When considering the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai, with its international reputation for scholarship, education, and leadership, it’s hard to overstate the revolutionizing contributions of Rosanne M. Leipzig, MD, PhD, Gerald and May Ellen Ritter Professor, Geriatrics and Palliative Medicine.
As the first clinician educator in Mount Sinai’s history to be granted tenure, Dr. Leipzig overhauled the Brookdale Department’s approach to education and played a critical role in creating the modern geriatrics fellowship program and, subsequently, the national integrated geriatrics and palliative medicine fellowship program. Under her leadership, one in five geriatricians in the United States received their training at Mount Sinai. She is also an internationally recognized leader in geriatrics and evidence-based medicine and has received numerous awards for her work.
In 2021, Dr. Leipzig stepped aside from her position as Vice Chair for Education and assumed a new role as Vice Chair Emerita. Now, with a new book coming out in the fall of 2022, Honest Aging: An Insider’s Guide to the Second Half of Life, Dr. Leipzig is looking ahead to envisioning and implementing new solutions for today’s older adults. She explains more in this Q&A.
When you first came to Mount Sinai, what were the needs you identified and the changes you started enacting?
I came to Mount Sinai 25 years ago. At that time, the field of geriatric medicine in the United States was still pretty new and not really understood by many of our colleagues. No one questioned the need for pediatricians to care for children because their physiology, illnesses, disease presentations, responses to medications, and psychosocial needs differed greatly from those of adults. But they didn’t get that the same is true for older adults, as well. Most doctors who cared for older adults considered themselves ‘geriatricians’ by experience, even though they had never had specific training in geriatrics medicine. At times this could result in delayed diagnoses, adverse medication effects, inappropriate treatments, and lack of awareness of community resources that can greatly aid persons in their care.
Mount Sinai recognized this and started the first department of geriatrics in a U.S. medical school 40 years ago, assuring that every medical student had as much training in geriatrics as they did in pediatrics or obstetrics and gynecology. Think about it: Almost all doctors care for older adults in their practices, very few provide care to children or deliver babies. But Mount Sinai was one of the first, if not the first, medical school to require training in geriatrics, just as they did in pediatrics and ob-gyn.
What specific steps did you take?
I was recruited to be Program Director for the Geriatrics Fellowship, and soon I became the Vice Chair for Education. As I started to redesign the Fellows’ curriculum, it became clear that our field had not distinguished between what students, residents, geriatrics fellows, and practicing physicians needed to learn about caring for older adults. We were teaching everyone everything. To remedy this, and also to make it clear how geriatrics differed from usual adult medicine, we spearheaded a national project to develop consensus on the knowledge and skills every graduating medical student needed so they would be competent caring for older adults on the first day of their internship. We followed this with competencies for residents and then for geriatrics fellows. These competencies are used throughout the country to develop educational experiences for trainees, as well as our own Continuing Medical Education courses, including mini-fellowships in geriatrics for non-geriatricians.
Deciding what to teach was just part of the need. Physicians also need to be taught how to teach because it is engaging and exciting teachers who pass their passions on to their students, and thus to patients and families. We invested in training, sending some of our faculty for a month-long immersive experience at the Stanford Faculty Development Center for Medical Teachers. In return, they taught what they had learned to our faculty and fellows. This training continues to this day. The Brookdale Department is now known for having some of the best geriatrics and palliative medicine teachers and educators nationally and at Mount Sinai. The fellows we trained have become the backbone of our current faculty. Some of our faculty are in top leadership positions at Icahn Mount Sinai, while former fellows hold similar positions throughout the country.
"Not every older person needs a geriatrician as their primary care provider. But all doctors caring for older adults need to have a basic knowledge of geriatrics."
-Rosanne M. Leipzig, MD, PhD
How did you change the fellowship program?
Attracting the best and the brightest to our fellowship program was another area I identified as a critical need early on. Geriatrics and palliative medicine may not appeal to young physicians-in-training for several reasons, including the complexity of the patient care (which actually is what attracted many of us into the field), how difficult it can be to help these complex patients in our broken health care system, and the huge debt many incur for their education—which unfortunately influences their choice of field. We have met this challenge by focusing on training the next generation of leaders in the field, and have created novel, attractive, innovative training programs.
For example, working with the American Board of Internal Medicine, fellows in other medical specialties such as gastroenterology or cardiology are now allowed to spend one year of their fellowship in geriatrics so that upon graduation they can be board certified in both specialties. Will they practice primary care geriatrics? Probably not, but they will infuse geriatrics into the care of their patients, their specialties, and their teaching. We developed the first integrated geriatrics and palliative care fellowship, started a geriatrics-internal medicine residency program. Now we are working on mid-career fellowships in geriatrics and palliative medicine, since doctors often recognize how critically important these fields are after having practiced medicine for a while.
Fast forwarding to today, what are some new challenges in geriatrics that trainees face, and how can clinician educators help prepare them?
The biggest challenge we face is how to provide appropriate care to the ever-increasing number of older adults. When I started working in geriatrics, 12 percent (one in nine) of the population was 65 and older. Now it's closer to about 17 or 18 percent (more than one in 6). Not every older person needs a geriatrician as their primary care provider. But all doctors caring for older adults need to have a basic knowledge of geriatrics.
We need to think outside the box for how to best care for these patients and to train non-geriatricians in ‘Geriatrics 101.’ Older adults are cared for by specialists when they are ill. Our fellows are learning to co-manage patients with surgeons, neurologists, cardiologists, and other specialists both in the hospital and in the community. We’re helping health systems become “age-friendly.” This is really exciting and requires skills that weren’t part of a traditional fellowship—learning about leadership and how to do quality improvement with an interdisciplinary team. Our faculty has developed a robust quality-improvement program for our trainees that focuses on concerns within our practice and hospitals.
Can you give an example of changes that are happening?
More patient care is occurring in non-hospital settings, however even in 2021, physician training is still primarily with hospitalized patients. For older adults in particular, hospitalization can result in significant loss of function and requiring post-hospital stays in rehabilitation settings. Geriatrics clinician-educators work with hospitals to improve these outcomes for older adults, and are skilled in caring for patients in new models of care such as Hospitalization at Home, Palliative Care at Home and Visiting Doctors, medicine for the homebound.
Most physicians have not been trained in well-functioning, interprofessional outpatient practices with social workers, nurse practitioners, and pharmacists. Geriatrics clinician-educators have the skill and expertise to teach trainees a systematic way to provide patient-centered care, deal with guidelines that may not apply to their older patients, and access community resources such as blister packs for medications, physical therapy, low-vision centers, and support and education for those caring for people living with dementia.
Most doctors feel that the electronic medical record (EMR) is a blessing and a curse. We’re trying to make it more of a blessing by harnessing and “geriatricizing” it, improving the care of older adults throughout Mount Sinai Health System. For example, we have changed the medication dosages listed for people 65 and older, making it more likely that the correct doses for older adults are prescribed. In the EMR, we have created an easy-to-use template for Medicare Annual Wellness Visits, so even non-geriatricians will know if their older patients are falling, having memory problems, or need help to improve their safety at home. We developed a new algorithm to identify which inpatients are at the highest risk of falls using data from the EMR. Whenever new data are entered, the algorithm is updated, providing staff with their risk of falling, why this is happening, and what can be done to decrease the risk. Several more projects are in the works, including making it easier to identify patients who are frail.
Could you talk about your work with naturally occurring retirement communities (NORCs)?
The traditional concept of a nursing home is anathema to a lot of baby boomers. They are seen as storage centers, not places to live. This is changing, however many people still don’t want to leave their homes. NORCs allow people to age in place. In New York City, most people live in high-rise apartment buildings, and the Department for the Aging has identified complexes with large numbers of older adults as NORCs. NORCs enhance the sense of a community and have social services, educational programming and entertainment, and some health services.
For the last five years, Joyce Fogel, MD, Associate Professor, and Gregory A. Hinrichsen, PhD, ABPP, Associate Professor, and I have been collaborating with the Penn South NORC in Manhattan. With support from UJA-Federation of New York, we have developed programming for residents, caretakers, and family members. We've also been providing training and case conferences for the staff nurses and social workers, and we’re collaborating with a wonderful interior designer who specializes in age-friendly spaces. We’re developing a “dementia-friendly NORC” by educating all to be alert that some of their neighbors may be having difficulties and who to contact if this is the case. The education extends to the security and building staff. A donor has now committed money for an onsite day care center for those living with dementia.
How are you helping Mount Sinai continue to lead in geriatrics care?
The first thing I've done is to make room for the next generation of educational leaders. Our faculty is extraordinary, with great vision and drive, and they’re ready to take the next step as vice chairs and program directors. They will make sure that Mount Sinai continues to be No. 1 in geriatrics care. I will continue as a mentor and colleague to them and the rest of our faculty, using my many years of experience and connections to help them in any way I can.
My new portfolio includes community engagement. A secret weapon in our attempt to assure that the increasing numbers of older adults receive appropriate medical care is to educate older adults and their loved ones as to what that care is. The more they know what’s coming, what’s normal, and what may be concerning—and what they can do to improve their health and well-being—the more they will be able to have honest discussions with their providers and families, make wise choices about their health care, and make sure their medical care aligns with what’s important to them. This is the purpose of my new book, Honest Aging: An Insider’s Guide to the Second Half of Life, and of my new portfolio. I’ve been connecting with community centers, aging-in-place groups, faith communities, and others to identify the topics most important to their participants, and I am working with our faculty and fellows to design interactive, engaging workshops, talks, and “ask the doctor” sessions that combine information with skills and lists of local resources.
What is next for you personally, and for Mount Sinai, in terms of its service to the geriatrics community?
I still see patients at The Mount Sinai Hospital and at the Martha Stewart Center for Living Uptown. That’s what renews my passion to keep going to improve care for older adults. I just turned 70, so as a “geriatric geriatrician” I have insights that I didn’t have when I was younger, experiencing the challenges to aging in this country. I’m also spending more of my time teaching medical students, residents, and fellows, as well as the other members of our interprofessional care team.
One of the things I'll be doing is spending a lot of time on the road—on Zoom or in person—promoting my book, the field of geriatrics medicine, and Mount Sinai. I hope to raise awareness of ageism and to advocate for policies that enhance the opportunities for older people to have healthy and full lives.
When you look at the Mount Sinai program, what are you most proud of, or what do you think has been most valuable in terms of contributions to the field?
The physicians we trained, whether they specialized in geriatrics, palliative medicine, or another discipline. The approach to the care of older adults that they learned at Mount Sinai is changing the care of older adults in all settings across the globe. Many of our graduates work within academic medicine, some work to improve the care of older adults who are homebound, incarcerated, members of Native American tribes, living in other countries, and more.
Our graduates hold leadership positions throughout the country and have developed innovative models of care, research, and education. At Mount Sinai Health System, two of our hospital presidents are graduates of our fellowship program, as is the president and CEO of the New Jewish Home, our major nursing home affiliate, and our current Brookdale Department Chair Dr. Sean Morrison.
We have expanded the definition of what it means to be a geriatrician or a palliative medicine physician, taught our trainees how to accomplish change in large systems like medical centers, and incorporated leadership training into the fellowship program. Colleagues at Mount Sinai understand what geriatricians do, both for the individual patient and family, as well as to improve care of older adults in health care systems. It is a privilege and an honor to be a part of making this a reality.