For the past several years, I have taught the Final Diagnosis and Management course to adult gerontology primary care nurse practitioner (AGPCNP) students. Last semester, we integrated into this course some geriatric content such as sarcopenia, screening and treatment of tuberculosis in institutional settings, and antibiotic stewardship — and, of course, we have added content on COVID-19. Several of the nurse practitioner students didn’t get any experience in a post-acute or long-term care setting until this spring because of the earlier student/trainee restrictions related to COVID-19.
Although geriatric content is woven into their coursework, I have worried that their limited exposure to older adults during their clinical rotations over the past year may decrease their interest in pursuing a career in geriatrics. Before the COVID-19 pandemic, approximately one-third of the cohort implemented quality improvement projects in PALTC settings; they presented posters at the Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine, and they were introduced and welcomed into the Society. Some of these AGPCNP graduates went on to pursue careers in geriatrics and maintain their membership in the Society. The COVID-19 pandemic has limited these opportunities for the new cohort of students by delaying their exposure to geriatrics.
As we are all well aware, there is a significant shortage of geriatricians and other practitioners and professionals who care for older adults. According to the American Geriatrics Society (AGS), there are only 7,000 geriatricians in the United States, and only half of them are practicing on a full-time basis (“State of the Geriatrician Workforce,” AGS, 2020; https://bit.ly/3u13fdt
). By 2025, AGS estimates that the need for geriatricians will be over 33,000, which will far outpace the available supply given that one-third of geriatric fellowships are not filled. In the United States, approximately 15% of nurse practitioners are employed in PALTC settings (Ann Longterm Care
2015;23:19–24), and their numbers are growing. By contrast, fewer than 1% of physician assistants and 7% of social workers are working in PALTC (E. Salsberg, et al., Profile of the Social Work Workforce
, George Washington University Health Workforce Institute, 2017; https://bit.ly/3evbacc
So what can PALTC practitioners do to improve the pipeline of individuals who are interested in working with older adults? More funding for geriatric fellowships across disciplines, higher reimbursement for practitioners working in PALTC, and mandates to include geriatric competencies in curricula are worthy policy initiatives. But also we can commit to supporting and mentoring future trainees and students and sharing with them the satisfaction that we gain from a career in PALTC.
Training Opportunities in Geriatrics
It is estimated that only 14 hours of geriatrics-focused content is provided across four years of training in most medical schools (J Am Geriatr Soc 2020;68:2117–2122). To overcome this obstacle, some medical schools have adopted scholarly concentration programs. These programs focus on geriatric medicine and provide opportunities for training, mentorship, and the completion of a scholarly project in addition to the basic curriculum. There are nine of these scholarly concentration programs in geriatrics housed in medical schools across the United States. Some of them received their start from internal and external grant funding, and others are supported by geriatric faculty who volunteer their time to mentor the next generation.
Some universities and professional organizations take an interdisciplinary approach to geriatric education in the PALTC setting (MedEdPORTAL 2020;16:11059), and others focus on geriatric interest groups across health care disciplines. Trainees and students identify a variety of benefits of geriatric interest groups, including faculty mentorship, exposure to interprofessional education, opportunities to network and build relationships with future colleagues, and engagement in scholarly projects that help to advance their careers (Can Geriatr J 2020;23:264–269).
The Society’s Futures Program provides an excellent example of how a professional organization’s Foundation supports trainees and students in furthering their education in geriatrics. The Futures Program provides practitioners new to PALTC with not only education but also opportunities to develop relationships with their colleagues and network with leaders in the field. The Foundation Futures column in Caring for the Ages regularly features Futures graduates who have continued their career in PALTC. Two of the Society’s current Board members, Milta Little, DO, CMD, and Suzanne Gillespie, MD, RD, CMD, are both proud graduates of the Futures Program.
In addition to training programs, some employers like the Veterans Health Administration and larger health systems, often with Geriatric Workforce Enhancement grant funding, have created one-year geriatric fellowship programs for advanced practice providers to address the shortage of geriatric specialists. These fellowships for nurse practitioners and physician assistants, which focus on geriatrics and/or palliative care, help with the transition into practice and have become increasingly competitive and prestigious, given their limited availability.
Although geriatrics-focused training programs, fellowships, and interest groups are helpful in recruiting the next generation of practitioners into geriatrics, they are not readily available in all areas. In a 2019 qualitative study of geriatric medicine fellows, mentorship was described as one of the most significant factors in their decision to pursue a career in geriatrics (Gerontol Geriatr Educ 2021;42:38–45). In my experience, you can’t force mentorship, and a few key ingredients help make mentoring relationships successful: shared values and interests, mutual respect, a personal connection, reciprocity, and clear expectations (Acad Med 2013;88:82–89).
I have been fortunate to partner with several great mentors throughout my career as a clinician and a nurse scientist. I was fortunate to be mentored by a geriatrician during my first two years as a nurse practitioner in PALTC. As an adult nurse practitioner, I trained to care primarily for adults aged 40 to 65. Although geriatric content was part of my training, it was limited; I had to request my only clinical rotation in PALTC. Needless to say, I lacked some experience in geriatric prescribing principles and had to learn a lot about geriatric syndromes on the job and through continuing education that was focused on the older adults. Despite my lack of experience, my geriatrician mentor was patient and respectful with me.
She had completed medical school in the United Kingdom and residency and fellowship in the United States. We were both tea lovers and shared our personal connection over afternoon tea on days when a well-deserved break was in order, and we both loved working with older adults. The expectations were clear about when to contact her to consult, and she helped to hone my skills in geriatric assessment and management. In turn, we shared responsibility for the patients in the PALTC facility in terms of acute and regulatory visits. My availability on site helped to decrease her emergency and unplanned visits to the facility. My presence in the facility was able to increase medical representation in patient care plans and family meetings. She also helped me to network with other colleagues and consultants.
I have valued my relationship with all of my mentors, and I try to pay it back by serving as a mentor to others in the field of geriatrics. I know that many Society members have benefited from the mentorship that they have received, and they have gone on to mentor the next generation of PALTC practitioners. Please share some of the lessons you have learned from your mentors and mentees and how these have influenced your career in PALTC.
Dr. Galik is editor in chief of Caring for the Ages
. The views the editor expresses are her own and not necessarily those of the Society or any other entity. Dr. Galik is a nurse practitioner in LTC and community-based settings through a clinical practice with Sheppard Pratt Health System. She is a professor at the University of Maryland School of Nursing, where she teaches in the Adult-Gerontology Primary Care Nurse Practitioner Program and conducts research to improve care practices for older adults with dementia and their caregivers in long-term care. She may be reached at [email protected]
June 30, 2021
In this episode Wayne Saltsman and Elizabeth Galik discuss ethical considerations with COVID-19, mentoring in geriatrics, and Venous Thromboembolism Prophylaxis.