RAMS Geriatric EM Roadmap

Geriatric EMERGENCY MEDICINE Geriatric Emergency Medicine (GEM) is a complex and exciting field that is rapidly advancing to improve care for older adults, often defined as those aged 65 and older.

MED STUDENT (MS3/4)

JUNIOR RESIDENT

background

Senior RESIDENT

Resources

AUTHORS: Mejbel Alazemi, Natalie Elder, Shan Liu, Katie Davenport, Katherine Hunold Buck Welcome to the Geriatric Emergency Medicine Roadmap, your definitive step-by-step guide on how to succeed in Geriatrics at every training level. Don’t know where to start? Click on “Background” or select your training level above. A full list of fellowships, conferences, and podcasts can be found in “Resources.”

For pearls of wisdom from faculty and residents in the trenches, click on “Insider Advice.”

FELLOW

insider Advice

1 - SENIOR MEDICAL STUDENT MS3/MS4 Identifying an interest in geriatrics early gives you an advantage. There are a few steps you could take during medical school that will help you reach your dream Geriatric Emergency Medicine career.

• C onsider doing an elective in geriatrics. Electives in geriatric EM or an away EM elective at an institution that has a Geriatric ED and/or Geriatric EM academic faculty may be helpful.

• Finding a mentor early on who will guide and support you through your exciting journey is imperative. This is a relatively small subspecialty of EM, so you may need to identify a mentor who is a geriatrician or palliative medicine specialist.

• Work with your mentor to identify a small quality improvement project that you can lead in the field of Geriatric EM or an existing research project on which you can participate.

• Apply for the Medical Student Training in Aging Research (MSTAR) Program where, you will have the opportunity to carry out geriatrics research with top experts in the field. Although this program is commonly done between MS1 and MS2, a few students have done it as an elective during MS4.

• Consider getting involved on the national level. SAEM’s Academy of Geriatric Emergency Medicine (AGEM) has an Executive Board position for a medical student each year. They also offer scholarships to medical students to attend the Annual Meeting. This is an invaluable networking and learning opportunity!

• Consider joining the geriatric interest group at the American Academy of Emergency Medicine (AAEM).

• Consider joining and attending the ACEP Geriatric Emergency Medicine Section (GEMS) meetings where you can learn about the field, contribute, and network.

Choosing the right residency

• R esidency programs with an accredited geriatric fellowship, geriatric ED accreditation and/or geriatric emergency medicine academic faculty are the ideal environment to nurture your enthusiasm for the specialty and will have structure to support your interest and development.

My dream program does not have a strong geriatric training, what should I do?

• S eek out opportunities! For example, you could do a geriatrics elective at your home institution or as a visiting resident; collaborate on research with those within your department or geriatrics at your institution, or collaborate with those at other institutions.

• Network on a national level during SAEM and ACEP meetings.

• Consider an EM elective at an institution that focuses on Geriatric Emergency Medicine.

• Consider a Geriatric EM fellowship for additional training after EM residency.

2 - JUNIOR RESIDENT Although it is important to focus on succeeding and achieving the competencies required in residency, setting a career goal early on will aid you during residency and jump-start your career. You are required to do a residency QI project, a scholarly project, and an education presentation, so why not do them all on geriatric topics?

• M ost if not all residencies have resources available for you as a resident; learn about the geriatric EM resources available at your institution. Connect with potential mentors early to discuss your career aspirations and develop a plan during residency.

• A residency QI project could be something as simple as reviewing the weekly conference topics to assess if all the Geriatric topics are covered during your training, or working with your social workers and case managers to develop packets of information for caregivers of patients with dementia.

• I f you do not have sufficient resources or mentorship at your institution, consider getting involved in SAEM’s AGEM or ACEP’s GEMS. These groups have fantastic resources and members eager to help!

• Seek out opportunities to be involved in geriatric EM quality improvement or research projects.

• W hen given the opportunity to present a topic during didactics in residency, consider choosing a topic that incorporates older adults.

• I f you have not already, join SAEM’s AGEM and ACEP’s GEMS. Depending on your goals, the American Geriatrics Society may also be a good organization and has a subsection for interdisciplinary members and junior members.

• Apply for the AGEM resident member scholarship and the medical student and resident position on the AGEM executive board.

• I f your residency schedule allows, consider attending or even presenting research at SAEM or ACEP. This will also give you the opportunity to attend the AGEM and/or GEMS meeting and meet the national leaders in geriatric emergency medicine.

• A s you become involved in geriatric EM, think about what you want your career to look like. For example, do you want to be a geriatric EM researcher, the director of a geriatric ED, both, or something else? Talk with your mentors early as preparing your CV for your next application should be tailored to this goal. It will also help you decide which fellowship is right for you (see Fellowship section).

3 - SENIOR RESIDENT Continue with your enthusiastic involvement in the field of geriatric emergency medicine.

• Y ou now know how your ED functions. Are there important geriatric screening tools or other elements of the geriatric ED guidelines that you could help implement or improve in your ED? • C onsider an elective rotation in geriatric EM or geriatrics. A two-week internal medicine geriatrics elective can be a great refresher on the challenges our older patients have after an ED visit.

• C ontinue your QI and research efforts. Consider applying for a grant to continue your own research during or after residency.

See below under resources for a list of potential grants; importantly, there may be new opportunities or opportunities not included on this list.

• F inalize your plans for your next step. Learn about the application process and start to prepare your CV. Be sure that your CV is organized to show your interest and work in this area.

• A n overview of the fellowship is available through Emergency Medicine Residents’ Association. A directory with a list of the fellowships approved by SAEM is available here

4 - FELLOWSHIP Length of Fellowship:

1-2 years depending on the program with the possibility of completing an advanced degree in the 2-year program.

Accreditation:

Most geriatric EM fellowships are accredited by SAEM. They are not ACGME-accredited and therefore do not have a match

Application

• E ach program has a different application process. Check their websites and reach out to their contacts early to make sure you are prepared. Make sure you check the due dates carefully as they can vary.

• There is no limit to the number of applications you can submit, so consider applying to all programs you would be happy to attend if offered a position.

• Identify your ideal career goals as this will help you choose the right program.

• Work with your mentors to finalize your CV. Hopefully you have been involved in geriatric emergency medicine as a resident and your CV reflects your interest and dedication.

• Choose your letter writers carefully and ask those who know you well and support your aspirations.

Career Options After A Fellowship

Graduates of geriatric EM fellowships have many exciting career opportunities. These include: • Clinical activity – Working clinically in an ED while focusing on care for older patients.

• Education – Teaching geriatrics concepts to students, residents and clinicians in EM. • Research – Advancing the science of GEM. Administration and Service – Leading clinical, education and research programs.

• Administration – As more EDs are accredited there is an increasing need for geriatric ED medical directors and geriatric focused administrators Note: ACGME accredited geriatric fellowships are offered by the American Board of Internal Medicine and Family Medicine. Emergency Medicine applicants are generally not offered training in these programs. However, there is such a dearth of geriatric trained physicians that you may find yourself offered hybrid positions that include running inpatient geriatrics consultation teams or nursing home director positions. Just as EM-critical care dual-trained physicians decide where best to use their skills, you may have the opportunity to customize your career in interesting ways.

5 - BACKGROUND Why Geriatric Emergency Medicine?

The geriatric population is growing dramatically in the United States (US) and is expected to grow to more than 70 million in 2030 due to increased life expectancy and the aging of the “baby boomer”1 generation. According to the Centers for Disease Control, older adults comprised 15% of emergency departments (ED) visits in 2011 and are projected to increase to 33% by 2030.15 These patients have longer length of stays in the ED, typically require more tests, and have a higher risk of medical complications and functional decline after an ED visit2-6. Among ED admissions, 43% are older adults, and geriatric patients comprise 48% of all intensive care unit admissions.18 Compared to younger adults, older adults:16-20 • U se more medications • R espond to medications differently due to altered pharmacokinetics • A re more likely to have atypical presentations of disease • M ore commonly suffer from some degree of cognitive impairment • M ore frequently have adverse outcomes and readmissions after discharge from the ED In response to this great need, there are national and global collaborations to create ED environments filled with the necessary expertise and resources for this population.

History of Geriatric Emergency medicine Geriatric Emergency Medicine is a relatively young sub-specialty within Emergency Medicine. The first two geriatric EDs were established in the US in 200814. Since then there has been a substantial emergence of approximately 130 self-proclaimed geriatric EDs. In 2013, a joint group with representatives from the American College of Emergency Physicians (ACEP), The American Geriatrics Society (AGS), Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM) published a set of guidelines for geriatric EDs14 with the purpose of consolidating and highlighting the elements necessary for appropriate care of the ill or injured older adult patient in the ED. The Geriatric ED Guidelines are now the basis for formal Geriatric ED Accreditation through ACEP. Geriatric Emergency Department Accreditation (GEDA) aims to verify and oversee EDs that are providing outstanding care in accordance with the Geriatric Emergency Department Guidelines. Similar to Trauma Centers, EDs can receive one of three levels of accreditation based on how many of the 27 quality improvement protocols are followed. The protocols start with pre-hospital

Continued

care, ED care and equipment, and transition to outpatient care. Level 3 requires at least one MD/DO and one nurse who are focused on the treatment of older adults. Level 2 and 3 accreditation signifies more geriatrics protocols, personnel and expertise have been implemented in addition to a research program. For more in depth info refer to GEDA Guidelines. To date, over 100 geriatrics ED have been accredited.

The rapid development of Geriatric EM spans across the globe. The European curriculum in geriatric EM was published in 2016 by the European Society for Emergency Medicine (EuSEM) and the European Union of Geriatric Medicine Society (EUGMS). The main purpose of the curriculum is to define the expected competencies of ED and geriatric services in the EM setting.9 There are also several international EM conferences that include Geriatric EM content.

The Future of Geriatric Emergency Medicine?

Geriatric EM has a bright future and is looking for young talent. There is significant need for targeted clinical care quality improvement initiatives, geriatrics-focused research and improved education initiations. Your medical center may have a Geriatric EM specialist to guide you. Take a look at the membership of the SAEM Academy of Geriatric Emergency Medicine or review the list of Geriatric EDs at https://www.acep.org/geda/.

REFERENCES 1. Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine. Retooling for an aging america, building the health care workforce. 1st ed. Washington, DC: National Academic Press; 2008:316.

12. Lowenstein SR, Crescenzi CA, Kern DC, et al. Care of the elderly in the emergency department. Ann Emerg Med 1986;15:528-535.

2. Baum SA, Rubenstein LZ. Old people in the emergency room: age related differences in emergency department use and care. J Am Geriatr Soc. 1987;35:398-404.

14. Rosenberg M, Carpenter CR, Bromley M, et al. Geriatric Emergency Department Guidelines. Ann Emerg Med 2014;63: e7-e25.

3. Singal BM, Hedges JR, Rousseau EW, et al. Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients. Ann Emerg Med. 1992;21:802-807 4. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: projections from a multicenter data base. Ann Emerg Med. 1992;21:819-824 5. Strange GR, Chen EH. Use of emergency departments by elder patients: a five-year follow-up study. Acad Emerg Med. 1998;5:11571162 6. Denman S, Ettinger W, Zarkin B et al. Short-term outcomes of elderly patients discharged from an emergency department.J Am Geriatr Soc 1989;37:939–943 7. Carpenter CR, Griffey RT, Stark S, et al. Physician and Nurse Acceptance of Geriatric Technicians to Screen for Geriatric Syndromes in the Emergency Department. West J Emerg Med. Dec 2011;12(4):489-495.

8. https://www.reliasmedia.com/articles/142344-three-tier-accreditation-process-for-geriatric-eds-is-on-the-launch-pad. 2018. Three tier accreditation process for geriatric eds is on the launch pad. [ONLINE] Available at: https://www.reliasmedia.com/articles/142344three-tier-accreditation-process-for-geriatric-eds-is-on-the-launch-pad. [Accessed 1 December 2018].

9. Conroy, S, 2016. The development of a European curriculum in Geriatric Emergency Medicine. European Geriatric Medicine, [Online]. 7, 315-321. Available at: https://www.sciencedirect.com/science/article/pii/S1878764916300298 [Accessed 30 November 2018].

13. Sanders AB. Emergency Care of the Elder Person. St. Louis MO: Beverly Cracom Publications; 1996.

15. Wilber ST, Gerso LW, Terrel KM, Carpenter CR, Shah MN, Heard K, et al. Geriatric emergency medicine and the 2006 Institute of Medicine reports from the Committee of the Future of Emergency Care in the U.S. health system. Acad Emerg Med 2006;13(12):1345-51 16. Carpenter CR, Bromley M, Caterino JM, Chun A, Gerson LW, Greenspan J, et al. Optimal older adult emergency care: Introducing multidisciplinary geriatric emergency department guidelines from the American College of Emergency Physicians, American Geriatrics Society, Emergency Nurses Association, and Society for Academic Emergency Medicine. Acad Emerg Med 2014;21(7):806-9.

17. Strange GR, Chen EH. Use of emergency departments by elder patients: A fiveyear follow-up study. Acad Emerg Med 1998;5(12):1157-62.

18. Strange GR, Chen EH, Sanders AB. Use of emergency departments by elderly patients: Projections from a multicenter data base. Ann Emerg Med 1992;21(7):819-24.

19. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Med Care Res Rev. 2011(2);68:131-55.

20. Schnitker L, Martin-Khan M, Beattie E, Gray L. Negative health outcomes and adverse events in older people attending emergency departments: A systematic review. Australas Emerg Nurs J 2011;14(3):141-62.

10. “Emergency Medicine”. Emermed.uc.edu. Retrieved 19 Aug 2019.

21. Rosen T, Liu SW, Cameron-Comasco L, Clark S, Mulcare MR, Biese K, Magidson PD, Tyler KR, Melady D, Thatphet P, Wongtangman T, Elder NM, Stern ME. Geriatric Emergency Medicine Fellowships: Current state of specialized training for Emergency Physicians in optimizing care for older adults. AEM Educ Train. In press.

11. Jones J, Dougherty J, Cannon L, et al. A geriatrics curriculum for emergency medicine training programs. Ann Emerg Med 1986;15:1275-1281.

22. Hogan TM, Losman ED, Carpenter CR, Sauvigne K, Irmiter C, Emanuel L, et al. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Acad Emerg Med 2010;17(3):316-24.

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6 - RESOURCES Clubs and Memberships:

Grants & Scholarships:

•A cademy of Geriatric Emergency Medicine (AGEM)- SAEM

•A GEM student member Scholarship

•G eriatric Emergency Medicine (GEMS)- ACEP

•M STAR program

•G eriatric Emergency Medicine interest group- International Federation For Emergency Medicine

•A GEM Resident member scholarship

• Th e American Geriatrics Society

•G rants for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSSTAR)

Conferences:

• Th e Paul B. Beeson Emerging Leaders Career Development Award in Aging

•A cademy of Geriatric Emergency Medicine (AGEM) at the Society for Academic Emergency Medicine Annual Meeting

• Th e Dennis W. Jahnigen Career Development Awards Program

•G EMS section at the American College of Emergency Physicians conference

Textbooks

•A merican Geriatric Society meeting

Journals and Publications: •A cademic Emergency Medicine (AEM) •A nnals of Emergency Medicine • Journal of the American Geriatrics Society (JAGS) • Geriatric Medicine- The British Medical Journal

Blogs & Podcasts: •G EMCAST •E mergency Medicine Cases podcast-Episode 34

•K ahn J, Magauran Jr BG, Olshaker JS. Geriatric Emergency Medicine. New York, NY: Cambridge University Press; 2014.

•M urdoch I, Turpin S, Turpin B, MacLullich A, Losman E. Geriatric Emergencies. India: Wiley-Blackwell; 2015.

•M attu A, Grossman S, Rosen P. Geriatric Emergencies: A Discussion Based Review Book. Wiley-Blackwell.

•D resden S, Lindquist L. Geriatric Emergencies: A Case-Based Approach to Improving Acute Care

7 - INSIDER ADVICE Shan Liu, MD- Geriatric Emergency Medicine Fellowship Director, Massachusetts General Hospital “The world of geriatric emergency medicine is wide open. But I expect that as more EDs seek Geriatric ED accreditation that demand for faculty who focus on this will increase exponentially. There are so many ways to be involved— join AGEM, be an AGEM student rep, join ACEP GEMS or create a student group who is interested in geriatrics and invite national speakers. There is also an award for students through AGEM. There are similar opportunities at the resident level as well and there are so many ways to improve care for the geriatric patient and endless research questions. We have a great group of people in geriatric emergency medicine so we are always looking for new people who are passionate about it!”

Katie Davenport, MD – Assistant Professor of Emergency Medicine at UNC Chapel Hill Medical Center, Geriatric ED Medical Director of UNC Hillsborough and former fellow in Geriatric Emergency Medicine Research at Massachusetts General Hospital “A career in geriatric emergency medicine is exciting and fulfilling. The patient population is one of the most underserved and there are ample opportunities to be involved to improve the care of the older patient. From research opportunities in falls prevention strategies, safe medication use and delirium prevention to administration and operations needs in implementing geriatric focused protocols the chance for impact and influence in this field is endless. The group of ED physicians including those in ACEP GEMS and AGEM are passionate and inclusive of residents and medical students and serve as excellent mentors for a career in geriatric emergency medicine. I can’t imagine a better career path and hope you join our team!”

Manish N. Shah, MD MPH- Professor of Emergency Medicine, Geriatrics, and Population Health Sciences; Director, KL2 Program, Institute for Clinical and Translational Research; Co-Lead, Care Research Core, Alzheimer’s Disease Research Center, University of Wisconsin-Madison “Research in geriatric emergency medicine and then translating those findings into clinical practice is of utmost importance, as findings in other populations often do not apply to older adults. Studies can range from basic science investigations to better understand conditions to health services and health policy research to improve the delivery of care. Research complements our clinical practice and is also immensely rewarding as it advances the care provided by all emergency physicians to improve the well-being of our patients. Broad opportunities exist for students, residents, and fellows to develop a meaningful and successful career as a physician-scientist focused on geriatric emergency medicine.”

Lauren T. Southerland, MD- Associate Professor of Emergency Medicine at The Ohio State University Wexner Medical Center, Geriatric EM fellowship trained at William Beaumont Hospital, researcher and former Geriatric ED Medical Director.

“Older adults are the most interesting and exciting patients. I always learn something from them, whether it be an unexpected presentation, an obscure autoimmune disease or cancer, or something about their lives. Doing a Geriatric EM fellowship gave me additional insight and training above and beyond what I expected to learn. This has also contributed to my success in research and administration. I developed and implemented our Level 1 Geriatric ED and now have NIH funding to evaluate the use of geriatric screening tools for fall risk, delirium, and difficulties after the ED visit. Just as geriatricians have some of the highest career satisfaction, Geriatric-EPs are the happiest bunch in the ED.” Tony Rosen, MDM, MPH – Assistant Professor of Emergency Medicine at New York-Presbyterian Hospital / Weill Cornell Medical Center; Program Director for the Vulnerable Elder Protection Team; Researcher; and AGEM President 2019-2020.

“I’m really excited to be working in an area of Emergency Medicine that I believe is so important and where new strategies are transforming the care we provide to many of our most vulnerable patients. There are so many ways to contribute to Geriatric Emergency Medicine, through innovative research, strategies to improve education, and development of clinical programs and protocols. It’s really exciting to see Geriatric EDs launched around the country, but we still have so much to learn about how to provide optimal acute care for older adults. My interest in Geriatric Emergency Medicine began as a medical student (when I first became involved in the Academy of Geriatric Emergency Medicine!) and has continued through residency and as an attending. I completed a Geriatric EM fellowship, which really broadened my perspective on care of older adults, focused my interest, and offered me the opportunity to identify areas of research interest. Also, the growing community of folks interested in Geriatric Emergency Medicine is really collaborative, supportive, welcoming, and friendly. More senior and experienced members have been extraordinarily generous in mentoring and advising me (and many others!) at all stages of our careers, and it’s been critical for me. I strongly encourage students and residents to consider Geriatric Emergency Medicine – I think that they’ll find it’s a really important and growing niche where they can have a deep impact -- and make their career more fulfilling.”