Moussa Sissoko, MD
Boston University Medical Center
"My experiences with my grandparents and other older folks in Senegal definitely contributed to my decision to work in geriatrics. I’m very comfortable with older people. I enjoy talking to them. There’s so much to learn from them; they have had a full life of experiences."
Growing up in Senegal in the 1970s, Moussa Sissoko, MD, contracted polio when he was just 18-months old. He survived despite a dire prognosis, but was left with a pronounced limp—a handicap in a country where the handicapped were particularly vulnerable and often reduced to begging.
"I remember my mom telling me, "You've got to make sure you get educated; if not, you're going to be in the street asking for help like most of the handicapped people in this country," Dr. Sissoko recalls.
After going on to earn multiple degrees in biology, biochemistry, and medicine, Dr. Sissoko is now about to start a fellowship focusing on the care of another particularly vulnerable group: older adults with cancer. Next July he'll begin a fellowship in geriatrics/oncology at Boston University Medical Center.
"Even when I was very young I was interested in biology and other sciences," Dr. Sissoko says. "When I was small I'd catch little rats and mice and study them. My dad bought me an encyclopedia and I'd just sit down and read about animals, and biology, and chemistry. It was a fascination."
That fascination led him to earn a BS in biology and biochemistry at the Lycee Technique Maurice de La Fosse in Dakar in 1984, and a Diploma of Technology in Laboratory Sciences at the University of Dakar two years later. His first job in the field was as a technician in a hospital microbiology laboratory doing HIV and AIDS research. After going on to complete a biochemistry laboratory internship in Senegal he earned his Maitrise de Biochmie in Bordeaux, France, then returned home and spent 10 years supervising microbiology, immunology-serology, biochemistry and hematology labs in Dakar.
It was in Senegal that Dr. Sissoko met his wife, Dara Seybold, an American medical anthropologist involved in AIDS research. The two married in 1998 and moved to Maryland where she started graduate studies in anthropology at the University of Maryland at College Park and he earned another bachelor's degree, in bioscience, before beginning research work in oncology. He found oncology, like hematology, extremely appealing "due to their complexity and because there's so much to discover in this area."
"I like to be around people, and to talk to people, and find sitting in a lab all by myself all the time, among cold tubes and beakers, pretty boring," he says. A career doing research and teaching medical students, however, appealed tremendously, says Dr. Sissoko, whose interests led him to earn an MD at St. George's School of Medicine in Grenada in 2007.
His experience in medical school and during his residency at West Virginia University/Charleston Area Medical Center convinced him that geriatric oncology-hematology would be the best possible place for him. The American Geriatrics Society caught up with Dr. Sissoko and asked him more about his decision to pursue a career focused on older cancer patients.
Q: When led you to decide on a career in elder healthcare?
A: I started getting interested in geriatrics during my first rotation at West Virginia University. Early on I had a rotation in hematology/oncology and the first thing I noticed during that rotation was that most of the patients were elderly. And I realized that, as patients, the elderly are very different than younger people. They are very different physiologically, and have different reactions to medications than younger patients. Many of them have complex co-morbidities such as dementia, liver disease, kidney or heart disease and take multiple drugs that can interact and cause side effects. And these drugs are mostly tested in younger, healthier people who may not respond to them in the same way older people do. This made me start thinking that we have to find a better way to treat elderly cancer patients - and at least 50% of cancer patients are 65 and older. That's when I started getting interested in geriatrics.
Q: Is that what prompted you to pursue a geriatrics/oncology fellowship?
A: My hematology rotation got me interested in geriatric oncology - including research in geriatric oncology, because there's so much we need to know about how the elderly are affected by cancer treatments.
But I decided to go into geriatrics after I was named Chief Resident in internal medicine in my third year of residency. That year Marshall University -- which is also in West Virginia -- was chosen to participate in the Chief Resident Immersion Training (CRIT) program. The program teaches Chief Residents how to care for older patients, and how to train the residents they work with to care for older patients. Marshall included West Virginia University/Charleston Area Medical Center in the program, so I was able to participate.
CRIT was awesome. It should be extended to every single resident. The program was very extensive. It taught you how to approach elderly patients, and about managing co-morbidities and dealing with polypharmacy. It taught other things, including how to distinguish dementia from delirium and about the social needs of seniors. It confirmed what I was thinking about the need for better geriatric care in oncology. It helped me decide to do the fellowship.
Q: Are you planning to focus on geriatric oncology and hematology then?
A: My goal is to successfully complete my fellowship. Then I'd like to do research in geriatric oncology and teach because there's so much to learn and teach in that area. There's so much research that needs to be done into how older people are affected by chemotherapeutic drugs, for example, a decrease in cognitive function after initiation of chemotherapy, co-morbidities, and polypharmacy.
Q: Are you planning teach and do research in the US?
A: Yes. I'm a US citizen and my wife and our four kids are too. But another goal of mine is to do something in Senegal. They need a lot of help there - there's not much modern geriatrics care in Senegal.
Q: You've noted that older adults have a different place in Senegalese society than in the US. Could you talk about that a bit? Did it contribute to your decision to go into geriatrics?
A: I grew up with my grandfather and grandmom in Senegal. Back home, kids often stay with uncles or grandparents. I was really attached to my grandparents. They taught me religion and many other things. My grandfather was a scholar in Islam -- most people in Senegal are Muslims -- and being with him meant spending time with other older folks who came to see and talk with him. I learned a lot about life from them. In my culture, older people are an important part of the society. They're the ones you go to when you have a problem, the ones you go to for comfort and guidance. Here, older people can be kind of on the margin of society, unfortunately.
My experiences with my grandparents and other older folks in Senegal definitely contributed to my decision to work in geriatrics. I'm very comfortable with older people. I enjoy talking to them. There's so much to learn from them; they have had a full life of experiences. And yet they can be limited by diseases associated with aging. I think my enjoying the company of older adults, and my interest in the complex health problems, like cancer, that they have both contributed to my interest in geriatrics and geriatrics oncology-hematology. It's very compelling.
Holly L. Stanley, MD
Coordinated Care for Seniors
"I love all the intricate puzzle solving and the advocacy work in geriatrics."
Growing up, Holly Stanley, MD, was as comfortable in a hospital as she was in her own home. In fact, the community hospitals where her mother worked were like second homes.
"I was raised in small community hospitals," says Dr. Stanley, a native of southwestern Florida who decided at age 4 that she wanted to become a doctor. "My mom, a surgical nurse, was a single parent, so I'd often go to work with her. I'd sleep in ICU waiting rooms on weekends, I'd hang out with the ICU nurses and all kinds of doctors—I was their little protégé."
Drawn to the intellectual stimulation, the challenge of solving clinical puzzles, and the satisfaction of helping, comforting, and connecting with patients that medicine affords, Dr. Stanley enrolled at the University Of Florida College Of Medicine after graduating from the University of South Florida. Deciding to become a doctor had been easy. But deciding what kind of doctor to be, wasn't nearly as straightforward, says Dr. Stanley, a geriatrician who has, in the course of her career, established and directed a geriatrics fellowship program, a hospital-based senior health center, and a private practice that's thriving even though she has opted out of the Medicare program.
Well into her internal medicine residency at the Virginia Commonwealth University (VCU) School of Medicine in Richmond, however, Dr. Stanley still wasn't sure what she'd do next. Each of the internal medicine subspecialty fellowship options she considered had drawbacks. Most had too narrow a focus for Dr. Stanley, who wanted to work in a field with a more holistic approach, and one that was concerned with "the whole body," not just, say, the nervous system. Toward the end of her final year of residency, Dr. Stanley was approached by another physician who'd been a resident at VCU and had just established the geriatrics division at the university affiliated Veterans Administration medical center. He asked her to join him. She hadn't given geriatrics a thought before. A native of Charlotte County—the county with the nation's highest concentration of adults 65 and older— Dr. Stanley knew she'd enjoy the company of older adults. So she accepted the post.
Within months of starting, she was hooked.
"I loved all the intricate puzzle solving and the advocacy work in geriatrics," explains Dr. Stanley, who discovered that providing care to older adults—who tend to have complicated and overlapping health problems—was highly challenging, exciting, and rewarding.
Dr. Stanley went on to direct VCU medical school's first geriatrics fellowship program from 1987 to 1992. Building the program was extremely gratifying. Dr. Stanley had started her career in geriatrics at a time when medical schools were just beginning to create geriatrics fellowships, and hadn't done a formal fellowship herself. At VCU, she particularly enjoyed designing the kind of fellowship program she wished she'd had. "It was fun," she says. "And I loved teaching."
Because the program provided care to Veteran's Administration patients, however, fellows got less experience caring for older women than Dr. Stanley thought appropriate. She tried to convince school administrators to start a community-based program that would serve more women—not only to increase fellows' exposure to a more representative group of older adults, but also to increase older adults' access to comprehensive geriatric assessment and treatment. When the college cited financial constraints and decided against opening the community-based program, Dr. Stanley took another tack. In 1991, she started a senior health center at a nonprofit hospital in Richmond, and served as its director and as the sole physician on its interdisciplinary healthcare team.
"I loved the process of creating the center—using my creative juices to put something together, problem solving, and dealing with the challenges of bringing people on board," says Dr. Stanley. Once the center was up and running, she relished being able to see a diversity of patients. In 1997, however, the Balanced Budget Amendment changed the way the program, and others like it, were reimbursed. And this began to change the way the center operated. "We differed in our views of what the program's mission should be," says Dr. Stanley, describing the conflicting perspectives she and the hospital administration had of the center. "The nature of the practice was going to change, as was the kind of patient we saw, and the amount of time and resources we had." Ultimately, Dr. Stanley decided to pursue her vision independently. In 1999, she opened a now flourishing private practice, Coordinated Care for Seniors.
"My vision was to have a resource for those really complicated, time-consuming, increasingly frail and problematic patients who weren't being well managed in the traditional system," she explains. "I wanted to be that resource."
Having her own practice allowed Dr. Stanley tremendous flexibility. Not only could she see the most complex and challenging patients, she also had more control over her schedule. The mother of three children, she'd always made balancing work and family life a top priority.
When she opened the practice, Dr. Stanley was well aware of how difficult it was for many geriatricians -- and other physicians whose patients were, for the most part, Medicare beneficiaries—to make a living. Medicare's reimbursement rates were notoriously low. "But I thought, ‘I'm pretty clever. I should be able to figure out the Medicare reimbursement thing,’" recalls Dr. Stanley, whose practice is in Richmond, where she and her family live. "I thought, ‘I just need to understand the rules and code correctly and, of course I'll make a living.’"
It wasn't as easy as she'd expected.
Dr. Stanley considered going the "private contracting" route—opting out of the Medicare system, establishing her own pay schedule, and seeing patients willing and able to cover the tab themselves. Because she was paid more equitably for her time, she could afford to give low-income patients discounts, or waive her fee entirely. "My Mama didn't raise me to only take care of people with money," says Dr. Stanley. She couldn't discount or waive her fees for particularly needy patients before, she notes, because Medicare law requires participating physicians to give the same discount to all patients—regardless of need—if they give a discount to any.
It's because she's committed to ensuring that older adults -- no matter their financial assets -- get quality care, that she's also involved in efforts to reform Medicare, Dr. Stanley explains.
In 2000, when the American Geriatrics Society (AGS) asked Dr. Stanley to participate in an American Medical Association (AMA) committee that offers the Centers for Medicare and Medicaid Services advice on reimbursement issues, she jumped at the opportunity. Dr. Stanley is still actively involved with the AMA committee, officially known as the Resource Based Relative Value System Update Committee, or RUC.
If she knew, as a resident, what she now knows about geriatrics, its challenges, and its rewards, would she still choose the field?
"I would," Dr. Stanley says, without missing a beat.
"There's nothing I'd prefer to do—I wish there was something I'd prefer to do!" she adds, laughing. "But there isn't. It's intellectually very stimulating; you have to think outside the box. And the patients are so wonderful. You're so appreciated. It's very rewarding."
"Geriatrics isn't exactly an easy place to be," Dr. Stanley says, after a brief pause. "But it's kind of a fun, exciting place to be because it's on edge, because it's evolving."
