Creating a Geriatric Medicine Fellowship Program in 10 “Easy” Steps

Authors


Address correspondence to Shannon Keane English, Grand Rapids Medical Education Partners/MSU Family Medicine Residency, Associate Program Director, Geriatric Fellowship Program, 300 Lafayette Ave SE, Ste. 3400, Grand Rapids, MI 49503. E-mail: englissk@trinity-health.org

Abstract

The aging of the U.S. population poses one of the greatest future challenges for family medicine and internal medicine residency training. One important barrier to providing quality education and training in geriatric medicine to residents is a serious and growing shortage of practicing geriatricians and geriatrics faculty. The Accreditation Council for Graduate Medical Education currently accredits 45 family medicine–based and 107 internal medicine–based geriatric medicine fellowships in the United States. There are 13 American Osteopathic Association–certified geriatric medicine fellowship programs. In this article, the authors examine the rationale for the development of additional geriatric medicine fellowship programs and offer some practical suggestions and pointers for those interested in developing their own geriatric medicine fellowships. The authors write from the perspective of their own recent experiences with the development and accreditation of a family medicine residency-affiliated fellowship in geriatrics. Other residencies may find this article useful in determining the feasibility of developing a geriatric medicine fellowship for their programs and communities and will find practical guidance for beginning the process.

According to the U.S. Department of Health and Human Services Administration on Aging,1 the number of adults aged 65 and older will increase to 72.1 million by 2030, representing 19% of the population. Demand for geriatricians to provide expert care to older adults is rising. Numerous training institutions are exploring creation of geriatric medicine fellowship programs to address the need for physician experts and faculty in geriatric care, to increase the number of practicing geriatricians in their communities, and to strengthen the geriatrics teaching and role modeling of core residencies for resident and student trainees.

Program directors and administrators may rightly ask, “Why create a new geriatric medicine fellowship program in our community when 50% to 67% of existing geriatric medicine fellowship positions go unfilled each year?” The rationale can be found in the idea that demand for geriatricians exceeds that of almost all other disciplines; if program size and number were based on learner interest, family medicine, general internal medicine, and general pediatrics programs everywhere should be closing at accelerated rates. The task has been to recruit intensively and from within residencies, increasing geriatrics providers and educators by offering the fellowships in the communities where residents train in their individual disciplines.

This article offers some lessons learned while starting an Accreditation Council for Graduate Medical Education (ACGME)–accredited, family medicine residency–sponsored geriatric medicine fellowship program and offers a potential framework for others beginning fellowship programs. This roadmap does not replace the ACGME program guidelines, and any question or conflict of information should be referred to a ACGME representative.2 When this program was set up, an ACGME representative was extremely useful in explaining any issues or questions about requirements quickly and directly answered communications.

STEP 1

Review ACGME program requirements for the core residency with which the fellowship will be affiliated. This is a great starting place and helps focus plans regarding what the process will entail.

Core ACGME residency programs in family medicine or internal medicine sponsor ACGME-accredited geriatric medicine fellowships. On the ACGME Web site, access “family medicine” or “internal medicine” and the documents for “Common Program Requirements,” “Institutional Program Requirements,” and “Program Director Guide to the Common Program Requirements.” The specific program requirements for geriatric medicine fellowship programs are found under the “Program Requirements”; review “Subspecialty Requirements” and “Geriatric Medicine.” The Program Information Form (PIF) is the summative document submitted to the ACGME for program approval. The Residency Review Committee meets three times per year. Submission deadlines for the PIF are 2 months before each meeting and are found on the main ACGME page under “Meetings & Workshops-RC Meetings.” PIFs for geriatric medicine fellowship programs are evaluated during the meeting for the core residency. A helpful frequently asked questions section for new program approval is on the main page under “Site Visit & Field Staff.” At the top of the main page is “Program Directors and Coordinators,” which also warrants a look, in particular “How to Apply for Accreditation in Seven Easy Steps.”

STEP 2

Determine the faculty and core program affiliation. For the current program, meetings with potential faculty to assess interest were begun 14 months before PIF submission. Geriatric medicine fellowship programs must have a designated program director, as well as one “additional key faculty member,” and maintain a faculty-to-fellow ratio of at least 1:1.5 if training more than two fellows. The program director must possess an ACGME Certificate of Added Qualifications in geriatric medicine; experience in geriatric medicine, education, and scholarly activity; and a career commitment to academic geriatric medicine.3

The “additional key faculty member” must have qualifications similar to those of the program director and devote “a substantial proportion of time” to the training program. Family medicine residency requirements include a minimum of one FTE of faculty time per six residents.4 One might extrapolate this to geriatric medicine fellowships and surmise that, for a new fellowship program training two fellows, the program “should” plan on 33% of this, or a 0.3 FTE physician devoted to fellowship activities, supervision, and didactic or clinical teaching.5 Program directors must document in their PIFs the time spent in administration, research, didactic teaching, and clinical supervision. Although no specific percentage of time representing “adequate” time devoted by the geriatric medicine fellowship program director to the program was found, family medicine core program requirements specify that program directors devote at least 1,400 h/y (∼27 h/wk or 3 d/wk) to resident administration, teaching, precepting, and attending duties exclusive of patient care time without residents. In internal medicine core program requirements, the sponsoring institution must provide 50% support or at least 20 hours per week for the program director, who is required to devote an average of 20 hours per week to the subspecialty (geriatrics) fellowship program.6 One proposed breakdown of support for new faculty is summarized in Table 1.7

Table 1. Example of Annual Budget
PersonnelFull-Time EquivalentWages, $Benefits, $
  1. Used with permission: Geriatrics Fellowship Development: An Analysis of Community Resources and Projected Costs. John E. vanSchagen, MD. Family Medicine Digital Resource Library (online). Available at http://www.fmdrl.org/index.cfm?event=c.beginBrowseD#1998.

Fellow1.050,36314,605
 Program director0.119,000
 Core faculty0.115,000
 Program coordinator0.14,3001,247
 Contracted personnel 6,300 
 Total personnel 94,96315,852
Operations
 Supplies (office, medical, educational, audio/visual, stationery)  2,000
 Telecommunications (pagers, voice, fax, data)  140
 Postage and shipping  500
 Photocopies 150
 Subscriptions and publications200
 Dues, licenses, and fees  2,000
 Recruitment and public relations (e.g., brochures, advertisements, etc.)  2,000
 Nonresident education (e.g., travel, lodging, meals, course fees)  5,000
 Resident education (e.g., travel, lodging, meals, course fees)  5,000
 Miscellaneous expenses  1,000
 Graduation  1,000
 Fellow meals  4,400
Total operations  23.3%
Total fellowship budget  134,205

Sometimes confusion arises regarding perceived but incorrect limitations on a geriatric medicine fellowship program based upon whether its core program is family medicine or internal medicine or whether the program director or faculty is internal medicine or family medicine or has a doctor of medicine (MD) or doctor of osteopathy (DO) degree. Program directors of internal medicine or family medicine geriatric medicine fellowships can be family medicine or internal medicine physicians, and fellows in family medicine or internal medicine programs can be MD or DO internists or family physicians, but the program director of an ACGME fellowship program must have completed an ACGME (not American Osteopathic Association) geriatric medicine fellowship program.

STEP 3

Secure funding for faculty, educational materials, and fellows. Meet with the program director for the core residency, who will have extensive knowledge of trainee funding and sources of educational support. The ACGME has published guidelines on institutional funding of trainees.8

Traditionally, the training and benefits costs of residency positions and faculty and administrative salaries are funded through the Centers for Medicare and Medicaid Services (CMS) using a formula derived in the mid-1970s under the Better Business Act. Based on the determined need per hospital, CMS placed a “cap” on the number of residency positions funded and continues to fund training on this basis. The cap is hospital specific, but the sizes of programs can change if cap positions are transferred within the hospital between different training programs. For instance, the family medicine residency could grow by one resident per class if the internal medicine residency decreased its class size by one resident per class if both are at the same hospital. Positions may be available at a hospital “under the cap” when a residency or fellowship has closed, or gone unfilled, and a new geriatric medicine fellowship program could assume these. More commonly, there will be no available CMS funding above the cap. In these cases, funding for a geriatric medicine fellowship program, including fellow and faculty salaries, must be obtained through direct institutional sponsorship, the Department of Veterans Affairs, private philanthropic foundations, grants including from the Health Resources and Services Administration (HRSA), and donations.7,9

In addition to funding cap limitations, CMS funds are available only for training in the resident's initial board certification specialty (not to exceed 5 years or 1 year past the formal training period in “combined” primary care specialties). CMS funding is reduced by 50% for subsequent (fellowship) training except for geriatric or preventive medicine training, which is still funded at 100%.10 This CMS exception for geriatric medicine fellowship positions under the cap is often misunderstood and may make a big difference in the justification of fellowship costs to a sponsoring institution.

Although work and patient visits performed by a fellow may not fully support the fellow's salary and benefits, the value of a fellow's billable patient encounters will partially offset training costs.

Some changes under the Patient Protection and Affordable Care Act provide incentives for residents to do geriatric medicine fellowships, and hospitals will create new jobs for geriatricians interested in contributing to an accountable care organization. Ultimately, supply and demand could affect an excess of specialists who may not be reimbursed well enough in the future (because of constraints under accountable care organization structures) and increase the need for geriatricians to assist with transitional care and cost-effective post- and subacute care. For example, one large university hospital system increased its geriatrics faculty from eight to 30 by being market savvy and helped to fix cost overrun problems that previously could not be addressed effectively; now the hospital is covering 60% of the geriatricians' salaries because of these doctors' significant savings to the system.

Offer solid reasons why a fellowship program is a good idea and locally necessary. Develop a sales pitch and present it frequently to whichever institutional officers will listen. Review the Institute of Medicine's report Retooling for an Aging America and the associated documents.11 Prepare solid reasons why your institution needs to train specialists in elder care, including financial benefits and ways in which geriatric medicine specialists improve patient care and decrease hospital length of stay and readmission rates. Collect facts and specific examples demonstrating need for better geriatric care in your community. A useful article that summarizes the process of analyzing community resources and projected costs affiliated with geriatric fellowship development is available.7

Finally, do not to allow lack of definite funding to prevent proceeding to subsequent steps. Attainment of ACGME accreditation and the associated prestige may well be the final push needed to “find” fellowship funding.

STEP 4

Decide how many training spots you will offer. Program size will depend on funding and available CMS-funded positions “under the cap,” as well as availability of philanthropic or hospital support of training costs. Rotation training sites and available geriatrics faculty will also be determinants. One can choose to seek ACGME accreditation for four fellows and subsequently choose to train only two fellows per year, but one cannot train six fellows when accredited for fewer.

STEP 5

Roughly plan out the block and longitudinal rotations, mandatory conferences, and research. One of the challenges in creating a new geriatrics program is the lack of specific rotation block guidelines, as exists for internal medicine or family medicine residencies. Fellows must gain “adequate” or “sufficient” experience in various areas, but guidelines are frustratingly silent or pleasantly liberating regarding specific rotation scheduling. The vagueness may be intentional, to allow programs with varying resources (e.g., a community with no geropsychiatry facility) to flex their program to the available experiences and design an “away rotation” rather than a longitudinal experience to meet certain experiential requirements.

For family medicine–geriatric medicine fellowships, fellows need 12 months of full-time training experience, which includes a geriatric consultation program, a longitudinal 12-month experience in long-term care (including hospice and home care), ambulatory care accounting for 33% of the fellow's time (including home care, adult daycare, home hospice, outpatient rehabilitation), and geriatric psychiatry. Most programs include 2 to 3 months of subacute rehabilitation, 2 months of physical medicine and rehabilitation, 2 months of hospital medicine, 1 month of hospice, 2 months of geropsychiatry, and 1 to 2 months of electives (Table 2). According to current ACGME guidelines for family medicine5 and internal medicine6 geriatric medicine fellowships, fellows must spend one half-day in ambulatory work of their “primary specialty” (family medicine or internal medicine). An additional 1 to 2 half-days are spent in a primary care geriatrics office and 1 to 2 half-days in their long-term care practice. Geriatric medicine fellowships must also facilitate contact with a mentor from the primary specialty of each fellow.5,6 Although mentorship work in one's “primary specialty” had previously been encouraged only in family medicine–geriatrics programs, these are also noted in the ACGME requirements for internal medicine–geriatrics programs. Finally, other programs were searched online and their structures, faculty, block, and longitudinal rotation schedules, program outlines, and didactic and lecture schedules and content reviewed.

Table 2. Example of Rotation Schedule
MonthFellow 1Fellow 2
  1. Longitudinal rotations: half-day per week in office of fellow's primary specialty (family or internal medicine); 2 half-days per week in Geriatric Health Center (primary care outpatient geriatrics); 1–2 half-days per week in retirement community (long-term care nursing home and assisted living); half-day per week lecture or didactics.

JulyHospice or palliative careGeropsychiatry
AugustInpatientGeropsychiatry
SeptemberSubacute rehabilitationInpatient
OctoberGeropsychiatryInpatient
NovemberGeropsychiatrySubacute rehabilitation
DecemberInpatientSubacute rehabilitation
JanuaryInpatientHospice or palliative care
FebruaryPhysical medicine and rehabilitationElective
MarchPhysical medicine and rehabilitationInpatient
AprilElectivePhysical medicine and rehabilitation
MaySubacute rehabilitationPhysical medicine and rehabilitation
JuneSubacute rehabilitationElective

Programs can choose to adhere to a traditional July 1 to June 30 training year or to accept fellows “off cycle” beginning during different months. This could improve a program's fill rate, allowing residents who complete their initial residency training late (or graduate off cycle) to become fellows.

STEP 6

Plan lectures and didactics. Review the ACGME Program Requirements in Geriatric Medicine for family medicine5 or internal medicine6 regarding lectures and didactic curriculum. Consider whether you will have a lecture for half a day each week, one noon lecture daily, or some other arrangement. The ability to recruit faculty for these lectures affects their timing, scheduling, and locations. Plan out how you will monitor and evaluate the didactic instruction fellows receive. Many institutions fold fellows into existing Grand Rounds, distance learning, online educational modules, or residency lecture series with specific geriatric content to help meet this requirement; these alone cannot comprise your entire didactic educational plan. Plan out core lectures that the geriatric medicine fellowship faculty will provide, as well as any required online or off-site experiences.

STEP 7

Network and generate curriculum documents. Identifying an experienced geriatrics program director who will mentor your new geriatric medicine fellowship director is extremely helpful. Membership in the Association of Directors of Geriatric Academic Programs is important. A nearby program, a colleague across the country, your own former program director, or a new contact garnered from a recent meeting of the American Geriatrics Society may be willing to share or critique curriculum documents. Consider affiliating or networking with nearby experts at teaching institutions or a division of geriatrics at a university medical school. A HRSA grant to the Department of Family Medicine at Michigan State University College of Human Medicine prompted and supported the authors' own experience with developing a new geriatric medicine fellowship program. Through this grant, a network of geriatric medicine fellowships across the state was developed to share resources, curricula, evaluation processes, and mentorship. Your program generates curriculum documents, which are submitted with your PIF to summarize your program and the individual block and longitudinal rotations that constitute the fellows' experiences in competency format. Each should note how the rotation will teach, monitor, and assess mastery of requirements in the core competencies.12 The Portal of Geriatric Online Education provides access to numerous resources, including a competency-based fellowship curriculum guideline.13

STEP 8

Generate and sign Program Letters of Agreement (PLAs). PLAs are the formal one- to two-page letters of agreement between the training institution and other institutions training fellows submitted with the PIF to the ACGME. They are generated with any other facility where fellows will do a required formal rotation not governed by the sponsoring institution and list the faculty, the responsibilities for teaching, evaluating, and supervising fellows, the content and duration of educational experiences, and the policies and procedures governing fellow education. Most of this can be addressed in a short statement referring back to the curriculum, program policies, and procedure documents. PLAs are not required for sites where the fellow does elective work. PLAs exist already between your sponsoring institution and other institutions providing training experiences for residents; review these. Unless your institution's existing PLAs specifically mention “geriatric fellows,” generate new PLAs specifically addressing training of geriatric medicine fellows. The ACGME has published a guideline for PLAs.14

STEP 9

Review and complete your PIF. If you are like most, you began the process by reviewing the Program Requirements and PIF on the ACGME website. When you are ready to complete the PIF in earnest, even if you have a saved or partially completed PIF that you have been working on all along, return to the ACGME Web site and download a new copy of the PIF from which to generate your final document for submission. Based on our own unfortunate experience, the PIF template occasionally undergoes revision and may do so during the time you are completing it. The questions asked, as well as the order in which questions are presented, can change dramatically. Submitting a previous format of PIF that the ACGME has subsequently updated will be less likely to promote a successful result. Obtain the latest version of the PIF and recheck this in the weeks immediately before submitting your final draft. Begin work on your PIF as soon as you are able and plan on its submission early; in our experience, we started working on the PIF 14 months before its submission (Table 3). You cannot receive an ACGME program accreditation number until your PIF is approved; this occurs without a site visit and without your program necessarily being “up and running.” Graduates of unaccredited programs do not qualify to sit for the Certificate of Added Qualifications examination in geriatric medicine. Assuming your program gains accreditation successfully at any point during fellows' training, they will be able to take the examination. Lack of accreditation during recruitment may become problematic because fellows may favor ACGME-certified programs. Although it may be helpful to assure applicants that your application is in process, it is understandable that lack of certification and an ACGME program number will make your program harder to find and less appealing for applicants. Unaccredited programs are not listed in most Web site databases or with the National Resident Matching Program (NRMP).

Table 3. Timeline of Experience
16 months before: Meet with faculty, hospital administrators; gauge interest
14 months before: Work on Program Information Form (PIF), curriculum, faculty, funding
2 months before: Submit PIF and all supporting documents
ACGME approval of new geriatric medicine fellowship program
0–1 year after: work on correction of any issues noted in approval process
2–3 years after: ACGME site visit

STEP 10

Actively begin recruiting geriatric fellows. Many geriatric medicine fellowship programs are located in urban areas or are affiliated with a large, university-affiliated hospital system. Consider who your fellows might be and where they will come from. Many prospective fellows from community-based residency programs may gravitate toward community-based fellowship programs, and we have built our program, which is networked with five other similar programs15 and Michigan State University, with this in mind. The most obvious sources of fellows are the residencies in your health system. Plan on recruiting fellows from early in their residencies, encouraging medical student and resident trainees with great geriatrician potential to do a geriatrics elective rotation and participate in the American Geriatrics Society conference or the American Medical Directors Association Foundation “Futures” program as attendees or presenters. Consider other nearby residency programs with graduates choosing to further their training locally. Target these programs with a recruitment letter and do a geriatric didactic teaching lecture, pitching the fellowship then. Work with your information technology department to build a fellowship Web site modeled after your core residency's page; link to it from that page as well as from other residency programs. Review Web sites of your core program as well as other geriatrics programs to see what applicants see when they search for fellowship programs. There may be practicing or pre-retirement physicians who are interested in retooling or shifting gears, so it is important to publicize your new program within your hospital, other nearby hospitals, and the local community.

Consider registering for the NRMP. Most programs currently fill outside the match, accepting applicants on a rolling basis. Benefits include signing highly desired fellows “on the spot” and filling fellowship positions early in the recruitment year. Fellowships adhering to the match could find that many desirable applicants had already accepted other positions. Many fellowship directors may soon choose to sign up to fill at least some of their positions using the NRMP match; benefits include ease and standardization of application, a designated “interview season,” and availability of a complete database of potential fellowship sites for applicants on the NRMP site. Fellowship programs can choose to fill some, all, or none of their positions using the NRMP match.

Geriatric medicine fellowship program positions have consistently increased since 1998, although the number of positions filled began declining in 2007.11 Plan on working hard to fill each position offered. Recent data indicate that only 54% to 67% of available geriatric medicine fellowship positions filled in the past 5 years.9,16 With a growing number of programs being developed9 and nearly 35 new geriatric medicine fellowship programs gaining accreditation since 2005,17 the effort required to recruit fellows for any given program will grow.

CONCLUSION

We successfully recruited our first fellow from within our university-affiliated residency programs and are currently seeking our second fellow for next year. Geriatric medicine fellowship programs are useful and rewarding additions to communities and to teaching programs, and interest in geriatric medicine and care of older adults has made development of such programs more attractive. We recommend starting the process early, 12 to 24 months before planning to start your first fellows, and proceeding through the outlined steps, referring to current ACGME guidelines. It is anticipated that new joint family medicine and internal medicine geriatric medicine fellowship program requirements will be released for comment in the near future. We hope that guidelines applicable to internal medicine and family medicine geriatric medicine fellowship programs will clarify existing requirements and streamline the development of new fellowship programs in geriatrics. It is important that new programs maintain close contact with the ACGME after accreditation, to maintain awareness of new or changed program requirements and to work on any citations or deficiencies in preparation for the upcoming site visit.

ACKNOWLEDGMENTS

The authors wish to thank Dr. William Short, Family Medicine Program Director of the Marquette Family Medicine Residency Program in Marquette, Michigan, and Dr. Walter Nieri, Geriatric Fellowship Program Director of the Banner Health Geriatric Fellowship Program in Sun City, Arizona, for suggestions and review of this manuscript.

Conflict of Interest: Both authors are employed by and receive portions of their salaries from the Grand Rapids Medical Education Partners/MSU Family Medicine Residency Program.

Author Contributions: English: original writing and layout of paper, direct involvement with and firsthand knowledge of development of geriatric fellowship program. vanSchagen: major revisions and edits of paper, contributions to original writing, direct involvement with and firsthand knowledge of development of geriatric fellowship program.

Sponsor's Role: None.