by Jeff Mortimer

When, in 1980, Willard Scott, the affable NBC-TV weather announcer, first began recognizing Americans for the rare achievement of reaching their 100th birthday, he received a handful of letters from centenarians and their families. Today he receives more than 100 letters every month. The number is likely to keep going up: Americans over 85 are the fastest growing segment of the population.

For some, like comedian George Burns, who happily quipped his way to 100, life was a joy almost to the very end, and a continuing source of new one-liners ("I get a standing ovation just for standing!").

For others, becoming their older selves is not so funny, not the triumph of productivity and recognition that Burns experienced to the end. Aging, like so many other factors that influence our physical and mental health, is a very individual thing.

Given the very large numbers of much older Americans on the horizon (it is predicted that within 10 years most physicians will spend half their time caring for older patients), the challenge for those charged with training the next generations of physicians is large indeed. How to teach a young physician, who will not personally experience the profound effects of aging for another half-century, what it means to be old? How to treat the old? How to give older patients the best care possible?

No medical school in America is taking these questions more seriously than the University of Michigan, where geriatrics has had strong leadership for almost 20 years and where a new $2 million grant will energize the weaving of geriatrics into every fabric of the school's curriculum.

"The goal is to see defined curriculum and content in place that is a documented part of the education of every student who graduates from the University of Michigan Medical School and every resident who completes residency training in a relevant discipline," says Jeffrey Halter, M.D. In 1984, William Kelley, M.D., then head of internal medicine at the Medical School, recruited Halter from the Seattle Veterans Affairs hospital to begin assembling the U-M Geriatrics Center, an umbrella organization for geriatrics research, education and patient care in the U-M Health System. The Geriatrics Center was approved by the U-M regents in 1987 and continues to be directed by Halter.

When Alan Mellow, M.D., Ph.D., associate professor of psychiatry and chief of the division of geriatric psychiatry, arrived in Ann Arbor in 1988, the U-M's collective geriatrics consciousness had already been conspicuously ahead of the curve for a decade or more, in the Medical School as well as in public health and the basic and social sciences. Both the Turner Geriatric Clinic and the Institute of Geron-tology have been around since the late 1970s.

"When I came to Michigan to start our program," Mellow says, "I emphasized to my department chairman that this was a 'growth industry,' an area in which it was important for Psychiatry to have strength in the coming years."

The neighboring VA system, a longtime U-M partner in both education and clinical care, had also been selected in 1988, after a national competition, as a site for a new Geriatric Research, Education and Clinical Center (GRECC), one of 21 national centers of excellence in the VA system. A year later, the U-M Pepper Center was launched, the first federally funded Claude D. Pepper Geriatrics Center in the nation.

This rich historical matrix was crucial to the Geriatrics Center's recent successful bid for a four-year, $2 million grant from the Nevada-based Donald W. Reynolds Foundation, established in 1954 and now one of the nation's largest private foundations. Donald Reynolds owned more than 100 businesses, primarily in the newspaper, radio, television and outdoor advertising industries, known as the Donrey Media Group. The money — along with significant support from the Medical School, another key factor in securing the award — will be used to infuse geriatrics consciousness into almost every facet of the medical training the U-M provides. In the process, standardized models will be developed for teaching and testing trainees everywhere else.

"There is a long tradition of interest in aging here at the University of Michigan," says Halter. "For many years, a lot of people across the campus have been interested in aging — the social aspects, epidemiology, the impact on society and on Social Security, in addition to issues directly related to health. The Medical School initiatives that started here in the late 1970s have not been happening in isolation."

Ironically, U-M's tradition was almost a liability in getting the Reynolds grant, says Mark Supiano, M.D. (Residency 1987), director of the GRECC, associate professor of internal medicine and senior associate research scientist in the Institute of Gerontology. Supiano directs the Reynolds grant's geriatrics initiative in medical student education, while Brent Williams, M.D., also an associate professor of internal medicine, heads the comparable effort for house officers. "The Reynolds Foundation was interested in stimulating geriatrics in institutions where there was perhaps less of a geriatrics presence," Supiano says. "One of our concerns was that we were viewed as having too much, and wouldn't need additional funding to support these activities." Michigan's long history of success in geriatrics won the day.

Williams expresses his charge simply and dramatically. "The University of Michigan has around 800 house officers at any given time," he says. "Of those, only about 200 are in programs that include any form of training in geriatrics. The purpose of this project is to move as close to the 800 as we can get." Mellow adds, "The strength of the program we've gotten funded is that it's really going to infuse this at every level of the Medical School curriculum, from the day future physicians walk in the door as medical students up to the time they are out in practice or even on the faculty."

The support of the Dean's Office was also key to receiving the Reynolds grant. "We've had a significant decrease not only in revenues to support graduate medical education but also in clinical dollars that, in the past, would have also been available to support

education broadly. But we really thought it was important for us to make the commitment to invest in this educational enterprise," says James Woolliscroft, M.D. (Residency 1980), executive associate dean, director of graduate medical education and a professor of internal medicine. Woolliscroft notes, as do many others, that "a lot of the credit really goes to Jeff Halter. He came here when geriatrics was just beginning to emerge, and he's developed a very strong section of geriatrics that is recognized internationally."

Faculty development is at the core of the Reynolds initiative, and that work has already begun through faculty training from geriatricians as well as instructors in other specialties and subspecialties (principally internal medicine, psychiatry and neurology) which already include geriatric skills in their training. Those identified as "core" faculty will train their colleagues in other disciplines how to apply geriatrics knowledge to discipline-specific needs. This helps with both instructional credibility — students will be learning from "their own" teachers rather than "outside" geriatricians — and with long-term sustainability.

"This is a huge project," says Karen Hall, M.D., Ph.D. (Residency 1997), an assistant professor of internal medicine and a research scientist at GRECC. Hall is possibly the only person in North America who is board-certified in internal medicine, gastroenterology and geriatrics in both the U.S. and Canada. "We're talking about disciplines as disparate as ob/gyn, emergency medicine and surgical subspecialties, and then medical students from year one to year four. Our hope is, if we can do this successfully, it will get medical students so oriented to geriatric issues that they won't have any problem identifying them, thinking about them and dealing with them. Right now, if you ask most students or residents what it's like to care for an older person, they find it intimidating."

"Attitudes may be the heart of it," says Williams. "If you could open up resident physicians' attitudes so they automatically, reflexively, look at the whole person, where they came from, how they function, what their goals and needs are as a person, then everything else would be easy, because they would ask the right questions and strive to find the answers."

Of course, the desirability of "looking at the whole person" isn't limited to the treatment of elderly patients. Just as the geriatrics initiative is expected to produce exportable instructional models, so geriatrics techniques themselves are applicable to medical practice in general.

"I think part of the Medical School's support for this initiative and what we're planning to do related to the Reynolds grant is that a number of the things we'll be teaching the students about the health care of older people apply to health care more broadly," says Halter. Happily, the grant intersects with, and nicely complements, a three-year review of the Medical School curriculum whose goal is a better alignment with the real world of contemporary practice.

"We're emphasizing to a much greater degree the socio-cultural aspects of the individual and how that relates to their wellness and their care," says Joseph Fantone, M.D., associate dean for medical education and a professor of pathology. "We want our students to think of the patient in the context of his or her social and cultural environment and overall health status."

"Our goal is to provide a meaningful geriatrics experience for every graduating U-M medical student," says Supiano. "We don't want our students to say, 'Yeah, I did a one-week rotation in geriatrics and I now know how to take care of older people.' We want them to gain a real sense of what it means to be a good physician to an older person."

"Geriatrics is inherently patient-centered," says Williams. "The unit of caring is the whole patient, which was the baseline for traditional medicine. Now, in many practices, the unit of caring is an organ system or a practice context, like a single emergency room visit or a single consultation/referral. It can be bound by anatomy or it can be bound by time, but it shifts away from the patient as the center of focus. The Reynolds grant provides an opportunity to do the two things I love most: develop new programs for teaching physicians at the residency level to do better medicine, and teach people to take care of the whole patient."

Also:

Treating Older Patients: Not just 'older versions of younger adults'

How will we know what works and what doesn't?