Matt Dane Baker, PA-C, DHSc, Executive Dean of the College of Science, Health, and the Liberal Arts at Philadelphia University, gives all of his students, whether they be aspiring PAs, NPs, audiologists, or occupational therapists, a dose of reality:
“You know, you guys will be taking care of me someday. You won’t be able to avoid me. Even if you say you’re going into orthopedics because you want to take care of David Beckham—you won’t be! You’ll be taking care of me when I break my hip.”
Baker isn’t there yet, but his point rings true: America as a nation is getting older. The fastest-growing segment of the population is those older than 85, with a rapidly increasing group older than 100. We’re living longer, and we’re doing so with comorbid conditions and chronic illnesses that killed off previous generations at younger ages.
The recurring question has been: Who will care for us as we age? Geriatrics as a specialty remains a hard sell, so advocates say the time has come for its concepts to be better incorporated into primary care. And as the advanced practice nursing (APN) community transforms its educational process in response, clinicians who care for older adults continue to debate the wisdom of the changes.
NURSING’S RESPONSE TO THE PROBLEM
The changes to APN education—the elimination of the gerontology and adult NP and CNS tracks and the introduction of a combined adult/gerontology track—originated with the 2008 release of the National Council of State Boards of Nursing Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education. While there was initial controversy over the decision to eliminate the GNP track at a time when America is bracing for a “silver tsunami,” that fervor had quieted down.
That is, until this spring, when the American Nurses Credentialing Center and the American Academy of Nurse Practitioners Certification Program sent out letters indicating that after 2015, the gerontology and adult NP certification exams would no longer be offered. (The letters were sent at the request of the American Association of Colleges of Nursing [AACN], to provide a timeframe for schools to ensure their graduates are prepared to sit for the new adult/gero exam.) That communication seemed to reignite the passion of GNPs and others who care for older adults.
“I know that individuals who have chosen gerontology as their major in the past, and our colleagues who are very committed to care of the older adult, have had a real sense of loss around the ending of programs focused solely on gerontology,” says Geraldine “Polly” Bednash, PhD, RN, FAAN, Chief Executive Officer/Executive Director of AACN. “But it was very clear in the minds of educators and clinicians working to develop the consensus model that the patients many of us are seeing today are older adults.”
Echoing that point is Elizabeth Galik, PhD, CRNP, President of the Gerontological Advanced Practice Nurses Association (GAPNA) and an Assistant Professor in the School of Nursing at the University of Maryland, Baltimore: “No matter where you practice as an NP—perhaps excepting neonatal, unless you’re dealing with a grandparent—you’re going to encounter older adults.”
The issue is twofold: While GNPs are passionate about what they do, there aren’t many of them. Data indicate that as few as 2% of NPs are GNPs; in 2010, AACN says, there were 3,967 certified GNPs. Enrollment in GNP programs has not been increasing, either.
Coupled with that is the reality that many, if not most, older adults are being seen by ANPs, whose training did not specifically prepare them to address the problems of aging. Furthermore, some states, such as Maryland, make distinctions about the age range of patients that traditionally prepared ANPs and GNPs can manage and treat.
“Our view was that we needed to dramatically revamp the educational programs” to address all these issues, according to Bednash. “It was a response to the reality of the population they’re providing care to and the need to be sure that they have all the knowledge and all the skills available to give the best evidence-based care to older adults.”
“When you stop to think about ‘How do we create capacity?’ one of the ways we do that is to make people who want to take care of adults have to take care of all adults,” says Debra Bakerjian, PhD, RN, FNP, Vice Chair for FNP/PA Studies, Department of Family and Community Medicine, and Assistant Adjunct Professor, Betty Irene Moore School of Nursing, University of California–Davis. “That’s the impetus of this program; if we just focus on the GNP, we’re going to continue—despite everybody’s best efforts—to have a very small percentage of folks who are trained in geriatrics.”
The University of Maryland has already launched its adult/gero NP program, and Galik has seen improvements as a result. “I used to teach in the standalone GNP program, and our cohort of students every year was usually four to six,” she reports. “This fall, I am finding geriatric placements for 36 students in our adult/gero program. Many of them would not have specifically picked gerontology, but now they’re getting exposure to it because they’re in a combined program.”
Many students have been surprised to discover how much they enjoy working with older adults. “By having this opportunity, I think ultimately we’ll see more people enter the field than we did when we had specific programs,” Galik says.
For those who want to become true experts in gerontology, GAPNA and other stakeholders are currently in discussion about development of a specialty certification. Bednash notes that this would “provide another opportunity for enhanced capacity in geriatrics. But it won’t be for licensure or for entry into the role of an APN; it will be a personal choice that someone will make to go on and get additional education.”
In the meantime, Galik says, the expertise of GNPs and geriatricians will be needed to facilitate the changes. “Just as we need our students entering these combined programs to keep an open mind about different populations that they’ll care for and in different settings,” she says, “we need our GNPs and our gero experts to help educate and to provide precepting experiences.”
THE FUTURE IS NOW
While the rationale for transforming NP education is solid, there are still those who worry that a combined adult/gero education program will be “gero-lite.” Added to those voices—and moving outside nursing—are others expressing concern that very few clinicians are adequately trained to care for older adults.
“I do worry about whether we, as a health care provider community, will be well trained to deal with this population,” Baker says. “Gerontology NPs and physician geriatricians are very well trained. But there’s not a lot of them, so I understand the move toward trying to make every generalist a specialist in this as well.”
Clinician Reviews Editorial Board member Freddi I. Segal-Gidan, PA, PhD, Co-Director of the Alzheimer’s Research Center of California at Rancho Los Amigos National Rehabilitation Center in Downey and Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, compares caring for an older adult to understanding a foreign language. If you know the English alphabet, you can technically read French or Spanish, which use the same letters; however, you won’t know what the words mean.
“It’s still medicine; they’re just presenting differently,” she says. “That’s the piece that I think has to be taught…. If the NPs can train people to do that, and do it well, from my perspective, kudos to them. That’s what I would like to see us doing in PA education.”
PAs, obviously, are educated as generalists. The proportion identifying themselves as specializing in geriatrics is small: The 2010 American Academy of Physician Assistants Census indicated that 671 PAs were clinically practicing in this area. Recruitment is just as difficult as it is among nurses; Kathy Kemle, PA-C, MS, Assistant Director of the Geriatrics Fellowship/Geriatrics Division, Department of Family Medicine, Mercer University School of Medicine, Medical Center of Central Georgia, offers an elective in geriatrics for any PA student. “I don’t get many takers,” she says. “I haven’t had a student [for that course] in probably two years.”
Geriatrics as a career path isn’t “sexy.” Some view it as depressing. It doesn’t pay well, because the best reimbursement goes to procedures or to aspects of care that can be easily quantified. There aren’t any flashy tech toys.
“We don’t have a little instrument that we can plug the patient into and download the data,” Kemle says. “Clinicians don’t get paid to listen and think, and that’s what we do in geriatrics.”
The nursing community formulated its response to the difficulty of enticing students into gerontology. But what about current practitioners?
“The consensus provides a framework for the clinicians of the future, the new graduates who are going to provide primary and acute care services to older adults,” Bednash says. “All of the providers in this country have to be concerned about making sure that they are maintaining their capacity to care for the patients they see in their everyday work.”
How? The obvious, easiest answer is through CE/CME (or, as the PAs will switch to, MOC). But as in other contexts, gerontology and geriatrics lectures and modules don’t attract sell-out crowds. Requirements, therefore, may be needed. Bakerjian, for example, suggests license renewal or certification maintenance could be tied to a minimum number of hours devoted to education in geriatric specialty care. (Segal-Gidan, for that matter, thinks a similar carrot could be used at the primary education level: If 20% of the questions on the boards had a geriatric/gerontology focus, she says, then people would have to learn about this patient population in order to pass.)
Even if clinicians are mandated to acquire specialty knowledge in geriatrics, there is still the question of how much primary care providers—taxed with knowing something about everything—can be expected to learn. Geriatrics is a complex topic, which many clinicians don’t fully appreciate.
Baker is reminded of the mid-’80s, when primary care clinicians were told they should all be trained to care for HIV patients. “When there was only one test and only one medication, AZT, that was terrific,” he says. “But when that became really complicated, with lots of drugs and lots of tests, and viral loads and CD4 counts, and mixtures of drugs depending on resistance, it got a little harder for primary care providers to give the best possible care.”
The difficulty with geriatrics is that it requires a change in thought process; it challenges clinicians to examine the whole person and his or her familial and social issues, rather than focus on a single organ system or disease state. It also requires familiarity with how conditions present in older patients—some of the differences from younger adults surprise the uninitiated.
“You have to have a much higher index of suspicion,” says Segal-Gidan. “For example, heart attacks as you get older don’t present with chest pain; they present with confusion. So someone who is confused and goes to the emergency department is not necessarily someone who needs an antipsychotic. You have to think differently.”
Physiological changes as a body ages can have significant consequences—for example, how the body absorbs and metabolizes food. “This is key in the area of pharmacology, because medications get absorbed at a slower rate or a faster rate or not at all,” says Bakerjian. “We have greater risk for drug interactions when we get older.”
Kemle recently saw a hospice patient whose case highlights some of the unintentional blunders made when clinicians aren’t trained to think geriatrically. The 100-year-old woman had lost more than 100 pounds in six months and underwent “gazillions of dollars’ worth of tests,” none of which showed a malignancy. Her family was told to take her home and obtain hospice services. When Kemle and her colleagues saw the patient, they discovered the problem was her medications. Once the offending ones were withdrawn, the patient “started eating like a champ,” Kemle says.
“I’m sure the people who started this little lady on all the drugs that were killing her had very good intentions—and most likely, when they were started, they were appropriate,” she adds. “But in 2012, when she’s not eating because she’s digitalitoxic and she’s on a drug that gives her gastritis and another that makes her mouth dry—people don’t seem to understand that this is a different person sitting in front of them.”
Furthermore, the patient underwent a battery of (it turned out) unnecessary tests, at great expense and with the potential to cause more harm than good. “And all we had to do was sit down and listen to her for five minutes,” Kemle says.
Listening is the skill most often cited by clinicians who care for older adults. Other concepts they all mention include the holistic approach and “looking beyond your particular organ system.” And sometimes, it is essential to recognize that what the patient needs most may have very little to do with heavy-duty medical care.
“We try to figure out what’s the most important thing to maximize this person’s function and joy in life,” Kemle says. “Say this patient just wants to go across the street to visit her neighbor—getting her a rolling walker may do her more good and make her happier than all the cholesterol-lowering agents in the world.”
Meeting the needs of America’s aging population is going to require teamwork, whether that means pairing a family practice physician with a GNP or a geriatrician with a primary care PA. Clinicians may also need to acquire knowledge in areas they would typically leave to other professionals.
“If you’re doing an advanced directives family conference, or if you have to decide whether to place a PEG tube, these are complex discussions,” says Baker. “You have to have a little legal background, you have to know about psychosocial and family dynamics, and how to run a meeting where there might be different opinions and how to diffuse tension and move things along.”
All of this is daunting—but there will come a time when it is no longer optional.
PROACTIVE VS REACTIVE
What will it take for the US as a nation—and clinicians in particular—to act on this impending crisis? Given our penchant for being reactive rather than proactive, the silver tsunami may have to hit with all its force before the necessary steps are taken. Otherwise, patients and their families may have a lot to say about the care received (or not).
Every geriatrics provider has at least one story of an older patient whose ailment was missed or misdiagnosed. There is the woman who was seen twice in the hospital by an otherwise excellent neurologist, who missed her Parkinson’s diagnosis because the patient didn’t present with the expected tremors. Or the woman awaiting surgery for a fractured shoulder, who was about to be discharged to a house with multiple staircases where she lived alone, because no one thought to ask about her home situation (and with a prescription for Vicodin, no less, despite a previous hospitalization in which she had an adverse reaction to the drug).
Perhaps the most egregious case was the woman who wasn’t eating and who told hospital staff the reason was that her mouth hurt. No examination was performed, but a PEG tube was placed. Kemle saw the woman later in a nursing home and diagnosed candidiasis; within two weeks, the tube was removed. “Now, she didn’t have a complication from the tube,” Kemle says, “but I’ve seen three people die as a direct result of their PEG tubes. What a tragedy if this woman had had a complication from something she never needed.”
To be blunt: People have filed lawsuits for less.
Even if malpractice doesn’t become an issue, patient demand may force changes to the way health care is provided to older adults. Baby boomers are anticipated to be quite vocal about what they expect.
“Right now, we’re caring for an older population that pretty much says, ‘If you say so, doc,’” says Bakerjian. “But we’re going to be challenged more and more with the patient who comes in with his laptop and you’ll be talking and he’ll say, ‘Well, let me check that out on the Internet.’ There is a very demanding group of folks heading our way, and they’re going to want the best care they can get. That means we have to be ready for them.”
Expectations will be high and finances may be low—a classic recipe for widespread dissatisfaction. “I’ll be expecting to get the care that my dad gets now, in his mid-80s, and I won’t get that for the money I put into the system,” says Baker. “And my kids, who are in their 20s and in the working world, are going to be largely unhappy that they’re spending a huge amount of their salary just to support people like me.”
The only sure thing is that older adults are going to appear more and more in nearly every practice setting. The best things a clinician can do are accept and act.
“You’re not going to be able to escape the aging population—your practice is going to be more and more geriatric-infiltrated, whether you picked that specialty or you didn’t,” says Baker. “So accept the reality that you’re going to care for these people. And once you’ve accepted that, you need to get some of this specialized knowledge, through the CE/MOC process or postgraduate education. You need to seek out opportunities to become better at this particular set of competencies.”
And you’d better do it before Baker joins the geriatric set!