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Preparing for an aging boom
By Anita Martin

Embracing end-of-life care

In addition to holistic care and human contact, Snyder’s passion for geriatric medicine is fueled by concerns about how the U.S. manages chronic illnesses and palliative care.

“I think that particularly end-of-life issues are where we, as a medical profession, fail,” Snyder says. “We’re taught to do everything possible at all times—that people aren’t supposed to die, which is ridiculous.”

Snyder recalls a patient from her internal medicine rotation—for a month and a half he couldn’t breathe without a respirator, and he showed no signs of improvement. Snyder asked her attending physician at what point he planned to suggest hospice, an organization that helps patients with terminal conditions—and their families—to cope with the process.

“He looked at me like he was insulted. He just said, ‘I’m not giving up,’” Snyder says. “No one would talk to this dying patient about hospice. I think a lot of docs feel like a failure when a patient dies, even with older patients. They’re just not willing to face it. As a result, patients suffer and so do physicians.”

Snyder believes that the inability of physicians to accept and cope with death contributes to the low popularity of geriatric medicine, where death rates are relatively high. She suggests that all medical schools provide training in death and dying.

“There’s surprisingly little medical school preparation in this area,” says Tracy (Thompson) Marx, D.O. (’92), assistant professor of family medicine. “But (at OU-COM) we offer a range of classroom and clinical training on death and dying, hospice and palliative care.”

The curriculum integrates interactive and multimedia approaches, including a simulated patient lab on breaking bad news and the reading of Confessions of a Reluctant Caregiver, written by playwright Merri Biechler, M.F.A., evaluation assistant in the Office of Academic Affairs.

Marx has noticed that patients increasingly expect better end-of-life care, and she expects that trend to continue. “As baby boomers get older, they’ll demand better palliative care. We’re trying to dispel fears and myths about death and dying among our students.”

Advocating for change

Kyle Allen, D.O. (’86), believes that the nation’s delayed reaction to the impending geriatric medicine workforce crisis reflects a “collective denial of aging and mortality.”

 “There’s still this fountain of youth concept, a kind of belief that death may actually be optional,” says Allen, medical director of post acute and senior services for the Summa Health System Division of Geriatric Medicine.

“Every airplane has its own flight plan; each one must descend at a different slope,” he says. “We all have our own way to land, so to speak, but we don’t do a good enough job of managing these natural trajectories of older patients or patients with chronic illnesses.”

At any given time, one or two OU-COM students work with Allen in Cuyahoga Falls General Hospital, an affiliate hospital of Summa Health and a CORE teaching hospital, where Allen serves as clinical associate professor of geriatric medicine. Summa has increased the geriatrics rotation from two to four weeks because of its robust teaching programs for aging and geriatric medicine, reflecting how much value Allen and his colleagues place on the field.

“Training in the care of older adults must be more emphasized in medical and other allied health professions,” Allen says, adding, “I believe OU-COM is ahead of most medical schools in that area.”

Allen teaches students that the role of the geriatrician, and any doctor dealing with chronic conditions, is to optimize the “glide path.” This can be tricky business with elderly patients, as they frequently suffer from multiple, ongoing conditions.

A 2000 survey found that nearly 70 percent of adults over the age of 65 report at least one chronic condition, with the highest numbers coming from Medicare beneficiaries. This creates a major problem when it comes to physician payment, Allen says, considering how Medicare reimbursements work.

Medicare, like most third-party providers, pays physicians to perform procedures, such as colonoscopies, bypass operations or hip replacements. It won’t pay for preventive or ongoing managed care, that is: the time physicians spend assessing patients’ needs or talking to them about improving lifestyle trends.

“We need to realize that aging is a process, not an event, and we need to reform how we train—and how we compensate—physicians and other health professionals so that they can manage that process proactively, not respond to events,” Allen says. “At Summa, we’re finding innovative ways to do that.”

Summa Health System, a not-for-profit that includes six hospitals and eight medical centers in Northeastern Ohio, offers its own insurance plan, SummaCare, to patients. This cuts out the third-party provider system, so instead of paying an insurance company’s administrative costs and additional fees—which factor in a 20 percent profit margin for stakeholders—extra money can be reinvested directly into the health system to improve medical service.

As a result of this innovative provider model, Summa was one of just four hospitals out of 3,700 nationwide picked by MedPAC, the Congressional advisory panel for Medicare, for further study on cost and quality.

Allen, who also serves as chief medical officer for the Area Agency on Aging board of directors, devotes a great deal of professional energy toward reforming health care policy, particularly for older adults. He directs the new geriatric medicine fellowship at Summa Health, and he recently began a fellowship of his own. He was accepted into the Practice Change Fellow Program, designed to expand and improve leadership in promoting quality care to older adults. These efforts help to inform his research; he is currently the principle investigator for two National Institutes of Health grants studying innovative care models for older adults.

“I’m motivated by being an agent of change,” Allen says. “I think that my training at OU-COM reinforced that. It’s what osteopathic medicine is all about. Dr. (Andrew Taylor) Still was an advocate for change, because he saw that the current system didn’t work. When geriatricians are paid less for more training; when insurance creates disincentives for higher quality care—we need to recognize what doesn’t work about the current system, and work toward change.”

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