Small Medical School in State With Large Elderly Population Tapped for Innovative Geriatrics Education Program

Marshall University's Joan C. Edwards School of Medicine, in Huntington, West Virginia, is a small medical college with limited resources, but a strong commitment to meeting the healthcare needs of a state with a large number of older residents.

So when Shirley Neitch, professor of medicine and chief of the school's sections of geriatrics and general internal medicine, heard about the Chief Resident Immersion Training in the Care of Older Adults (CRIT) demonstration project, she rushed to apply.

"I knew immediately upon reading the description that CRIT would be of enormous potential value to us," says Dr. Neitch.

The innovative demonstration project -- which launched last year with five medical schools participating -- trains chief residents to diagnose and treat health problems common among older adults, and to better prepare the medical students and residents who they supervise to do the same. The program also aims to encourage positive attitudes toward caring for the aging, foster leadership and teaching skills, and improve collaboration among the specialties and subspecialties involved in elder care.

This past June, the Association of Directors of Geriatrics Academic Programs (ADGAP) -- which administers the project -- announced the names of four new medical schools selected to participate in the second round of CRIT. The four are the Medical College of Wisconsin, and the medical schools at Yale, the University of Cincinnati -- and Marshall.

"We were thrilled!" Dr. Neitch says.

Training healthcare professionals to meet the unique healthcare needs of older adults is a growing priority nationwide -- and a particular challenge in West Virginia. The Mountain State is one of the nation's "oldest." It ranks close to the top for both median age and percentage of population over 65. Unfortunately, older adults in West Virginia also rank near the bottom on a number of key measures of health.

West Virginia is considered a rural state -- with more than half of its population living in what the Census Bureau classifies as rural areas. And Marshall's medical school, founded in 1977, has, from the start, been committed not only to recruiting students from rural parts of West Virginia, but also to placing graduates in clinical practice in the region. The majority of the roughly 50 medical students Marshall graduates each year pursue careers in primary care. Given the high percentage of older West Virginians, Dr. Neitch and her colleagues had long recognized the pressing need to ensure that all of their trainees know how to care for older adults -- who are likely to make up a sizeable share of their patients.

Marshall has several significant geriatrics training resources, including its Hanshaw Geriatric Center. An ambulatory care facility, the center offers geriatric evaluations and primary care for older patients. Marshall is also home to a driving assessment clinic for older people, provides geropsychology services, and trains students and residents in three local nursing homes where faculty members serve as medical directors. A family medicine faculty member spearheads the Seniors' Services program at one of Marshall's affiliated hospitals. And Marshall is involved with statewide initiatives such as Geriatrics Educators of the Medical Schools (GEMS) of West Virginia and the West Virginia Geriatrics Education Center, based at West Virginia University in Charleston. But the teaching staff at Marshall -- which offers fellowships in cardiology, pulmonology and endocrinology but not geriatrics -- is stretched.

"Our internal medicine and family and community medicine departments include a total of seven faculty members with geriatrics credentials and expertise, but neither department has been able to develop a true full-time geriatrics teaching program," explains Dr. Neitch, herself a certified geriatrician and one of the seven. "We estimate we have about two to two-and-a-quarter full-time equivalent faculty to teach geriatrics to our 120-plus resident trainees. Each department feels that it is barely fulfilling its own departmental needs for geriatrics care and teaching."

The CRIT program, Dr. Neitch says, is a breakthrough for Marshall. The school gets support from local and regional foundations. But it's too small and has too few administrative resources to meet the criteria for geriatrics programming grants from the National Institutes of Health or organizations such as The John A. Hartford Foundation or the Reynolds Foundation.

"There is no doubt in my mind that enabling our few available geriatricians to expand the institution-wide dissemination of geriatrics knowledge through CRIT will be of immeasurable value," she adds.

Boston University Medical Center (BUMC) pioneered the highly successful CRIT program in 2005 with funding from the Donald W. Reynolds Foundation. And the program showed impressive results right out of the gate. The 16 BUMC chief residents who participated in 2006, for example, saw their scores on a test of geriatrics knowledge jump more than 40% after they completed the two-and-a-half day intensive educational retreat that's at the heart of the program. They also showed significantly greater understanding of multifaceted geriatric health problems, expertise in assessing older patients, and related skills. In 2007, the John A. Hartford Foundation awarded a $2.095 million grant to ADGAP and Boston University to replicate the program via the nationwide demonstration project.

Medical schools at the universities of Colorado, Kansas, Nebraska, Rochester, and South Carolina were chosen to participate in the first phase of the CRIT demonstration project last year. Each participating institution receives a 30-month grant of $114,000 to conduct two intensive training retreats and follow-up training for their chief residents. Teams that include both a chief resident and a faculty member responsible for residency training in surgical and medical specialties attend the interactive 2 1/2 -day retreats. Most chief residents also develop and implement projects designed to foster geriatric education or improve a specific element of clinical care. Each retreat includes roughly 15 chief residents and their mentors.

The CRIT demonstration project review committee was looking for several things when it evaluated applications for the program this year. Among others, it considered a school's ability to sustain the program, demonstrated commitment in the accompanying letter from the dean of the school, whether a non-geriatrician would serve as principal investigator (PI) or co-PI, the strength of the school's geriatrics program, and the potential impact the grant would have.

"Marshall was like the little engine that could - it really scored very high in all of the parameters, except that, like many schools with limited resources, it didn't have a powerhouse geriatrics education program," says CRIT demonstration project director Sharon A. Levine, MD, Associate Professor of Medicine and Director of the Geriatrics and Geriatric-Oncology Fellowship Programs and Associate Dean of Academic Affairs at BUMC. "But their ability to have an impact, the buy-in from the residency directors and dean, their passionate description of how they'd institutionalize this program, and the changes they could make beyond their institution made us really willing to take a chance on this little engine that could. We all know that, because of workforce trends, there will never be enough geriatricians to take care of all the older folks, especially in rural places where there are very few geriatricians. We saw that, with Marshall, the impact could be very great."

So enthusiastic about CRIT are Dr. Neitch and colleagues at Marshall that they're already generating interest in the program among others in the Geriatrics Educators of the Medical Schools (GEMS) of West Virginia group.

"We're already seeing an interest in the CRIT program from others in GEMS - and we're a year away from even having our first retreat," Dr. Neitch said early this past summer. "We're exploring the possibility of one or more educators in that group attending our CRIT retreat and planning to make this a GEMS-sponsored and - nurtured program for the future."