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“No Placefor Sissies.”The next big health challenge for older patients may not be their ageBy Bobbie FisherThere’s an iconic photograph of movie legend Bette Davis holdingan embroidered pillow that says, “Old age ain’t no place forsissies.” For her it was true: in her biography, she wrote that she wasterrified of getting older. Perhaps she foresaw the statistics that areworrying many in the healthcare profession today.In March 2013, the American Geriatrics Society published adocument entitled, “The Demand for Geriatric Care and the EvidentShortage of Geriatrics Healthcare Providers.” The document listedthe following:The report noted that it is estimated that approximately 30,000geriatricians will be needed by 2030 to accommodate these patients.Unfortunately, the report went on to say that far fewer medicalstudents are pursuing advanced training in geriatrics. Americans are living longer and therefore are accumulatingmore diseases and disabilities. One in five Americans will be eligible for Medicare by 2030. Those 65 and older are expected to account for almost 20%of the US population by 2030. About 80% of older adults require care for chronicconditions, such as hypertension, arthritis and heart disease.8 www.hrphysician.comMore than a year later, the statistics are still unsettling.The June 8, 2014 online edition of The Wall Street Journal featured anarticle by writer Barbara Sadick, confirming that not only are fewerresidents choosing the extra year of training required to becomea geriatrician, those going into other specialties typically get littleexposure to the special health needs of the elderly during the courseof their training.Given how many Americans are aging, what accounts for theshortage? Sadick offers this observation: “[Medical students]discover that in a fee-for-service, volume-based system, caring forolder Americans isn’t nearly as lucrative as other medical specialties,partly because office visits with frail seniors typically run longerthan average so the volume is less. Some may avoid the field because Older adults account for a disproportionate share ofhealthcare services: 26% of all physician office visits; 35% of all hospital stays; 34% of all prescriptions; 38% of all emergency medical responses; and 90% of all nursing home use.caring for the elderly often means making patientscomfortable, not curing them.”Another reason, not touched upon by Sadick,might well be the inherent difficulty of dealingwith aging patients whose capacities may have beencompromised by advanced years. These older patientscan be demanding, argumentative, stubborn andnotoriously hard to communicate with.Whatever the reason, it’s hardly a new phenomenon.Dr. Ignatz Leo Nascher, who coined the word‘geriatrics’ in 1909, was a champion of geriatricmedicine throughout his professional life. Accordingto the published history of Mt. Sinai Hospital, whichestablished the first academic geriatrics departmentin the United States, Dr. Nascher encounteredindifference and often the outright censure of boththe medical establishment and the public for hisbelief that geriatrics should be recognized as a majorspecialty of medicine. Dr. Nascher’s published research includedthe first US textbook on geriatric medicine in 1914: Geriatrics: TheDiseases of Old Age and Their Treatment.Dr. Nascher’s belief is now accepted in the mainstream. In 2006,geriatrics was formally recognized by the American Board of MedicalSpecialties as a subspecialty within Family Medicine, InternalMedicine and Psychiatry & Neurology. And in a July 2007 BritishMedical Journal article, author Dr. A. M. Clarfield wrote, “Muchmaterial, especially that on therapeutics, is of course dated. However,the clinical approach described and, above all, the spirit of hopeexpressed in [Dr. Nascher’s] book are as relevant today as they werealmost a century ago.”Of course, any comprehensive discussion of geriatrics also meanscontemplating what patients, caregivers and doctors alike can bereluctant to talk about: how to recognize – and prepare for – thetime it becomes evident a geriatric patient’s life is drawing to a close.The October 15, 2014 episode of the NPR program Here and Nowfeatured an interview with surgeon and Harvard medical professorDr. Atul Gawande, about his recently published book, Being Mortal:Medicine and What Matters in the End. Dr. Gawande describes,from a surgeon’s point of view, the decision-making process aboutcare at that point. A staunch advocate of palliative care and hospiceservices, Dr. Gawande describes several cases where these serviceshave sustained the quality of a terminal patient’s life – even if it meantshortening that life. Talking to patients, explaining that even at thatstage, they can have a choice, is a profound gift, he writes: where onepatient might wish only for comfort and ease and lucidity, anothermight be willing to put up with great pain in order to experience afuture milestone like a wedding or a birth. Recognizing the specialrole each can play in the life of a geriatric patient, the American Boardof Internal Medicine recently added Hospice and Palliative Care as aseparate Board certification.Above all, it’s important that doctors know what theirpatients want. Physicians and other healthcare providers knowfar too well the devastating and far-reaching effects of trying to offercompassionate and appropriate care to patients whose wishes aren’tknown. Talking about advanced care planning may not be easy, but itmight well be one of the most important conversations a doctor willever have with a patient.At the end of the day, as the following pages of this magazinewill demonstrate, Hampton Roads is blessed with a medicalcommunity skilled in providing care for older Virginians at everystage of their lives – even at the end – and dedicated to educatinga new generation of physicians who will put the lie to Bette Davis’fears. In 21st Century Hampton Roads, old age is a place in whichto thrive. Obesity is a disease.Help your patients lose weightwithout surgeryChoose Dr. Gaglione’s practice whereyour patients will lose weight , and learnhow to eat for nutrition. Treatment and EducationMargaret MacKrellGaglione, M.D., FACP Treatment and maintenance programs available; mealprograms and grocery store food programs available;use of pharmaceutical therapeutics as appropriate.Tidewater Bariatrics is the only full in-clinic HMR program inthe state of Virginia.1405 Kempsville RoadChesapeake757.644.6819www.twb4u.comFall 2014 Hampton Roads Physician 9

Robert M. Palmer,MD, MPHJohn Franklin Chair of Geriatrics, EVMSDirector, Glennan Center for Geriatrics and GerontologyDr. Robert Palmer took a somewhat circuitous route to thedirectorship of the Glennan Center for Geriatrics andGerontology. He says he was born to be a doctor, but didn’t realizeuntil he was in medical school that he was destined to become aninternist – and it wasn’t until 10 years after his residency that hewent into geriatric medicine. The two compelling passions thathave inspired him throughout a nationally distinguished career havebeen internal medicine – “It offers the combination of taking care ofpatients and focusing on the mechanisms and treatment of disease,”he says – and working to improve the way healthcare is delivered, onboth a small and grand scale.He received his medical degree from the University of Michigan atAnn Arbor, and as his interest in public health continued to grow, heearned a master of public health at the University of California at LosAngeles. He calls those years transformative. He worked for the LACounty Department of Health Services in Pico Rivera, a primarilyMexican-American community, where with funding from the NationalHeart, Lung and Blood Institute, he was principal investigator anddirector of a program to create hypertension screening, detection andtreatment in the community. That program, he says, has been thetemplate for everything he’s done throughout his career.From LA, he took a position at Oregon Health Sciences UniversityMedical School in Portland, ultimately being appointed director ofthe internal medicine residency program.At that time, geriatrics was a new specialty, not yet a certifiedfellowship program. “There was such a lack of understanding abouthow to take care of older people,” he says. “Our knowledge of agingwas almost non-existent.” In geriatrics, he saw opportunities both asan educator and a community advocate to enter a field that clearlyneeded champions.After pursuing a fellowship in geriatric medicine at UCLA, hemoved to Cleveland and joined the faculty at Case Western ReserveUniversity Medical School. With his colleagues at Case, he created acomprehensive geriatrics program focusing on hospital, long-term andoutpatient care.10 www.hrphysician.comHe became research partners with Dr. Seth Landefeld, a generalinternist and kindred spirit. “We wanted to figure out a cost effectiveway to take better care of hospitalized patients, in a continuousquality improvement process,” Dr. Palmer says. Their work becameknown as Acute Care for Elders – or ACE – a nationally recognizedmodel that offers enhanced care for older adults in speciallydesigned hospital units, delivered by an interdisciplinary team ofmedical professionals, including geriatricians, advanced practicenurses, social workers, pharmacists and physical and occupationaltherapists. The care in an ACE unit is compassionate and patientcentered, with a demonstrated measurable reduction in the lengthof hospital stays for these patients. In addition, the costs are lesson an ACE unit than on typical care units. Despite this, Dr. Palmersays, “We’re still struggling to get this model of care to becomestandard practice.” The National Institutes of Health agrees: in arecent abstract, NIH researchers wrote, “Low presence of ACEunits warrants further research as to reasons more hospitals have notincluded them, given the available evidence for clinical, functional,and economic benefits.”Dr. Palmer assumed the directorship of the Glennan Centerfor Geriatrics and Gerontology in 2011, and he has attacked thatposition with the same zeal and innovation that marked his otherendeavors. Since his arrival, the Glennan Center has collaboratedwidely with other departments at EVMS in a variety of researchand educational endeavors, and continues to strengthen its ties toorganizations within the community.The faculty of the Glennan Center enjoy clinical practice inoutpatient, nursing facility, and palliative care settings. The MemoryConsultation Clinic performs detailed evaluation of patients withcognitive decline through a comprehensive team approach to boththe medical and psychosocial needs of the patient and caregivers. Dr.Palmer and his colleagues are expanding the practice and the researchprogram, adding a Geriatrics Consult clinic to provide a comprehensivegeriatric assessment for frail seniors, with recommendations given to thepatient, family and referring physician.He is working with Dr. Marissa Galicia-Castillo toexpand clinical programs in hospital and long-termcare-based palliative medicine: “We’re now providinginpatient palliative care consults in two Sentarahospitals and a Sentara skilled nursing facility. We’realso directing a palliative care and hospice programin collaboration with our partners at Beth SholomVillage and Jewish Family Services.” He’s also aconsultant at one of the Sentara hospitals that featurean ACE Unit, and direct Geriatric Medical Services atSentara Norfolk General Hospital.His commitment to improving the quality ofresident education in geriatrics is evident. “We’reheavily engaged in teaching of all learners at EVMS,”he says, “medical and physician assistant students,residents in internal medicine and family medicine,and fellows training in geriatrics. This past year welaunched a grant to train Chief Residents of ninedifferent departments in the principles of geriatricpractice, patient safety and quality improvement.”Future plans for the Glennan Center includecreating innovative, sustainable clinical programs tobenefit the seniors in the community, and to expandresearch in geriatric safety, palliative care and dementia.With its community-based health care partners, theGlennan Center is ready to implement the “TripleAim”-to improve the patient experience in all sitesof care; to improve the health of the elderlypopulation of Hampton Roads; and toreduce the costs of health care.“The challenge for us now,” he says, “isto more deeply engage the communityin advocating for even better care for ourseniors.” Fall 2014 Hampton Roads Physician 11

Teresa L. McConaughy, MDMedical Director, Riverside House CallsDr. Teresa McConaughy and Dr. Paul Evans have a lot in common. They’re both Boardcertified in Family Medicine; they’re both Assistant Clinical Professors of FamilyPractice at Virginia Commonwealth University. They’ve both dedicated their careers tocaring for the at-risk older population.They also happen to be husband and wife – and while they both did their residencies atRiverside Regional Medical Center, they’re quick to note that Dr. McConaughy went tomedical school in the South (Medical University of South Carolina College of Medicine) whileDr. Evans earned his MD in the North (at the University of Connecticut School of Medicine).The two physicians met while they were both on the faculty of Riverside Family Practice,in the residency program. “At that time, geriatrics wasn’t really a fully established specialty,”Dr. Evans says. “There were people doing geriatrics for many years, but there wasn’t formalspecial training.” When the fellowship in geriatrics was introduced, Dr. Evans became itsfirst director.Dr. Evans and Dr. McConaughy both enjoyed the residency program and genuinely likedteaching, but ultimately decided to leave the faculty and go into practice. They joined theCommonwealth Family Practice in Newport News, where they treated men, women andchildren. “There were a lot of geriatric patients,” Dr. Evans says, “and eventually, Riversideasked us to start a new practice in Grafton, Patriot Primary Care, in 2006. We stayedthere until 2013.”He also began doing geriatric consultative work at the Center for Excellencein Aging in Williamsburg (now the Center for Excellence in Aging andLifelong Health, or CEALH), working with patients with early geriatricsyndromes. Through the Center’s research arm, Dr. Evans and hiscolleagues were working with new medicine and other innovativetreatments for Alzheimer’s disease. He serves as principal investigatorfor clinical studies at CEALH.“And then, PACE had just opened in Hampton,” Dr. Evans continues. “Dr.Petitjean, who had served on the residency faculty with us, was the primaryphysician at the program, which had quickly grown to 70 or 80 participants. Dr.Petitjean was still doing some teaching at the residency program, so they askedif I would be willing to help out. I began splitting my time between PatriotPrimary Care and PACE. That transitioned to full time at PACE, which inturn transitioned to my being named Medical Director at PACE.”When Dr. Evans left Patriot Primary Care, Dr. McConaughy sayshe bequeathed her many of his patients, adding to her already largepractice. “I had been thinking about leaving the office practice, andlooking for ways to do geriatrics differently,” she remembers. “I love12 www.hrphysician.comPaul E. Evans, III, MDMedical Director, Riverside Program ofAll-Inclusive Care for the Elderlyfamily practice; I was enjoying taking care of babies and adolescents and all other ages that camealong with family practice, but I was evolving as a physician.“With older patients,” she says, “I loved listening to them, I liked hearing their life stories, andgetting to know them and their families. And I wanted to be able to provide care that wouldbetter help them transition to wherever they were going.”When Dr. Kyle Allen came to Riverside in 2011, he brought a number of innovativeideas with him, one of which was establishing a house calls practice. “It wasn’ta novel idea,” Dr. McConaughy says, “as they’re in existence all across thecountry, mostly in the midwest. But it was definitely a novel idea forRiverside.” It was an idea that touched her personally, as she hadseen her own mother’s health decline in the final years of her life,and understood immediately how a program of regular homevisits could benefit such patients.Today, as Medical Director of Riverside House Calls, Dr.McConaughy cares for more than 130 patients, seeing eachone about once every four weeks. “In a busy practice, I mighthave 15 minutes with a patient in an exam room,” she explains.“Now I can manage my time to accommodate a half hour to 45minutes in their home, whatever time it takes. And I can spend the time I need tospend to do a better job taking care of these incredibly amazing people.”Part of taking care of these patients can involve conversations about sensitivetopics like advanced care planning and end-of-life decision making. “Both Pauland I look at it as part of our responsibility to initiate the conversation and helppeople articulate their wishes,” Dr. McConaughy says. “It’s one of those thingsthat too often gets shoved under the rug, and unless we bring it up, patientswon’t bring it up. So we have to do it in a way that expresses our commitmentto respect their wishes and needs, so that they know we’re guiding their carebased on what they want.”The physicians’ paths don’t often cross these days, they say, although theysometimes have the opportunity to send each other patients. “Typically, Imight wave to her on I-64 if I see her car going by,” Dr. Evans says, “and she’llwave if she sees mine.”They acknowledge some of the same stresses inherent in caring for older,frail patients with complex medical conditions. “We share stories of ourpatients,” Dr. Evans says. “We ask what the other would do in a particularsituation. We share the joys and some of the hardships – and we alwayslearn from each other.” Fall 2014 Hampton Roads Physician 13

MarissaGalicia-Castillo, MDDr. Marissa Galicia-Castillo is an anomaly:born in Hampton Roads, she attendedcollege and medical school in HamptonRoads, completed her residency and internshipin Hampton Roads, and did her fellowship inHampton Roads. An early interest in scienceand medicine drew her to the Magnet Schoolfor Health Professionals, a collaboration formedin 1986 to initiate early preparation for highschool students for careers in the healthprofessions through innovative biomedicalcurriculum and mentoring. She attendedOld Dominion University for three years,completing her fourth and final year atEVMS, graduating in 1994 with a degreei

Medicine. He is a member of the Sentara Taskforce for Joint Replacement surgery and is the Board President at the Sentara Obici Ambulatory Surgery Center. Silvina M. Bocca, MD, PhD, HCLD Reproductive Endocrinology and Infertility Dr. Bocca is an Associate Professor of ObGyn at EVMS. She is Board certified in Reproductive Endocrinology and .