VA Site Directors: Andrea Schwartz, MD MPH (Geriatrics); Lara Skarf, MD (Palliative Care)
With nearly half of all living veterans aged 65 or older (va.gov/vetdata), clinical training in geriatrics is critical to continue to innovate and adapt the VA’s health care system to meet the needs of older veterans. VA Boston serves as a key training site for the Harvard Medical School Multicampus Geriatrics Fellowship, a premier training site for clinicians and leaders in the care of older adults. After completing residency in Internal Medicine or Family Medicine, geriatrics fellows spend a year rotating through different sites of care for older adults, including the hospital, home care, nursing home, and clinic. The Harvard program includes rotations at Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Hebrew Senior Life, Mount Auburn Hospital and PACE (Program for All Inclusive Care for the Elderly). At VA Boston, geriatric fellows participate in two core rotations: Palliative Care and Outpatient Geriatrics.
Fellows spend about 6 weeks on the inpatient Palliative Care service, under the leadership of Dr. Lara Skarf, where they learn to care for veterans with serious illness and those at the end of life. Working with an interdisciplinary team which includes a nurse, social worker and chaplain, fellows assist with pain and symptom management, goals of care discussions and hospice referrals. During their palliative care rotation, Geriatrics fellows work alongside a Palliative Care fellow in the new VA/BIDMC Palliative Care Fellowship, as well as medical students and residents, and participate in educational seminars on topics such as leading code status conversations, running family meetings, managing nausea, and pain at the end of life.
The outpatient Geriatrics rotation at VA Boston, led by Dr. Andrea Wershof Schwartz, provides an opportunity for fellows to learn about interdisciplinary care of older adults in the ambulatory setting, as care of older patients increasingly requires both team-based care as well as involvement of multiple specialties. Fellows work in the geriatrics consult clinic, working along side staff and trainees from pharmacy, social work, nursing and neuropsychology, to care for older veterans referred for polypharmacy, frailty, falls or cognitive impairment, among other reasons. This unique training experience brings together learners from different disciplines, who each offer their perspective in a pre-clinic huddle to review the veterans undergoing geriatric assessment that day. The VA Geriatrics clinic also serves as a continuity clinic site for one fellow each year.
As technology changes, the outpatient Geriatrics rotation has grown to include experience in VA Boston’s Telegeriatrics program, which brings the team virtually to veterans at CBOCs (Community Based Outpatient Clinics) where geriatric expertise is not available on site. Fellows also rotate through specialty clinics serving older veterans, including Physical Medicine & Rehab, Neurology Memory Clinic, Osteoporosis, ALS and Preventive Cardiology clinics. Fellows spend time learning from clinicians to whom older adults are frequently referred including occupational, kinesio and physical therapy, audiology, optometry, podiatry, speech pathology, prosthetics, and Driver Rehab. Additionally, fellows participate in the VA’s My Life My Story initiative, under the leadership of Dr. Susan Nathan, which collects veterans’ life review narratives as a tool to help care teams get to know them, and improve patient and provider satisfaction. The VA Geriatrics outpatient rotation continues to expand and seek new partnerships to best prepare geriatricians for caring for older patients using a team-based approach.
After their clinical year, some graduates of the Harvard Geriatrics fellowship spend a second year engaged in scholarly work, where they join 2nd year Boston University Geriatric fellows in the New England GRECC – Geriatrics Research Education and Clinical Center (va.gov/grecc). Fellows work with mentors to develop projects in geriatrics that range from educational, clinical innovation to population research; this past year the fellows’ projects included work with the VA Home Based Primary Care team, the Harvard Medical School geriatrics curriculum, and the VA Geriatrics-Renal clinical pilot.
Recognizing the need for all clinicians to gain skills to meet the needs of the aging population, geriatrics fellows in the Harvard program participate in a Medical Education curriculum, led by Dr. Schwartz, in which they expand their skill sets as teachers and educators. Through a seminar series, regular feedback on their presentations and a mentored teaching experience precepting geriatrics home visits with first year Harvard Medical Students, they graduate geriatrics fellowship well prepared to teach what they have learned. Graduates of the fellowship go one to become geriatricians in a variety of clinical settings, including primary care, consult geriatrics, inpatient, hospice, home visits, nursing home, PACE and rehab, as well as leadership roles in health policy, medical education and population management. As more veterans reach their 8th and 9th decades of life, the VA continues to serve as a leader in adapting health care systems to best meet their needs; VA Boston serves as a leader in training the next generation of geriatricians.