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LTC Physicians Encourage the Next Generation

2013; Elsevier BV; Volume: 14; Issue: 1 Linguagem: Inglês

10.1016/j.carage.2013.01.001

2377-066X

Joanne Kaldy,

Aging and Gerontology Research

With student loan debts north of $100,000 and feeling pressure to choose an “exciting” specialty, many young physicians dismiss long-term care as a career choice. Yet, those physicians who have embraced the field say that their younger colleagues are missing something special, and these veteran physicians are eager to show off the rewards of long-term care and geriatrics. “We've been successful at attracting physicians out of our residency-fellowship program who didn't originally see this as an option,” said Dr. J. Kenneth Brubaker, CMD, a staff and faculty member of the Lancaster (Pa.) General Geriatric Specialists and chief medical director for the Pennsylvania Department of Aging. Like others elsewhere, Dr. Brubaker has led residents and fellows to long-term care through innovative programs, enthusiastic mentoring, and efforts to dispel myths and misconceptions about caring for elders. Dr. John Voytas, CMD, medical director of Bloomfield Hills Nursing Center in Michigan, noted that the current national focus on health care presents opportunities to discuss long-term care with students and young physicians. “I always start by saying that it's nice to be able to put yourself where there are opportunities,” he said. “There will be more opportunities in what I call ‘true elder care’: caring for those who are 75 to 85 and older. … We need to sweeten the pot when we talk about geriatrics. This includes highlighting the flexibility [physicians] can enjoy and the challenges of caring for the wide array of conditions common in this population.” Dr. Voytas is fellowship program director in the division of geriatrics at William Beaumont Hospital near Detroit, where he often takes on a geriatric fellow and an internal medicine resident at the same time. “The key to training young physicians is to get them to embrace the passion for elder care across the spectrum … and break the myth of what it is to be involved in elder care. The way to do this is to expose them early on to how interesting geriatric practice is. I can tell them that I've had lots of broad experience and know how challenging and exciting this field is.” Once young physicians receive adequate and broad exposure to long-term care, many of them are impressed. Dr. Noel DeBacker, CMD, a multi-facility medical director in the Chicago area and a faculty member at the Northwestern University Feinberg School of Medicine, noted, “The thing students find most fascinating is the quiet revolution that has gone on in nursing homes. These settings are totally different than they were 30 or even 10 years ago, thanks partly to the advent of subacute care and rehab. This has emerged as a much more important area of nursing home medicine, and students are very excited to see this.” It is important to enable and encourage students and young physicians to spend time with patients and families in long-term care, Dr. DeBacker said. Nevertheless, he recommended limiting medical students' contact with demented nursing home residents early in their training. “If students only see patients with advanced dementia, it's easy for them to assume that everyone in this setting is like that,” he explained, “and this certainly isn't the case. Exposure to long-term care residents with dementia needs to be presented in a balanced and sensitive way.” On the other hand, contact with dedicated nursing home staff is almost always positive for physicians in training, according to Dr. DeBacker, “We need to enable students to spend time with the director of nursing, the admissions coordinator, the social worker, the CNAs, and others.” Even when students come to a geriatrics fellowship with no special interest in pursuing the field further, physicians can make the most of this opportunity to inspire these young people. “We try to make the education experience as positive as possible,” Dr. Brubaker said, and sometimes it changes people's minds. “We had a young physician 2 years ago who wanted a geriatrics fellowship to back up his family practice training. Now he runs a geriatrics teaching program,” Dr. Brubaker said. While Dr. Voytas encourages early exposure to geriatrics for medical students, he stressed that it's never too late. ”I did a midcareer geriatrics fellowship, and it was the best thing I ever did. Now I encourage physicians to reinvent themselves in this field,” he said. He noted that the variety of LTC focus areas – from subacute care to hospice and palliative care to research and education – can appeal to physicians seeking a change of scenery. As an experienced physician, Dr. Voytas was especially drawn to the medical director's role. He said, “For me, this was the most challenging and interesting [of] opportunities; it presented a chance to make a real difference.” Financial considerations play into young physicians' career choices, Dr. Voytas acknowledged. “Geriatrics pays less than internal medicine or specialties. It's unrealistic to expect young physicians to say, ‘Okay, I'll take 15% less to care for the elderly.’ We need to increase financial incentives and opportunities.” Easing the debt burden on young physicians is one goal of Northwestern University's DeBacker Primary Care Imperative. It provides scholarships of $25,000 to medical students who choose primary care. “Most physicians who go into long-term care are drawn from the ranks of primary care physicians,” said Dr. DeBacker. “So it makes sense to increase the number of primary care physicians and increase their exposure to subacute [care and] rehab early on. This will increase the number of nursing home and postacute physicians down the road.” Dr. Connie Zong, a 2011 DeBacker scholarship recipient and a postgraduate level physician at Advocate Lutheran General in Park Ridge, Ill., said, “For me, my student loan debt is this amorphous monster hiding in the shadows. This scholarship has eased that burden. It makes the debt seem less tangible.” She said she feels freer now to pursue her passion of working in primary care and promoting preventive medicine. “Addressing student loan debt makes a difference,” said Dr. Brubaker. “It can help bring physicians to the field who have an interest in geriatrics but think that it's not financially feasible.” He added that experienced physicians can help their young colleagues directly by providing support and resources on business planning, reimbursement, and billing and coding. “Newer physicians don't always know what they can bill for. We need to be prepared to help young doctors understand issues such as the RVUs and so on.” Dr. DeBacker said that the scholarship program isn't only about money. It also is designed to enhance the primary care education experience. “Our goal is to introduce high-impact primary care education sooner to students,” he said. “To accomplish this in a way that is both meaningful and effective, we want to devote our most exceptional primary care educators to this effort for mentoring, role modeling, small group learning, and substantive interactions with students and patients in the primary care setting.” The program therefore provides salary support to educators for their time with students, Dr. DeBacker said. “If this model catches on at other universities, it could have the potential to be part of a national solution.” Even if they aren't affiliated with a medical school, university, or some other organization with deep pockets, medical directors can do much to help attract young physicians to long-term care, Dr. DeBacker suggested. “Reach out to program directors at area medical schools and hospitals with residency programs and tell them about what is happening in long-term care. Often, because they don't spend time in this setting, they don't understand long-term care medicine. Once they have this information, they are better equipped to determine and dedicate resources to allow for nursing home education.” Even those medical directors who already have a relationship with area schools shouldn't assume that program directors understand or appreciate long-term care medicine, Dr. DeBacker cautioned. Dr. Voytas suggested, “If you have an opportunity for even just one fellow for a couple of weeks out of the year or to have a student spend some time with you, take advantage of it. I know it takes time, and they may not go into geriatrics right away, but don't be surprised if 5 years down the road one of them calls to thank you.” He added, “It is so rewarding to have someone tell you that this experience made a difference and changed the direction of his or her career.”