Centers of Excellence in Geriatric Medicine and Training

Centers of Excellence: Support for Clinician Education

Paradoxically, clinician educators-academicians focused on training the next generation of doctors-have not always had good career paths at most American teaching hospitals. Promotion pathways have historically been based on a basic science paradigm, which requires academicians to acquire grant funding for their research and to publish. Almost by definition, this paradigm precludes clinician educators from professional advancement as their work was not of central interest to promotion and tenure committees. Another part of the uphill battle for clinician educators is the requirement that they support 100 percent of their salary by seeing patients-a recipe for burnout when added to the demands of teaching.

Starting in the early 1990s, many medical centers began to develop career tracks for clinicians interested in education, with geriatrics often leading the way. These clinician educators not only teach but also devise new educational paradigms to improve geriatrics education. The challenge has been to make this career pathway parallel to the scientific research pathway and to avoid second-class citizen status for clinician educators.

For the Hartford Centers of Excellence, the introduction of formal clinical-educator career tracks has allowed them to expand the teaching of medicine for older patients. At Boston University, Dr. Rebecca Silliman and her colleagues use the Hartford Center of Excellence funding to train clinician educators who are not geriatricians. "There's a great need to train clinicians in other specialties about geriatrics, so they will not only be better providers but also better teachers," says Dr. Silliman.

Center of Excellence funds support fellows and junior faculty as they train to become clinician educators. Funds can also be used for curriculum development. The Mount Sinai School of Medicine Center of Excellence is committed to making the clinician educator career path more attractive and viable. "We have used the Center of Excellence to develop a cadre of physician educators who are well respected and who deliver geriatric content throughout the institution," says Dr. Rosanne Leipzig.

Bringing Geriatrics Education to a Department of Family Medicine

When Laura Goldman, MD, joined the Department of Family Medicine at Boston University in 1998, “no one was focused on geriatrics and there was no one to head up the geriatrics program,” she says. In addition, the department wanted to set up a nursing home practice. “This was an experience we felt was essential for training our residents.”

Laura Goldman, MD with Viviana Ionescu-Tiba, MD, Boston University, Boston, MA . As Director of Geriatrics in the Department of Family Medicine, Dr. Goldman transitioned from clinician to expert faculty with Center of Excellence support. Today, she champions geriatric content within the medical curriculum.

Before coming to Boston University, Dr. Goldman had been in clinical practice for 16 years. But she lacked expertise in geriatrics. To gain the geriatric-focused training she needed, Dr. Goldman became a Center of Excellence in Geriatrics Faculty Scholar. “This was not only an opportunity to fill a niche for my department, it took my career off in a different direction,” she says.

Today Dr. Goldman is the Director of Geriatrics in the Department of Family Medicine, where she designs and teaches the geriatrics curriculum for the pre-doctoral and residency programs, and she directs the department’s nursing home practice. After attending the Stanford Faculty Development Program, where she trained in teaching geriatrics in primary care, Dr. Goldman now teaches these seminars to second-year residents. “I’ve been focusing all of my efforts towards becoming proficient in geriatrics,” she says.

When a new textbook was adopted for the third-year family medicine clerkship, Dr. Goldman was astounded to discover that the textbook contained nothing about geriatrics. She and her colleagues immediately went to work to add reading material about geriatrics to the curriculum. “We take care of a lot of older people, so this is absolutely necessary,” she says, adding that “the Center of Excellence experience gave me the legitimacy and the contacts to influence the curriculum in this way.” 

Since Dr. Goldman first arrived at Boston, the Department of Family Medicine has come a long way in it’s commitment to geriatrics. From having essentially no focus on it at all, the department now sees geriatrics as an area of growth and seeks to recruit more geriatricians. “Our nursing home practice took off instantly,” says Dr. Goldman, so this has been an area of growth as well.

“It’s been very fulfilling for me as a midcareer faculty member to have the opportunity to change course and do something new and different,” she says. “It’s almost a luxury for a doctor to be able to focus on learning and teaching.”

Mount Sinai's Geriatric Education 'Czar'

During his medical residency training in 1994 at Englewood Hospital and Medical Center in Englewood, New Jersey, Rainier P. Soriano, MD, saw nursing home patients admitted to the hospital with severe pressure ulcers and an array of ailments that discouraged him from desiring a career in geriatric medicine. Today, as Assistant Professor of Geriatrics and Director of Medical Student Education in the Brookdale Department of Geriatrics and Adult Development at the Mount Sinai School of Medicine, he’s not only committed to geriatrics but also intent on integrating geriatric content throughout the pre-existing medical school curriculum at Mount Sinai. Dr. Soriano attributes this transition and his change of perspective to a move to Mount Sinai School of Medicine and to his year as a Hartford Foundation Center of Excellence scholar.

Rainier P. Soriano, MD, Mount Sinai Medical Center, New York, NY, with 2nd year medical students. Dr. Soriano, a Center of Excellence in Geriatrics Faculty Scholar, successfully lobbied to change grading guidelines to increase the weight of geriatrics in students' medical clerkship marks to better reflect patient demographics.

When he first arrived at Mount Sinai School of Medicine, Dr. Soriano planned to use his geriatrics fellowship training to pursue his goal of becoming a director of a fellowship program. During his second fellowship year, he received a Hartford Center of Excellence grant and used the financial support to attend the Stanford Faculty Development Program in Palo Alto, California, which teaches clinical teaching skills. “Once you’ve attended the program, you then return to your academic institution and use the skills you’ve learned to teach others how to teach,” says Dr. Soriano.

This proved to be the catalyst for a change in career plans for Dr. Soriano. On returning to Mount Sinai, he turned his focus to teaching medical students and, in particular, to making sure they receive a healthy dose of education and training in geriatrics. In 2000, he took advantage of a change in the medical school curriculum to help design a new Integrated Medicine-Geriatrics Clerkship for third year students. He successfully lobbied for a change in the grading system as well, carving a larger role for geriatrics in determining students’ marks. Prior to the change, medicine was an 8-week program taught in the third year and geriatrics was a 4-week program in the fourth year. “Teaching geriatrics in the fourth year sometimes feels like a lost cause,” says Dr. Soriano. “The students have already matched to their desired residencies and learning geriatrics is not their top priority,” he says.

The new 12-week integrated clerkship he helped to create is a win-win situation for geriatric education at Mount Sinai. “Medicine is one of the most important core clerkships,” says Dr. Soriano. “Every student wants to get an honors grade in medicine so they will have a better chance of obtaining the residency that they want.” Geriatrics now contributes one-third to the grade, so every medical student who wants an honors grade in medicine must also do well in geriatrics.

Dr. Soriano also teaches in the preclinical years, and he directs the Introduction to Clinical Medicine/Physical Diagnosis course for second years, called The Art and Science of Medicine II. In this capacity, he is able to incorporate geriatric principles early in the medical school training. Dr. Soriano also teaches a course in practical teaching techniques for fourth-year medical students. “We use geriatrics content in this course, which is my way of reinforcing geriatric principles to fourth year students while also imparting teaching skills that they can use in their residency,” says Dr. Soriano.

“With the support from the Hartford Foundation, I was able to gain additional training in medical education and the accompanying skills for effectively disseminating geriatrics into the medical school curriculum,” says Dr. Soriano. Rosanne M. Leipzig, MD, PhD, Vice Chair for Education, and Director of the Hartford Center of Excellence at Mount Sinai School of Medicine jokingly refers to him as the ‘czar’ of geriatric medical student education at Mount Sinai.

"The Hartford Centers of Excellence program is unique in that it recognizes that in the field of geriatrics, education is just as important as clinical care and research," says Dr. Soriano. "It's refreshing to get support for what you do as a clinician educator in geriatrics."