By the year 2050, more than 20 percent of the U.S. population is projected to be above the age of 65. The aging population is not only growing, but living longer than ever before, calling for additional and specially trained physicians. By the age of 75, the average American lives with two or three chronic medical conditions, some with several more, according to the American Geriatrics Society (AGS). In addition to needing management of care for chronic illnesses, aging populations have unique preventive care needs, and additional social, psychological and environmental factors also come into play.

Unfortunately, there is a shortage of physicians who specialize in geriatric consultative, primary and end-of-life care. The Division of Geriatric Medicine is working to ensure its fellowship trainees are well schooled in all approaches to and philosophies of caring for their aging patients.

The Division of Geriatric Medicine has established a new one-year Hospice and Palliative Medicine Fellowship program. The goal of which is to "promote excellence in hospice and palliative medicine education through the provision of a variety of clinical educational and research experiences in the field," says Marcos Montagnini, MD, fellowship program director. Dr. Montagnini completed his own fellowship training in geriatric medicine at U-M in 1998 and went on to develop a palliative care program in the Division of Geriatric Medicine at the Medical College of Wisconsin. He returned to U-M in 2007 to develop the palliative care fellowship program here, and to lead the palliative care program at the VA Ann Arbor Healthcare System.

Funding for the new program was awarded by the VA's Office of Academic Affiliations through a highly competitive process. The support is ongoing and supports positions for two fellows each year.

The comprehensive and multidisciplinary curriculum covers pain management and symptom control at the end of life as well as assistance in many other areas, including psychosocial and spiritual support, bereavement support for families, control of complications and co-morbidities that can cause life-threatening illnesses and optimizing function for quality of life. Fellows design and complete a scholarly research project with mentorship. Those who choose to pursue their research can continue their work during a second year.

One former fellow designed and conducted a survey of some 200 geriatric patients assessing attitudes about hospice and palliative care. Patients are often referred to palliative and hospice services very late in the disease process, explains Dr. Montagnini, so such services are underutilized. The data is still being analyzed but should yield new insights into patient-and physician-barriers to seeking these types of care.

During their fellowship year, trainees rotate through the VA Ann Arbor Healthcare System, University Hospital, Mott Children's Hospital and Arbor Hospice, a community-based hospice care facility. The VA rotation includes palliative care consultations for inpatients, outpatients and those receiving home-based care. Fellows work closely with faculty from numerous disciplines, including internal medicine, oncology, nephrology, geriatrics, surgery, family medicine, pediatrics, social work, psychology, and chaplaincy to hone their clinical and leadership skills. "It's an innovative program," says Dr. Montagnini, "because of its multidisciplinary nature and the range of passionate faculty and preceptors who are leaders in their fields." Fellows may go on to start a palliative care program at a hospital or health system or lead a hospice care program. Others may pursue additional training for academic research careers.

The division strongly supports the new program. "We need to have more physicians prepared to care for patients who have life limiting illness," says Dr. Montagnini, "and to understand the significant needs of their families as well. Several studies show a lack of physician preparedness for end-of-life care. Our goal is to address this gap."

Although the program is young, it has already attracted high-quality applicants. Current and former fellows will present three posters at the 2009 assembly of the American Academy of Hospice and Palliative Medicine.

The U-M Hospice and Palliative Medicine Fellowship program is in the first cohort, nationally, to receive accreditation by the Accreditation Council for Graduate Medical Education.

FROM LEFT TO RIGHT: Drs. Noel Javier, Erin Diviney-Chun, Marcos Montagnini, and Brandon Walters

The division also has supported a fellowship program in geriatric medicine since the 1980s. Division Chief, Jeffrey Halter, MD, led the program until 2002 (see article below). "Fellows have an extremely busy clinical year," says Robert Hogikyan, MD, MPH, current fellowship program director.

Trainees come from family medicine, internal medicine and a variety of other disciplines. They complete several rotations during their fellowship year, including gaining clinical experience in institutional long-term care at one of two community facilities. They provide geriatric medicine consultations at both the University and VA hospitals, and they receive training in hospice and palliative medicine through the VA hospital and Arbor Hospice. They also spend two months rotating through several sub-specialty clinics of the Geriatrics Center, including those focused on geropsychiatry, mobility and dementia care. A once monthly Geriatric Research Education and Clinical Center conference gives fellows a deeper understanding of topics related to physical medicine and rehabilitation, with interdisciplinary team presentations on numerous topics.

Research projects are encouraged, and fellows may pursue advanced training in the form of a second or even third year devoted to research. Some go on to additional training in sub-specialty areas such as oncology.

How fellows are evaluated and get feedback has evolved, particularly over the past year, says Dr. Hogikyan. In addition to traditional faculty evaluations, fellows receive input about their performance from patient satisfaction surveys and from nursing and administrative staff in the clinics through which they rotate. Specialized patient instructors, who are specially trained older adults, provide input from patients' perspective as well.

The entire experience adds up to compassionate, knowledgeable and experienced physicians: "It takes a certain type of person," says Dr. Hogikyan. "The person who chooses geriatric medicine has to enjoy working with older adults and with chronic illness and takes reward and reinforcement from those interactions. It takes a certain focus, one I think our trainees over the years have demonstrated with excellence."

LEFT TO RIGHT: Drs. Ji Won Yoo, Denise Flinn, Erin Diviney-Chun, and Robert Hogikyan

Jeffrey Halter, MD, director of the University of Michigan Geriatrics Center and Institute of Gerontology, was honored this year with the Nascher/Manning Award by the American Geriatrics Society. This prestigious and coveted award was presented at the society's annual meeting, held in Washington, DC in May.

Geriatrics Center Director Jeffrey Halter, MD

Established in 1987, the award honors Ignatz Leo Nascher, MD (1863-1944), an advocate for older adults who believed that medical care of the aged should be treated as a distinct specialty. He is credited with coining the term "geriatrics."

The Nascher/Manning Award is bestowed upon an individual who has demonstrated lifelong and distinguished achievement in the field of clinical geriatrics. Dr. Halter was chosen for his accomplishments and contributions as a "leader in the field of geriatrics, an educator and an author," in addition to possessing "outstanding qualities and skills the society wishes to honor."

Dr. Halter specializes in the treatment of diabetes in older adults. His research focuses on neuroendocrine regulation of metabolism in aging and in diabetes. He has published more than 250 research papers and book chapters and served as senior editor for the 6th edition of Hazzard's Geriatric Medicine and Gerontology (McGraw-Hill).

Dr. Halter has also shown tremendous leadership by directing the U-M Geriatrics Center, a collaborative initiative among 12 schools and institutes and 178 faculty to advance research into the health and healthcare issues of older adults and to provide top-notch clinical care. He has also successfully led the University's Institute of Gerontology, a hub of gerontological research, including many large multidisciplinary projects. In 2004 he oversaw the merger of the Geriatrics Center with the Institute in order to strengthen geriatrics- and aging-related work throughout the University. The clinical, research and training programs in geriatrics at U-M have been consistently ranked among the best in the United States.