1. Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD David Sandvik, MD James Campbell, MD

2. Complementary and Alternative Approaches to Fellow Recruitment Kevin Foley, MD Division Head of Geriatrics and Geriatrics Fellowship Program Director Michigan State University

3. Disclosures None (all presenters)

4. Learning Objective Review several “vital signs” reflecting the health of the specialty of geriatric medicine: the past, recent trends, and a forecast for the future.

5. We Need More Geriatricians!

6. Comparison of Number of Certificates Awarded to Number of Active Certificates in Geriatric Medicine (Family and Internal Medicine) Source: ABIM (Lou Grosso), ABFM (Gary Jackson), and ABMS. Data used with permission and compiled by Libbie Bragg and Gregg Warshaw, University of Cincinnati. Updated 2015

7. Geriatrics Fellowship Programs 1991-2 to 2013-4 Family Medicine Academic Year ProgramsFellows (All Years) Fellows > 2nd Year (% of all fellows) First Year Positions Available Fellows in 1 st Year Positions (% Filled) Fellows Completing Program 1991-9217 --- 1993-941617---21---7 2000-012328 3 (11%)4525 (56%)29 2009-104154 1 (2%)9553 (56%)65 2010-114564 09564 (67%)71 2011-124456 010256 (55%)69 2012-134165 5 (8%)9860 (61%)62 2013-144152 2 (5%)9450 (53%)64 Source: AMA and AAMC data from National Survey of GME programs, JAMA 1992-2014. Data through 2010-11 compiled by Geriatrics Workforce Policy Studies Center.

8. Geriatrics Fellowship Programs 1991-2 to 2013-4 Internal Medicine Academic Year ProgramsFellows (All Years) Fellows > 2nd Year (% of all fellows) First Year Positions Available Fellows in 1 st Year Positions (% Filled) Fellows Completing Program 1991-9275181--- 1993-9482208---142---111 2000-0196293 71 (24%)292222 (76%)247 2009-10107242 22 (9%)394220 (56%)294 2010-11104237 22 (9%)393215 (55%)284 2011-12105219 24 (11%)388195 (50%)273 2012-13105246 10 (4%)388236 (61%)275 2013-14105267 11 (4%)383256 (67%)276 Source: AMA and AAMC data from National Survey of GME programs, JAMA 1992-2014. Data through 2010-11 compiled by Geriatrics Workforce Policy Studies Center.

9. Geriatrics Fellowship Programs 1991-2 to 2013-4 Family Medicine and Internal Medicine Academic Year ProgramsFellows (All Years) Fellows > 2nd Year (% of all fellows) First Year Positions Available Fellows in 1 st Year Positions (% Filled) Fellows Completing Program 1991-9292198--- 1993-9498225---163---118 2000-01119321 74 (23%)337247 (73%)276 2009-10148296 23 (8%)489273 (56%)359 2010-11149301 22 (7%)488279 (57%)355 2011-12149275 24 (9%)490251 (51%)342 2012-13147311 15 (5%)486296 (60%)337 2013-14146319 13 (5%)477306 (64%)340 Source: AMA and AAMC data from National Survey of GME programs, JAMA 1992-2014. Data through 2010-11 compiled by Geriatrics Workforce Policy Studies Center.

10. Certification and Re-Certification by Year of Original Certification Family MedicineInternal Medicine Year Certified First Re-cert Second Re-certCertified First Re-cert Second Re-cert 1988752482 (64%)282 (38%)1,659830 (50%)426 (26%) 1990473318 (67%)196 (41%)1,204562 (47%)246 (20%) 1992597375 (63%)242 (41%)1,254650 (52%)292 (23%) 1994771415 (54%)234 (30%)1,568774 (49%)274 (17%) 1994 was the last year candidates could sit for the certification examination without completing fellowship training Source: Lou Grosso, ABIM & Gary Jackson, ABFM. Data used with permission and compiled by Libbie Bragg and Gregg Warshaw, University of Cincinnati. Updated 2015

11. Certification and Re-Certification by Year of Original Certification Family MedicineInternal Medicine YearCertifiedFirst Re-certification CertifiedFirst Re-certification 1996254123 (48%)291169 (58%) 199810352 (50%)337231 (69%) 19992819 (68%)183117 (64%) 20002722 (81%)200140 (70%) 20012118 (86%)193132 (68%) 20023024 (80%)270189 (70%) 20035340 (75%)262168 (64%) 20047242 (58%)256138 (54%) Source: Lou Grosso, ABIM & Gary Jackson, ABFM. Data used with permission and compiled by Libbie Bragg and Gregg Warshaw, University of Cincinnati. Updated 2015

12. National Survey of Allopathic and Osteopathic Geriatrician Academic Leaders – 2010* 51% of medical schools reported < 9 FTE geriatrics physician faculty Estimated 1,549 FTE geriatrics physician faculty in 159 medical schools Estimated 249,910 FTE supply of primary care physicians in 2015 † 39% of geriatrics program directors planned to relinquish leadership role by 2015 *Bragg, EJ, Warshaw GA, et al. J Am Geriatr Soc 60:1540-1545, 2012. † HRSA. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand, 2008.

13. Program Directorship Changes 2009-2014 Academic Year Newly Accredited FM/IM Programs FM/IM Programs with Withdrawn Accreditation Delta FM/IM Programs with at least 1 New Program Director Change 2009-201093+615 2010-201142 +26 2011-201221 +118 2012-201310 +125 2013-20142316 Source: ACGME Data Resource Books, 2009-2010 to 2013-2014.

14. ARE YOU PLANNING TO BECOME CERTIFIED IN A SPECIALTY? Specialty200920102011201220132014 Family Medicine6.4%5.6%6.3%5.9%6.2%7.3% Internal Medicine 16.0%15.3%15.8%16.1%16.4%17.3% Overall number of responses to question regarding all specialties 9,35611,15010,27810,16711,23012,041 Total FM + IM2,0962,3302,2712,2372,5382,962 AAMC, Medical Student Questionnaire, All Schools Summary Report, August 2013

15. Projection of the Number of Certified Geriatricians in 10 Years* Obs.YearForecastSTDL95U95 19201562320.04557046794 20201662900.05256686961 21201764020.05857077159 22201861360.05854696862 23201959580.06252686713 24202058030.06550946581 25202158370.07250556704 26202257490.07449636624 27202356580.07648606550 28202454890.07846996373 *Auto regressive integrated moving average (ARIMA) model for time series forecasting. Analysis provided by Yuning Hao, MS, Dept. of Statistics and Probability, Michigan State University

16. Summary Over the past 5 years The numbers fellows in first year positions, positions available, and fellows completing training have remained fairly constant. The number of fellows in the second year of training and beyond has decreased. Program directors have turned over at an increasing rate, possibly due to retirement.

17. Summary For geriatricians certified prior to the fellowship eligibility requirement, first re-certification rates are lower when compared to those after 1994. Second re-certification rates are very low. Of all geriatricians who were required to complete fellowship training, only 63% have re-certified for the first time (55% for 2004).

18. Summary There are now 6,256 certified geriatricians, the lowest number since 1994. The current influx of fellows is not enough to counterbalance the harmful effect on our ranks of low recertification rates. The number of certified geriatricians could fall below 6,000 by 2019.

19. Summary If new methods of recruiting trainees into geriatrics fellowship programs are not considered, the number of geriatricians will probably continue to decline and lead to a further increase in the shortage of geriatric medicine clinicians and educators. The alternative pathway to certification is one of those methods.

20. Recruitment of Mid-Career and Part-Time Practicing Physicians David Sandvik, MD University of South Dakota (USD) Sanford School of Medicine (SSOM) Evangelical Lutheran Good Samaritan Society Geriatrics Fellowship Program Director

21. Objectives 1.Review evidence that mid-career and practicing physicians are interested in geriatrics training. 2.Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics. 3.Review logistic barriers to training mid-career and practicing fellows and creative solutions. 4.Suggest new sources of geriatrics-trained physicians.

22. USD SSOM Fellowship History USD SSOM is SD’s only medical school –Community school with immersion model –Four primary campuses –Eight Farm and Rural Medicine (FARM) sites –Highly developed distance education infrastructure Fellowship accredited in 2011 Three of the first four graduates were mid-career physicians No fellows were matched in the 2014 Match Part-time track initiated for practicing physicians

24. Objectives 1.Review evidence that mid-career and practicing physicians are interested in geriatrics training.

25. Board Certification History IOM. 2008. Retooling for an aging America: Building the health care workforce.

26. Survey of all Practicing Primary Care Physicians in Arizona:1992* 702 of 1011 complete responses (69%) 242 would consider a geriatrics fellowship (33%) –2-year fellowship: 30% likely or very likely –1-year fellowship: 44% likely or very likely –Mini-fellowship: 74% likely or very likely –Part-time fellowship: 87% likely or very likely *Abyad A. Factors influencing the decision to enter a geriatrics fellowship. Educational Gerontology 2000;26:97-105.

27. AMDA Certified Medical Director (CMD)/American Board of Post-Acute and Long-Term Care Medicine (ABPLM)* Number certified since 1991: >3500 Current CMD’s: 2140 Percent recertified at least once: 73% Mean yearly certifications 2010-2015: 165 Partly online program the last two years Numbers are limited by space in face-to-face sessions *Personal Communication: Suzanne Harris, Director AMPLM

28. USD SSOM Recruitment History Part-time track initiated for practicing physicians –Word-of-mouth advertising One completed application withdrawn before starting One rural physician without FM or IM residency (unqualified for accredited track) –Recruitment letter to supporting health system Four inquiries Two hospitalists part-time fellows One physician boarded in two non-FM/IM specialties (unqualified) –One mid-career applicant accepted in Nov. 2014 –Other physicians have expressed interest

29. Evidence that Practicing physicians Will Pursue Geriatrics 1.Geriatrics Board Certification History 2.Survey of Arizona Physicians 3.AMDA’s Certified Medical Director (CMD)/American Board of Post Acute and Long Term Care (ABPLM) Numbers 4.USD SSOM Recruitment Experience

30. Motives for Practicing and Mid-Career Physicians to Pursue Geriatrics Training Desire to change practice style: burnout, etc. Desire for professional development and prestige: Confirmed in Abyad study (40%) Desire to improved the quality of care for older patients

31. Objectives 1.Review evidence that mid-career and practicing physicians are interested in geriatrics training. 2.Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics.

32. Training Mid-Career and Practicing Physicians is Good for Fellowships Fellowship curriculum must remain highly relevant New pathway into geriatrics for US graduates –Many become hospitalists –Many begin practice for financial and social reasons Educational debt Starting families –They could consider a part-time program

33. Training Mid-Career and Practicing Physicians is Good for Geriatrics Part-time pathways could be built into all fellowships Provide improved care of older patients in existing clinical sites, since trainees continue in current practices Increase the visibility of the specialty of geriatrics

34. Objectives 1.Review evidence that mid-career and practicing physicians are interested in geriatrics training. 2.Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics. 3.Review logistic barriers to training mid-career and part-time practicing fellows and solutions.

35. Logistical Barriers and Solutions to Training Practicing Fellows Relevance of education –Adult Learning methodology –Training is more of a collaboration –Solicit referrals from local Alzheimer’s Associations –Arrange outreach consultation days at nursing homes to see patients on antipsychotics, etc. Develop novel educational experiences –Nursing home night call added for weeks when fellows come off night call and miss a half day. Counted as less than hour-for-hour daytime learning experiences, but counted

36. Logistical Barriers and Solutions to Training Practicing Fellows Definition of part-time pathway: 2000 hours of approved education Schedules –Start training when the physician is ready –Every-other month or week? Location –Utilize physician’s personal practice for continuity clinics, nursing home panels and rotations: Send a roving faculty member to attend experiences –Develop distance learning technology seldom used in GME –Develop distant rotations with local geriatricians (multi-campus model fellowship)

37. Objectives 1.Review evidence that mid-career and practicing physicians are interested in geriatrics training. 2.Review why training mid-career and practicing physicians is a good idea for fellowships and the specialty of geriatrics. 3.Review logistic barriers to training mid-career and part-time practicing fellows and solutions. 4.Suggest new sources of geriatrics-trained physicians.

38. Sources of Geriatric-Trained Physicians I Traditional post-residency pathway Mid-career and practicing physician pathway Start more convenient, local fellowships –None of our past or current fellows would have moved away for a one-year fellowship, then returned –Satellite fellowships model (Michigan) –Multi-campus model (South Dakota)

39. Sources of Geriatric-Trained Physicians II Non-family/internal medicine-trained physicians (PM&R, Surg., Occupational Med.,etc.) –Train in a para-ACGME-accredited pathway –“Board certification” would require changes in board-eligibility Recertification of geriatricians who have allowed certification to lapse?

40. Sources of Geriatric-Trained Physicians III Convince health systems of the value of geriatrics and geriatricians –Concentrate on services requiring geriatrician such as patient discharges to SNF units –Systems might send their physicians for training –Systems might provide stipends –Two of our four graduates are Directors of Geriatric Services in health systems that had no geriatric services

41. Fellowship Part Time Alternative Pathway James Campbell MD, MS Fellowship Directors May 13, 2015 Pre-Conference National Harbor, Maryland

42. Learning Objectives Understand basics of why to offer Appreciate need for stakeholder assessment Understand how to do environmental assessment Comprehend multidimensional value assessment Steps to success Pitfalls to avoid

43. Background Work force –Supply –Demand –Total –Geographic mismatch –Program size mismatch

44. Assumptions Willingness to train is enough –What about money? –What about time? –What about location?

45. Assumptions Historical –Preconceived ideas –New program recent history –Worst case last 10 years –Best case last 10 years –Who weighs in?

46. Assumptions Culture –Academic –Research –Teaching –Productivity –Mission and vision statement

47. Stakeholder Assessment Patients Community –Service organizations –Government City Regional State Federal –Philanthropic community

48. Stakeholder Assessment Health System –Faculty –Operations Administration –Finance Administration –Chair –Service Line Director –CMO –CEO –Board

49. Value Added Business Case Story development Audience Service line alignment Revenue levers* –Average revenue Price Collections Case mix –Volume New patients Physical capacity Operational capacity * Weatherhead drivers of financial performance

50. Analyze on a System Perspective Capacity management Operational efficiency Effect on other service lines / departments Effect on GME Through-put

51. Beyond the Numbers Culture change –Behavior –Process

52. Change Certainty –Funding –Economy –Policy –Clinical practice

53. Steps to Success Recruitment Pre-approval Curriculum Accreditation

54. Pitfalls to Avoid Work with the Board of the applicant GME funding issues Billing issues Call Vacation Continuity clinical experiences