriatrics clinics. They are mentored by a primary care geriatrician and become part of these outpatient geriatric interdisciplinary teams.
Geriatrics Elective for IM and Family Medicine Residents: This one-month rotation tailors experiences in 1 of 3 tracks for second- and third-year residents with a particular career in geriatric medicine. These domains include community geriatrics, long-term care and geriatric specialty care.
 

Academic Fellowship Training in Geriatrics

Fellows with interest and aptitude can receive up to three additional years of training in research methodology, teaching, education administration as well as complete course work for a Masters in Population Health Sciences and Clinical Research. This mentored time allows trainees to partake in the rich research opportunities described above with an objective to produce independently-funded physician-scientists or clinician-educators. Historically this support occurs via two geriatrics-focused NIA T32 training grants (PIs: Drs. Asthana, Carnes), a VA fellowship in Older Women's Health (PI: Carnes), an Advanced VA Geriatrics Fellowship and a Palliative Care Fellowship supported by the Madison GRECC. As a testament to the high quality of geriatric fellowship training at UW, many of our past fellows have been awardees of prestigious career development grants including those from the Hartford/AFAR Foundations, Merck/AFAR, intramural UW Medical School grants and the Beeson Award. Ongoing sources of support are continually sought to provide a seamless training experience. Mechanisms also exist in the Division for further support as junior faculty in the form of two K12 grants from the NIH held by Dr. Carnes; an NIA Women's Health and Aging Clinical Scholar Development Program, and a Training and Education to Advance Multidisciplinary Clinical Research (TEAM) Program, 1 of only 6 grants funded in the country as a part of the NIH Roadmap Initiative.

Geriatric Psychiatry Fellowship Training

The UW and Madison VA GRECC Geriatric Medicine Fellowship Program has had a longstanding close alliance with Geropsychiatry faculty and trainees for over two decades. Under the leadership of Timothy Howell, MD, the Madison VA GRECC sponsors up to two geropsychiatry fellows annually who participate in training experiences in the VA Memory Assessment Clinic and other Madison GRECC-sponsored clinics. In turn, Geriatric Medicine fellows rotate through the Geriatric Psychiatry clinic. Geropsychiatry faculty direct the case-based Geropsychiatry Colloquium for Geriatric Medicine and Geropsychiatry fellows twice monthly. These collaborative relationships have provided a rich training experience in neurobehavioral disorders for Geriatric Medicine and Geropsychiatry fellows alike.

Geriatric Training for Other Health Disciplines

Geriatric Medicine faculty members also invest considerable time in the training of many other health disciplines in the context of course work and experiences in our geriatrics clinics. Social Work graduate students (6-8 per year) regularly complete field work in our VA geriatrics clinics. Our Division provides a series of eight lectures for all physician's assistant students within the Department of Family Medicine and mentors some of these students in our clinic. Many of our geriatricians and fellows teach in the Nurse Practitioner's graduate clinical seminars series. Robert Przybelski, MD, MS, provides geriatric instruction to over 200 emergency medical technicians for the City of Madison. He also trains over 20 paramedics each year in the principles of geriatrics in three-hour block experiences within our geriatrics clinics. Physical therapy, occupational therapy and speech and language pathology students regularly rotate on our geriatrics teams at the VA Hospital. Drs. Asthana, Atwood, and Carlsson have all mentored undergraduate students through the Undergraduate Research Scholars (URS) Program, a program working to improve the diversity of students represented among researchers across the UW campus. As a part of the Pathology 751 course, physician-researchers from the Division direct teaching sessions linking the pathology of AD with clinical presentation, further promoting translational research endeavors. Additionally, Dr. Carnes co-directed a new course this past summer with Professor Karin Kirchhoff in Nursing on Clinical Research Evidence. This course, taught in conjunction with the Health Sciences Library staff, instructed students how to perform systematic searches of clinical research evidence. Thus, overall, the geriatrics faculty at the UW is extensively involved in providing aspects of geriatrics training to allied health professionals.

Clinical Care

The UW Division of Geriatrics supports a nationally-recognized, comprehensive clinical program that provides a variety of primary and subspecialty care services to older adults. Its 17 fellowship-trained geriatricians work closely with geriatric psychiatrists, advanced practice nurses, neuropsychologists, psychologists, social workers, physical therapists, and occupational therapists to provide comprehensive clinical care to older adults. For over 26 years, the program has served the needs of aging adults in the community and throughout the State of Wisconsin. The primary clinical mission of the Division is to deliver exceptional geriatric specialty care, primary care and hospital-based services as it works alongside other world class clinical programs within the UW system. The strong links between the aging research and clinical programs provide distinctive translation of state-of-the-art, compassionate care to all of our patients and their families.

Our services span across a continuum of care settings including clinics, hospitals, homes, assisted-living facilities and area nursing homes. The Division staffs and manages an inpatient geriatrics unit at the University of Wisconsin Hospital (UWH). Given that hospitalizations can be landmark events in the lives of older persons resulting in a transition from health to frailty, the geriatric unit seeks to aggressively minimize these negative events and improve the functional trajectory of the older patient. The Division also provides Geriatric Consultation for inpatients at the UWH. It has recently initiated an innovative Acute Care for the Elderly (ACE) Consultation Service that serves at-risk older adults hospitalized in the UWH. Under the leadership of Dr. Mike Siebers, a senior geriatrician with acknowledged expertise in primary care geriatrics, this ACE program is actively evaluating patients at the UWH.

The Geriatrics Division supports outpatient clinics at four UWH clinics located within Madison: Oakwood Village, University Station, UW Clinic-East and UW Clinic-West. This network of geriatric-specific clinics is unique within the Midwest. We aim to provide holistic care that places equal emphasis on disease management, functional rehabilitation, prevention and, when necessary, end-of-life support. Our primary care extends into the community as we serve homebound seniors through the Wisconsin Care Partnership Program. We also meet the special care needs of those who reside temporarily or long-term in area nursing homes. Several of our geriatricians (Drs. Barczi and Siebers) either serve as nursing home directors or consultants in facilities in the Madison area.

Our clinical program boasts a spectrum of subspecialty emphasis clinics that distinguishes it from the majority of geriatric programs throughout the country. All of these clinics incorporate a multidisciplinary team approach to address the physical and psychological dimensions of common age-associated conditions. For example, "Bone Health and Osteoporosis Services," in conjunction with the Department of Medicine Division of Endocrinology and Metabolism, are offered at the West Clinic. Likewise, several "Comprehensive Memory Assessment Clinics" are held each week and a "Falls and Mobility Clinic" addresses this important issue. Interdisciplinary support in pharmacy, nursing, physical therapy, neuropsychiatry and social work is available at clinic sites as needed for each of the subspecialty emphasis and primary care clinics. Further, UW hospital-based clinics exist in geriatric sleep and dysphagia/swallowing disorders.

There are also consultative services available for geropsychiatry and a wide range of medical and surgical specialties. Noteworthy among the subspecialty groups is a close collaboration with the Wisconsin Comprehensive Cancer Center (UWCCC) and the Cancer and Aging Program (PI: Weindruch) funded jointly by the National Cancer Institute (NCI) and the National Institute on Aging (NIA). One of our geriatricians (Drs. Barczi) has expertise in managing symptoms and optimizing comfort in advanced, incurable illnesses.

The Division of Geriatrics is home for three centers of the UW School of Medicine and Public Health: the Center of Excellence in Women's Health, the Wisconsin Alzheimer's Institute (WAI) and the Hartford Center of Excellence in Geriatric Medicine and Education. All of these centers were founded by and are presently lead by Division faculty (Drs. Carnes, Sager). Under the supervision of Mark Sager, MD, the WAI sponsors a network of 30 Dementia Diagnostic Clinics distributed throughout the State of Wisconsin that provide state-of-the-art evaluation of cognitive impairments seen commonly among the elderly.

The VA GRECC is a National Center of Excellence for care of older adults within the VA Healthcare System. At the VA Hospital, there are both inpatient and outpatient geriatric consultations. The GRECC also sponsors outpatient primary care and subspecialty emphasis clinics for older veterans. Subspecialty emphasis clinics include Geriatric Evaluation and Management (GEM), Osteoporosis, Memory Assessment, Geriatric Sleep, Geropsychiatry, Palliative Care, Musculoskeletal, and Older Women's Health. The GRECC is the home of an innovative and nationally-recognized, Swallowing Disorders Program with a very active clinical component. The Palliative Care Consult Team at the VA is supported in part by GRECC-based geriatricians. The GRECC has outstanding support services in Rehabilitation and Physical Medicine where driving, gait and other functional evaluations are routinely performed under the supervision of occupational and physical therapists. Pharmacy support is also available for the elderly population.


Steven Barczi, MD
Director, Geriatric Medicine Fellowship
Associate Director-Clinical, Madison VA GRECC
University of Wisconsin School of Medicine and Public Health
GRECC Phone: (608) 280-7000
Voice Mail: (608) 256-1901 ext 11696
Fax: (608) 280-7291
Pager: 265-7000 ext 4852