An Update on AGS Fellows-in-Training

Fall 2001

An interview with Dr. David Reuben, Director of UCLA's multicampus program in geriatric medicine and gerontology and chief of geriatrics. Board of Directors for AGS, President of Association of Directors of Geriatric Academic Programs(ADGAP), Director of UCLA Claude Pepper Older American Independence Center

Q: Before we begin, could you tell us about your background and how you came into your current role?

Reuben: I started as a faculty member at Brown University in general internal medicine for seven years. In 1987, I entered a Hartford mid-career faculty scholars training program in geriatrics. I returned to Brown for one year, then I was recruited to UCLA as associate director of the Multicampus Program in Geriatric Medicine and Gerontology in 1989.

Q: What do you see as the future challenge of geriatrics?

Reuben: This depends on the area of geriatrics we are discussing.

1. For geriatricians who enter clinical practice, increasingly the question is how to structure their practices to be economically viable and efficient. With the change to a one-year requirement for certification, more internists and family physicians are entering geriatrics fellowships. Many of these geriatric fellows however, are choosing careers as clinicians rather than entering academics. As a result, there will be a new breed of geriatricians in the community, which will be very good for the elderly population. Nevertheless, evaluation and management services, the non-procedural care that geriatricians provide, are not well reimbursed. Frail patients require time. It is a challenge to provide comprehensive care and make a reasonable living. Traditional models of care for internal medicine and family practice are very difficult to apply in geriatrics. There will be new models of practice and geriatricians will move into different roles: inpatient care, nursing home, or ambulatory care. Some geriatricians may choose to focus on one of these areas instead of attempting to do all three. Others may assume administrative roles to augment income.

2. For academic geriatrics, there will be a need to find protected time for teaching. Departments and medical schools are just learning the message that geriatrics education is important. Consequently, the teaching demands have increased dramatically. Traditionally, there have been few funding sources for teaching. Some foundations have funded model programs, but at many institutions geriatrics faculty need to earn their salaries through clinical activities.

Q: Currently there are several internal medicine and family practice physicians practicing in the roles of geriatricians. Sometimes geriatric fellows are asked, what it is they do that makes fellows different? How would you answer?

Reuben: Fellowship-trained geriatricians receive formal training in caring for frail elderly, whereas those without fellowships are learning on the job without such structured experiences. There is an evidence base and skill set that fellowship training is designed to provide. Without formal training, it's like trying to be a cardiologist just from reading a cardiology book and caring for patients with heart failure.

Q: What do you think makes a successful research fellow?

Reuben: I just met with one today. He came to us with a PhD in epidemiology in addition to internal medicine training. He did a clinical year, then in his second research year he authored three manuscripts, that's 3 in a year. The papers were based on secondary data analysis;; nevertheless, they were all original research. Although not all successful fellows meet this standard, organization and productivity are good signs of success.

Q: For clinical fellows, what do you see as successful endpoints?

Reuben: I can think of a recent graduate who is now working for Kaiser-Permanente in San Diego. Clinical fellows should:

Find a great job where they can provide outstanding geriatrics care.

Have excellent clinical skills as judged by the faculty who have precepted them.

Display enthusiasm, excellent social skills, and be a team player.

Q: Do you think it is necessary to do a second year of geriatrics and why?

Reuben: It depends on what you want to do. In one year, you can become a sound clinical geriatrician. If you want to be a teacher, the second year may help in developing education skills and learning effective teaching techniques. If you plan to be researcher, you should have additional course work (i.e. health services research, public health, public policy, or bench research training). Most entering this career track would need two to three years. Everyone we have hired has attained advanced degrees or has had three or more years of training.

Q: What would be your ideal second year fellowship structure?

Reuben: For those who are destined to be teachers, I think that supervised teaching experiences-such as development of educational modules or lecturing. Faculty development and evaluation courses would also be valuable. For those entering research careers, the second year fellow should be enrolled in a MPH program or other formal curriculum and begin mentored research. The third year is protected time for research and taking advanced classes that are relevant to their research. These classes might include economics or advanced statistics.

Q: What is your advice for unpublished fellows to attain publications?

Reuben: Find a good mentor who can guide you, teach you how to write, and how to respond to reviews. In small programs where there are not research opportunities within the division, go outside of geriatrics to find a research mentor. Pair that mentor with a geriatrician mentor to maintain a geriatric focus. Finding more than one mentor is generally helpful.

Q: How would you suggest that academically oriented fellows find out about, apply and market themselves for entry level/junior faculty academic positions?

Reuben: First, their program directors should be assisting them. There is a network of directors communicating with each other. I am always getting phone calls from other places looking to hire an academic geriatrician. Second, they should look for positions in relevant newsletters and do online searches. Third, if you are interested in specific places, find the program directors and talk to them. Just start asking if they have any need for new faculty.

Regarding marketing oneself, a person should play to his or her strengths but avoid hardball strategies in negotiating a first job. If you are going to be researcher - market your promise. Most graduating fellows only have one or two publications when they apply for their first academic position. It is important to have adequate training. I look for those who have had specific research training as evidenced by completing a research fellowship. It is also good if they can present their own data and have completed research projects by the time of their interviews. They need to have good ideas and ambition and be unafraid of working nights and weekends. Finally, their mentors need to think highly of them.

Q: What trends in geriatric research should we focus on?

Reuben: Research topics in most areas of geriatrics are wide open. Geriatrics research can be centered within geriatrics programs. For example, geriatricians have led the research efforts on a number of topics to date including: falls; delirium; health services delivery; urinary incontinence; and elderly exercise programs.In addition, there are many opportunities for collaboration with subspecialists. Geriatrics is a perfect discipline for collaboration with subspecialists.

Q: Is there any other advice you may have for fellows deciding on which career direction to take?

Reuben: Geriatrics is a field that has tremendous career opportunities. Look at your role models and take the best parts of them and see what fits. For example, one of my mentors had the personality that I wanted to emulate, another one had the vision, and another taught me collaboration skills. Find all the right pieces and strive to be that person.

Q: How many mentors should a fellow have?

Reuben: Many mentors. At any point in time, I usually have three-four mentors and still do to this day. You should never be without a mentor.

Chau: Thank you very much Dr. Reuben.