The American Geriatrics Society - Education

Rebecca Elon, MD

Accepting the American Geriatrics Society's Clinician of the Year Award in 2007, Rebecca Elon, MD, a geriatrician, quoted the commencement speech Kurt Vonnegut had made at her alma mater, Rice University, a decade earlier.

Most of the fresh faced graduates earning their degrees that day wouldn't find fame and fortune, Vonnegut had predicted. They would, rather, find their destinies in "building or strengthening (their) communities." And this would be well worth celebrating. "Love that destiny," Vonnegut had exhorted his audience. "Communities are all that is substantial about what we create or defend or maintain in this world."

"Our communities are desperately in need of what we as geriatricians bring to the table - not only our skills and knowledge but also our compassion, our commitment, our diligence, our dogged determination to provide the highest quality care achievable for older adults and frail elders," Dr. Elon continued, making her acceptance speech.

Geriatrics -- one of the less glamorous and, thanks to current Medicare payment policy, one of the lower paid medical specialties -- isn't a place to seek either fame or fortune, she notes. But it is a field affording numerous opportunities to make lasting, and invaluable contributions to communities in need. Geriatricians like Dr. Elon are already in short supply nationwide and this shortage is expected to worsen dramatically as the population of older adults skyrockets in the next two decades.

"In geriatrics, there are enormous opportunities to make a difference locally -- there's just an enormous need," says Dr. Elon, a former member of the American Geriatrics Society's board of directors and former president of the Maryland Geriatrics Society. "If you want to work in a hospital, there's a huge need for geriatric hospitalists. If you want to work in a nursing home, there's a huge need for medical directors and other professionals in nursing homes. If you want to do primary care in the community, there's a huge need for that. You will be amazed at how you can make an enormous positive difference in the lives of older people and their families and your community -- on a daily basis."

The American Geriatrics Society's Clinician of the Year Award recognizes the importance of the geriatrics clinician by honoring a practitioner whose "devotion to patients and to the advancement of quality geriatrics care is nothing short of remarkable." And Dr. Elon's has been just that.

A voluntary part-time faculty member in the geriatrics division at Johns Hopkins University School of Medicine, Dr. Elon was a full-time faculty member at Hopkins and medial director of its Geriatrics Center until 1997, when she decided to cut back on her academic responsibilities to build a model community-based geriatrics practice to help meet the need for geriatrics care in Anne Arundel County, Maryland.

When she started the practice -- North Arundel Senior Care -- Dr. Elon and a nurse made up the entire staff. Over time, they added three physicians, a nurse practitioner, a physician assistant, a registered nurse, and office staff. They also created a larger, informal network that included other healthcare professionals in the area who provided older patients with needed services.

"We were able to bring a level of service to the community that previously hadn't existed," says Dr. Elon, who lives in Severna Park, Maryland with her husband, William Adler, MD, former chief of clinical immunology at the National Institute on Aging. "This was very, very satisfying."

Unfortunately, the practice wasn't financially viable -- in large part due to flaws in the Medicare payment system. So, shortly before receiving the AGS Clinician of the Year Award, Dr. Elon handed the leadership of the practice to her junior colleagues and set out to create a different kind of practice better suited to Medicare's payment structure. "My salary was the biggest line item in the budget, so I thought, "I'll take my salary out of the equation and, hopefully, the rest of the staff can make a go of it that way," she explains.

While developing plans for her new practice, Dr. Elon continues to serve on the faculty at Hopkins, and as director of physician services for the FutureCare Health and Management Company, which operates 10 nursing homes in the Baltimore-Washington D.C. area. She is also the national director for medical underwriting at Coventry Care Link, a provider of long-term care insurance, and the medical director of two Maryland nursing homes. Well known as an expert on nursing home care and reform, the care of frail older people, and medical ethics, she has published widely in these areas. She also serves on the Ethics and Judicial Affairs Committee of the Maryland State Medical Society and on the advisory board to the Maryland Health Care Ethics Committee Network.

The daughter of a dietician and great-niece of a Frontier Nursing Services nurse who founded a mission clinic-turned-hospital in the hollows of rural Kentucky, Dr. Elon got interested in medicine in high school. By the time she enrolled as an undergrad at Rice she knew she wanted to pursue a career in geriatrics. "It probably had to do with my father's family, in which there ware an incredible number of great aunts and uncles," she says. Spending a semester volunteering with a geriatric psychiatry community outreach program -- a requirement for a medical anthropology class she elected -- cemented her interest in the field. After earning her MD and finishing her residency and a geriatrics fellowship at Baylor College of Medicine, she stayed on at Baylor to establish a community-based geriatric medicine teaching practice.

Among other things, Dr. Elon took the medical students, residents and geriatrics fellows she trained into nursing homes in Houston. The experience was life-changing. "The conditions in the Houston nursing homes at the time, in the mid to late 80s, were abysmal, and my experiences in the homes was a sentinel event in my career, she recalls. "All of this made me think: What can be done to improve the lives of these people?"

A strong commitment to service to others -- particularly the underserved -- has always played a key role in her career decisions. It informed her interest in medicine in general, and geriatrics and long-term care in particular, acknowledges Dr. Elon, who wrote her thesis for her masters in public health at the University of Texas School of Public Health about the role of nursing home medical directors. That work led to a Kellogg National Fellowship and a faculty position at George Washington University, and later, at Hopkins.

The satisfaction she derives from providing vital services to older adults in need of care isn't the only thing that makes geriatrics attractive, however. The opportunity to spend time with older adults is equally, if not more, gratifying, she says.

"Perhaps the most satisfying aspect of geriatrics for me is the opportunity to meet the people who are the history of our nation," Dr. Elon explains. "During my training, I met an African American centenarian whose parents were born into slavery in this country. Now, you can read all about the Civil War and the Emancipation Proclamation, but when you sit across from someone whose parents were freed by that proclamation, it brings history alive. I took care of a woman who made hats for Thomas Edison's wife and saw the first public electric lights go on in New Jersey. Another patient was a wrestler in the 1936 Olympics and witnessed Jesse Owens run with Hitler presiding. I've had the honor of caring for the local men and woman who made our community what it is today. Geriatric medicine is fun - you will meet some of the most amazing people whose paths you would otherwise never have crossed."

Geriatrics is a wonderful field for anyone who's both interested in a career in healthcare and comfortable around older people, Dr. Elon says. Despite the shortcomings of the Medicare system, there are a wide variety of viable geriatrics career paths, she adds. The academic track is one well established track, and there are growing opportunities for geriatrics hospitalists. Careers as nursing home medical directors are another promising alternative thanks to increased medical directors' stipends. "You can now make a decent living as a medical director," she notes. And as a result of recent policy changes boosting Medicare payments for house calls -- payments for home visits now outstrip payments for office visits -- the home care track is an increasingly popular option as well.

Geriatrics also affords opportunities for creating your own career path, adds Dr. Elon. "There is still a lot of uncharted territory in geriatric medicine," she says. The new practice she's planning, she explains, will provide the administrative infrastructure to match physicians with nurse practitioners, physician assistants, or both, in geographically based teams. The teams will serve local nursing homes, assisted living facilities and also provide on-site medical services in adult day care centers and in patients' homes. Not carrying the expense of an outpatient office will help keep overhead costs down, Dr. Elon notes.

"By earning administrative income, such as medical directorship stipends, in addition to the fee-for-service clinical revenue, and keeping overhead costs to a minimum, this model can work," she says. "It can serve the functionally impaired older populations whose needs typically are not well met by our current system, and should have financial viability."

"There's great need for geriatrics practitioners and there are great opportunities," she adds. "You just have to be able to see beyond the frustrations and persevere. Geriatrics is a good place for people with big hearts and big vision who keep coming back."