PERSPECTIVES OF GERIATRICS BY PIONEERS IN AGING
A Quarter Century in Developing Geriatric Programs at Three Academic Health Centers: Highlights and Lessons Learned William R. Hazzard, MD
I
n 1975, Bob Petersdorf, my Medicine chair at the University of Washington (UW), called me to his office and without preamble asked me to assume leadership of the nascent program on gerontology and metabolism recently initiated in his department at the Veterans Administration (now called Veterans Affairs) (VA) Medical Center by Ed Bierman, my research mentor (who had just agreed to move to University Hospital as head of Endocrinology and Metabolism). Petersdorf extended his hand, I shook it, and the deed was done: no negotiations about positions, space, or salary and little discussion of its mission other than his stipulation that geriatric medicine—the medical care of elderly adults— needed to be added to gerontology (the study of aging) as the program grew toward divisional status. Why did I immediately accept this offer? Most of all because I respected and trusted Bob, we loved Seattle, and I needed a job! At the time I was a 39-year-old untenured associate professor and investigator of the Howard Hughes Medical Institute (HHMI) as Director of the National Heart, Lung, and Blood Institute–funded Northwest Lipid Research Clinic (NWLRC) at Harborview Medical Center, the safety net public teaching hospital in central Seattle. I had learned over my decade at the University of Washington that this new and growing medical school was conceived in an academic model heavily dependent on National Institutes of Health (NIH) funds and that to remain on the faculty, I would have to assume an important departmental role, even while effectively remaining self-supporting from nongovernmental sources, NIH research grants and clinical funds. At Harborview, I could leverage NWLRC resources to direct my research toward a program of preventive gerontology, with special focus on hormonal modulation of the sex and gender differential in lipoprotein metabolism, cardiovascular disease, obesity, diabetes mellitus, and
From the J. Paul Sticht Center on Aging, School of Medicine, Wake Forest University, Winston-Salem, North Carolina. Address correspondence to William R. Hazzard, Professor of Internal Medicine, Section on Geriatrics and Palliative Care, J. Paul Sticht Center on Aging, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157. E-mail: [email protected]
longevity, and as a young medicine faculty attending physician active on the wards, I was a familiar face to faculty and house staff at that busy inner-city hospital. So, impulsively entrusting my future to my charismatic chairman, I placed my fate in his hands—but with no real sense at the time of what opportunities and challenges I would face in my new career in gerontology and geriatric medicine. Thus, with the continuing support of Ed Bierman, we set out to build the “SeniorCare” geriatrics continuum at Harborview with encouragement from leaders there in hospital administration, nursing, and social work. Most instrumental in my education in this field was a full year of sabbatical study (with HHMI support) in 1977–78. Upon the advice of (Sir) Paul Beeson, recently recruited by Petersdorf to the University of Washington from Oxford, our family spent the year in the United Kingdom for me to study the British approach to geriatrics as a visiting lecturer in their famed National Health Service. In Oxford, geriatrics was a department in its own right, centered in the Cowley Road Hospital, a nineteenth-century institution on a “poor farm” campus, and had little connection with the Department of Medicine or the rest of Oxford University near the center of town. Suffice to say that, although I treasure indelible memories and lessons learned from that year, I returned to Harborview convinced that in the United States, geriatric medicine should be developed at the most prestigious academic health centers (AHCs) on the same platform of excellence in cutting-edge research as any other NIH-funded specialty to ensure that “the best and the brightest” would be attracted to our futuristic field—an upward-directed trajectory that would be selfsustaining and in the best interest of aging and elderly Americans to extend their “health span” until very near the end of their God-given life span. So I returned to Harborview and the NWLRC determined to earn the continuing respect of University of Washington colleagues and leverage our resources through NHLBI-funded metabolic clinical research with the assistance of talented metabolism fellows and faculty. Early on, this seemed promising, especially when our first geriatric fellow, Marsha Fretwell, a charismatic former chief resident recommended by Petersdorf, proved a veritable Pied Piper to students, residents, and future fellows, and the
DOI: 10.1111/jgs.12844
JAGS 62:1179–1183, 2014 © 2014, Copyright the Author Journal compilation © 2014, The American Geriatrics Society
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growing multidisciplinary SeniorCare program flourished in new inpatient and outpatient facilities. However, Petersdorf left for Harvard in 1979, my Howard Hughes support ended in 1980, and his successor could not support my position at Harborview. (I had to negotiate directly with the dean for a state-supported position as division head.) Finally, as Fretwell prepared to leave to initiate the program at Brown, I accepted the invitation from Victor McKusick, chairman of Medicine at Johns Hopkins (and HHMI adviser), to join his department to develop their aging program as his vice chairman at that venerable institution. With mixed feelings, we left our wonderful, leafy Seattle neighborhood in mid-1982.
Lessons Learned Do not wait for everything to be in place and guaranteed before starting an academic program in geriatrics—if you do, you will never begin one. Entrepreneurship, with its essential creativity and risk-taking, is critical for success in any new undertaking. Nevertheless, before accepting a position to lead a program in aging, carefully negotiate with an eye toward its enduring support. Leaders may leave, and institutional priorities may change, especially for programs that do not enjoy a self-sustaining financial base or, more ominously, will come to require ongoing cross-subsidy from other sources to sustain their teaching or clinical services. Think carefully before restricting the base of your program to a safety net hospital. Although “blood and guts” medicine may flourish there, patients at such institutions are generally younger; have undue socioeconomic and mental health burdens; and become sick, injured, and disabled before reaching old age, and more-prosperous citizens (and potential donors) generally try to avoid such institutions for their own care. Try to marry your research and clinical and educational programs in aging in a domain supported by the National Institute on Aging (NIA). Although I received a Geriatric Medicine Academic Award for program development from the NIA, in continuing to anchor my research in diseases supported by the NHLBI, I created a “schizophrenic” enterprise on an unstable funding platform. Although often difficult and painful, leaving an institution may facilitate your career development and allow for your dream of creating an aging program to be realized at a higher level at your new location. Likewise, your departure may enhance the prospects for the success of your successor as new terms are negotiated with her or him, a win-win outcome for our field.
JOHNS HOPKINS MEDICAL INSTITUTIONS (1982–86) Our 4 years in Baltimore passed quickly in a whirlwind of developments that in short order produced a major, wellbalanced academic program in aging at Johns Hopkins. This proved possible in that remarkable institution even while I devoted approximately 80% of my time and effort to supporting Victor McKusick in managing the Department of Medicine at the main medical campus in East Baltimore (his terse job description for me there: “Just be my alter ego”).
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During my recruitment, it became apparent that a dual strategy would be most productive in aging program development at Hopkins to most fully and rapidly realize its potential while efficiently leveraging my time and effort in the process. At the main campus (the “Mother Church”), I focused my principal efforts on the famed Osler medical service and residency program and its home in the small, academic division of (general) internal medicine. From that modest site, I launched a small geriatric assessment clinic and became immersed in divisional activities that provided a geriatric beachhead from which several outstanding fellowship candidates and future leaders migrated to our field. Nevertheless, the greater opportunity for success at Hopkins clearly lay in joining forces with the programs and faculty based in southeast Baltimore on the sprawling campus of the Hopkins-affiliated Baltimore City Hospital, site of the Gerontology Research Center, and the intramural program of the NIA with its famed Baltimore Longitudinal Study of Aging. There a 3-year fellowship training program was quickly initiated (in which Hopkins geriatric fellows were prepared for academic clinical and research careers). Hopkins subsequently acquired the entire 113acre site (now called the Hopkins Bayview Campus) and built a new hospital, a model geriatric care pavilion, and a spacious research and teaching building. Colleagues at that site who were critical to its success included Reubin Andres, clinical director of the Gerontology Research Center and inventor of the glucose/insulin clamp, John Burton (a geriatrician’s geriatrician, who immediately began to assemble a magnetic clinical, teaching, and fellowship program), and Andy Goldberg (another previous Bierman trainee) recruited from St. Louis as research director. Goldberg soon became a critical leader in our new NIA Teaching Nursing Home Program Project and director of a new General Clinical Research Center adjacent to the Gerontology Research Center. Each year, more Hopkins students, fellows, and residents began to populate the geriatric fellowship at Bayview. This became a vehicle for the career development of such future academic geriatric leaders as Walt Ettinger, Linda Fried, Jeff Williamson, and Jeremy Walston. Hopkins Bayview also became a fountainhead of innovative models for geriatric care, such as the Hopkins Hospital at Home program. Those years also marked publication of the first edition of the McGraw-Hill textbook, Principles of Geriatric Medicine and Gerontology, with Reubin Andres, Ed Bierman, and me as founding editors (now entering its seventh edition under the senior editorship of Jeff Halter, another Seattle VA metabolism fellow as protege of Dan Porte). My role in all of this frenzy-of-aging activity is perhaps summarized in metaphorical terms: I was but a seed crystal added to an already supersaturated solution for the program that rapidly crystallized during my first 3 years in Baltimore, which veritably flew by before Jack Stobo succeeded Victor McKusick as chairman. At that juncture, as I was contemplating my future, I met with my admired Dean, Dick Ross, and he flattered me by offering to create a separate Department of Geriatrics if I would stay, but recalling my months in Oxford and the isolation of geriatrics in its own department there, and from my experience as Victor’s only vice-chairman, I passed on his offer
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because I had developed the itch to try for a third time to build an academic program in gerontology and geriatric medicine—this time from the apex of the AHC as chairman of its largest unit: the Department of Medicine.
Lessons Learned In negotiating for support of your plan for geriatrics program development at your next AHC, seek solid funding for your own position from institutional leaders as evidence of their commitment to your success. For me in Baltimore, although clearly appreciating not having to obsess about funding myself from grants (my position as vice-chairman was tenured and supported equally from departmental and hospital sources), more important toward achieving my objectives was the strong partnership with my boss from the office adjacent to his as chairman of the largest department at the medical center. Sharing the power and influence of his position had most efficiently leveraged my time, energy, and institutional resources in rapidly assembling an integrated aging program at Hopkins. This exhilarating experience taught me an important leadership principle: to amplify my efforts most effectively, I needed to focus on recruiting the best talent to the program and then largely leaving them alone to pursue their ideas with my support while not squelching their creativity through micromanagement. As John Wooden wrote, as critical to his incomparable success in building the basketball program at the University of California at Los Angeles, there is no limit to what you can accomplish if you don’t mind who gets the credit. Teamwork, collaboration, and synergism among the leaders of your program will be essential to its success. Especially crucial to a program at an institution such as Hopkins as a community icon of excellence is a dynamic, charismatic, dedicated geriatrician to lead its clinical and educational activities, in the process attracting respect and discretionary support from grateful institutional donors. I cannot give enough thanks and credit to John Burton in this regard. If you feel an itch, scratch it! But not too fast. Proceed deliberately; think, plan, and seriously evaluate the pros and cons of the opportunity. Before agreeing to develop an academic aging program at a given location, you would be well advised to conduct a systematic SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis in formulating your strategy for success. If you are serious in this process, you will probably experience many sleepless nights along the way. Then, before you finally agree to accept the position, negotiate carefully, assertively, patiently, and deliberately!
WAKE FOREST UNIVERSITY (BOWMAN GRAY) SCHOOL OF MEDICINE (1986–99) In pursuing my dream at Wake Forest, I took 10 months and made 13 trips to Winston-Salem to negotiate my appointment as Chairman of Internal Medicine. Before I finally shook hands to seal the deal with Dick Janeway, CEO and Dean of the Bowman Gray School of Medicine of Wake Forest University, I had become convinced of his
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full support and deep understanding of the rationale and timetable of my plan to conduct a unique experiment there: To “gerontologize” the academic health center (to weave aging into the very DNA of Wake Forest—to build and sustain the program) and to do so from the chair of the largest department at the medical center (and university). To facilitate our final agreement and add concrete evidence of his commitment to this program, Janeway enlisted the support of his closest and most powerful adviser on the medical school Board of Visitors—for whom a new J. Paul Sticht Center on Aging would be built squarely in the middle of the medical center campus—and Paul Sticht himself testified to his personal support for this initiative by sharing his own story of frustration in trying to facilitate the medical care of his parents in their old age. In our discussions, I convinced both of them that we should pursue my unprecedented dream at Wake Forest by rebuilding and inflecting the existing department toward a more balanced model, enhancing its reputation as a superior clinical and teaching institution through selective recruitment of faculty with aging interests to important positions throughout our department. This would begin with investments in the human infrastructure critical to its long-term success. These would be focused in an expanded and more academic Section of General Internal Medicine (to include a nidus of academic physicians in Gerontology and Geriatric Medicine), as well as in faculty in each of our subspecialty sections, and we would progressively feature aging and geriatrics in our medical student, residency, and fellowship training programs. To strengthen the financial infrastructure of this program, while deliberately pursuing this opportunity and capitalizing upon my experience at Hopkins, I had carefully conducted a SWOT-like analysis of the environment in Winston-Salem. This led to receiving Janeway’s crucial pledge of support for a new internal medicine fiscal plan that would allow distribution of departmental “taxes” among our sections in a manner that supported the clinical, educational, and research programs in which all were united in our commitment to aging and geriatrics. Although this long period of inquiry and negotiation was new to me and often uncomfortable, at the conclusion of this extended “mating dance,” Dick Janeway, a powerful Winston-Salem financial wizard and business leader, congratulated me on having negotiated so cleverly in this marathon process. This was high praise and a good start to our long partnership in this unprecedented enterprise. Thus the experiment began on a sound footing—ironically, perhaps, on April Fool’s Day 1986. The following 12 years comprised the apogee of the arc of my career in academic gerontology,1,2 a position later summarized in an essay arguing that chairing a Department of Internal Medicine was the best job in academic medicine3—one especially gratifying, unifying when directed toward building a program for elderly adults that was effective, efficient, evidence-based, and focused on the needs of each older person. The path I followed during those years at Wake Forest proceeded along parallel, largely separate tracks—locally and (more quietly) nationally. On the local front, and especially in the first 3 years, I concentrated on rebuilding the department, starting with its Section of General Internal
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Medicine at the base of the pyramid of our residency, and “gerontologized” department. Wake Forest soon competed successfully for a new General Clinical Research Center and received a starter grant from the John A. Hartford Foundation in 1987 to formally initiate the J. Paul Sticht Center on Aging. Walt Ettinger arrived from Hopkins that year to head General Internal Medicine and soon launched a 3-year fellowship in gerontology and geriatric medicine in partnership with Curt Furberg in a new Department of Public Health Sciences. Soon thereafter, we received one of the first Claude D. Pepper Older Americans Independence Center grants from the NIA in collaboration with the Department of Health and Exercise Science at the Wake Forest Reynolda Campus together with our counterparts at the University of Tennessee at Memphis. Meanwhile, critical recruits in cardiology, infectious diseases, endocrinology, gastroenterology, hematology and oncology, nephrology, pulmonary and critical care, and rheumatology all enriched our aging research program under the umbrella of the J. Paul Sticht Center on Aging, and Wake Forest rose progressively in the ranks of academic health centers in the “NIH Derby.” As our department became stronger, and its academic reputation grew, I devoted more of my time to extramural activities, using my position as the first geriatrician to chair a department of internal medicine to advocate for our field on the national level in the Association of Professors (chairs) of Medicine. I also exploited my decade deeply involved in activities of the American Board of Internal Medicine (ABIM) to advance our cause, notably in a groundbreaking joint effort with the American Board of Family Practice that defined geriatrics as an “added qualification” and crafted a single certifying examination for candidates from both fields. On the board of the American Geriatrics Society (AGS) and as President and Chairman of the Board, I championed recognition of geriatrics as a primary care discipline. Most controversial, I also led a campaign to reduce the required duration of geriatric fellowships from 2 years to 1 year to attract more family physicians and internists to become trained and certified in our field.4 At the same time, I continued to advocate for support of the advanced academic preparation of future leaders through additional training and experience as educators and especially as researchers. When finally implemented by the ABIM and ABFP, the 1-year fellowship option effectively doubled the annual number of newly certified geriatricians but, predictably, simultaneously decreased the number pursuing even a second year of academic fellowship training (currently elected by only 7% of first-year fellows—especially concentrated at centers of excellence such as those recognized by the Hartford Foundation). In such extramural activities throughout my career, I have remained most committed to promoting the orderly career development of clinical investigators in aging and geriatrics (through my infamous “17-year plan”5). Here I have concentrated my efforts in programs supporting the “best and the brightest” future leaders of our field along the continuum of rigorous academic career development. This has been focused especially at two points of their greatest vulnerability to becoming lost to our field: beginning faculty shortly after completion of their clinical
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training (T. Franklin Williams awards for medical specialists (through the Alliance for Academic Internal Medicine) and Dennis Jahnigen awards for nonmedical specialists through AGS, both supported by the NIA, Hartford Foundation, and Atlantic Philanthropies, Inc.—and for those at later stages in career development but not yet independently funded by R-01 grants (Paul B. Beeson Career Development Awards in Aging Research—grants enriched in time, funds, and peer support at annual meetings (supported by the NIA and the Hartford and Starr Foundations and administered by the American Federation of Aging Research)). These parallel intramural and extramural activities, together with my local responsibilities in leading our Department of Internal Medicine, all became more frenzied as construction of the J. Paul Sticht Center on Aging (and Rehabilitation) neared completion in 1997—having quintupled in size and scope over a decade to include a geriatric ambulatory care clinic, an inpatient Acute Care of the Elderly unit, an adult–geriatric psychiatry unit, and two floors of rehabilitation facilities. In anticipation of increased demand for aging clinical and teaching services, Paul McGann and Jeff Williamson had been recruited to expand the clinical fellowship and care programs, and a grand opening celebration was planned for April of that year. By then, however, my “dowry” for building the Department of Internal Medicine and the Sticht Center had long since been exhausted, not all programs were flourishing, clinical margins had diminished, Ettinger had earned his MBA and gravitated toward executive leadership of academic health centers, and the financial position of the institution and our internal medicine department had become precarious. So not long after the center opened, my transition to the next stop in our nomadic academic lives had begun—which by the new millennium had brought us full circle back to Seattle, the University of Washington, and the same wonderful neighborhood that we had left nearly 3 decades before.
Lessons Learned “Gerontologizing” an academic health center through its Department of Medicine or a Center on Aging can leverage your efforts and resources to imbed aging into the culture, a transformation that will endure long after you have departed. To everything there is a season, and mine as Internal Medicine chairman at Wake Forest had nearly exceeded three U.S. presidential terms when the Sticht Center opened, so leave the stage before you are escorted to the wings—or in the immortal words of Kenny Rogers borrowed from the world of poker, “Know when to hold ’em and when to fold ’em.” In leaving, you may enhance the prospects for the success of your successors in continuing to build an aging program beyond your wildest dreams: The program at the UW today is stronger for my having left when I did. The program at Hopkins is stronger for my having left when I did.
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Nowhere is this principle better exemplified than at Wake Forest, where upon returning after 13 years, I recognize that geriatrics and gerontology and the Sticht Center on Aging (and Rehabilitation) enjoy an important institutional position of power and influence at all levels. The Wake Forest Baptist Medical Center and the Wake Forest School of Medicine have been truly “gerontologized.” Now more than ever, I am convinced that impulsively accepting Bob Petersdorf’s offer in 1975 was the best professional decision I ever made!
EPILOGUE: LOOKING AHEAD Having recounted the highlights of my nearly 4 decades in academic geriatrics, I conclude with remarks on how geriatricians as “supraspecialists” should address the urgent challenges facing our field to improve the care and quality of life of older persons through our efforts in research, education and training, clinical care, and public policy and advocacy. Our research must be creative even as it is practical and evidence based, with the care and welfare of older persons at the center of our critical and creative science. All of the National Institutes of Health and its centers— not just the NIA—must be engaged in this campaign in Bethesda and Baltimore as well as at AHCs across the United States. Our education and training programs must continuously escalate in sophistication and effectiveness in all of the relevant disciplines, many extending to the interdisciplinary and community settings most essential to ensuring a seamless continuum of care for older persons. Palliative care should be embraced as a natural part of this continuum. Two-year, integrated fellowships in both sister disciplines should be developed, an efficiency that should allow for some academic training in both. Geriatrics is a team sport, and understanding its nuances and complexities is essential to its effective practice and teaching. We should capitalize on the talents and contributions especially of the preponderance of women
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attracted to our field, for they (and their male geriatric colleagues) embrace and personify those attributes. Our “supraspecialty” must become ever broader in its scope and influence as the approaching tsunami of elderly Americans draws nearer and their earned entitlements in Social Security and especially Medicare become increasingly urgent fiscal and political challenges. A cadre of geriatricians with the requisite personal attributes, training, and experience in management, policy, government, and politics must be prepared to lead the necessary transformation of the U.S. healthcare system to meet the needs of these citizens. Even as these challenges grow, geriatricians become ever fewer in numbers as fewer than 1% of U.S. medical graduates elect to become certified through 1-year fellowships, and of those, few pursue additional training to become future educators, researchers, and leaders. Hence, leverage on the contributions of each of these physicians will become increasingly critical—even as we persevere in our efforts to attract the “best and the brightest” to our ever-more-urgent cause.
ACKNOWLEDGMENTS Conflict of Interest: The author certifies that there are no financial, personal, or other conflicts of interest with this paper. Author Contributions: Dr. Hazzard is solely responsible for all aspects of this manuscript, which appears only in this journal. Sponsor’s Role: None.
REFERENCES 1. Hazzard WR. Academic gerontology—or the aging of academicians. Clin Res 1984;32:3–8. 2. Hazzard WR. Academic gerontology—or the aging of academicians: Implications for aspiring academic geriatricians. J Am Geriatr Soc 1994;42:1123– 1127. 3. Hazzard WR. I love this job: Notes of an internal medicine chairman. Acad Med 1998;73:228–229. 4. Hazzard WR. Geriatric fellowship training: A revisionist proposal. J Am Geriatr Soc 1992;40:1175–1177. 5. Hazzard WR. A report card on academic geriatrics in 1991: The struggle for academic respectability. Ann Intern Med 1991;115:229–230.
A Quarter Century in Developing Geriatric Programs at Three Academic Health Centers: Highlights and Lessons Learned William R. Hazzard, MD
I
n 1975, Bob Petersdorf, my Medicine chair at the University of Washington (UW), called me to his office and without preamble asked me to assume leadership of the nascent program on gerontology and metabolism recently initiated in his department at the Veterans Administration (now called Veterans Affairs) (VA) Medical Center by Ed Bierman, my research mentor (who had just agreed to move to University Hospital as head of Endocrinology and Metabolism). Petersdorf extended his hand, I shook it, and the deed was done: no negotiations about positions, space, or salary and little discussion of its mission other than his stipulation that geriatric medicine—the medical care of elderly adults— needed to be added to gerontology (the study of aging) as the program grew toward divisional status. Why did I immediately accept this offer? Most of all because I respected and trusted Bob, we loved Seattle, and I needed a job! At the time I was a 39-year-old untenured associate professor and investigator of the Howard Hughes Medical Institute (HHMI) as Director of the National Heart, Lung, and Blood Institute–funded Northwest Lipid Research Clinic (NWLRC) at Harborview Medical Center, the safety net public teaching hospital in central Seattle. I had learned over my decade at the University of Washington that this new and growing medical school was conceived in an academic model heavily dependent on National Institutes of Health (NIH) funds and that to remain on the faculty, I would have to assume an important departmental role, even while effectively remaining self-supporting from nongovernmental sources, NIH research grants and clinical funds. At Harborview, I could leverage NWLRC resources to direct my research toward a program of preventive gerontology, with special focus on hormonal modulation of the sex and gender differential in lipoprotein metabolism, cardiovascular disease, obesity, diabetes mellitus, and
From the J. Paul Sticht Center on Aging, School of Medicine, Wake Forest University, Winston-Salem, North Carolina. Address correspondence to William R. Hazzard, Professor of Internal Medicine, Section on Geriatrics and Palliative Care, J. Paul Sticht Center on Aging, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157. E-mail: [email protected]
longevity, and as a young medicine faculty attending physician active on the wards, I was a familiar face to faculty and house staff at that busy inner-city hospital. So, impulsively entrusting my future to my charismatic chairman, I placed my fate in his hands—but with no real sense at the time of what opportunities and challenges I would face in my new career in gerontology and geriatric medicine. Thus, with the continuing support of Ed Bierman, we set out to build the “SeniorCare” geriatrics continuum at Harborview with encouragement from leaders there in hospital administration, nursing, and social work. Most instrumental in my education in this field was a full year of sabbatical study (with HHMI support) in 1977–78. Upon the advice of (Sir) Paul Beeson, recently recruited by Petersdorf to the University of Washington from Oxford, our family spent the year in the United Kingdom for me to study the British approach to geriatrics as a visiting lecturer in their famed National Health Service. In Oxford, geriatrics was a department in its own right, centered in the Cowley Road Hospital, a nineteenth-century institution on a “poor farm” campus, and had little connection with the Department of Medicine or the rest of Oxford University near the center of town. Suffice to say that, although I treasure indelible memories and lessons learned from that year, I returned to Harborview convinced that in the United States, geriatric medicine should be developed at the most prestigious academic health centers (AHCs) on the same platform of excellence in cutting-edge research as any other NIH-funded specialty to ensure that “the best and the brightest” would be attracted to our futuristic field—an upward-directed trajectory that would be selfsustaining and in the best interest of aging and elderly Americans to extend their “health span” until very near the end of their God-given life span. So I returned to Harborview and the NWLRC determined to earn the continuing respect of University of Washington colleagues and leverage our resources through NHLBI-funded metabolic clinical research with the assistance of talented metabolism fellows and faculty. Early on, this seemed promising, especially when our first geriatric fellow, Marsha Fretwell, a charismatic former chief resident recommended by Petersdorf, proved a veritable Pied Piper to students, residents, and future fellows, and the
DOI: 10.1111/jgs.12844
JAGS 62:1179–1183, 2014 © 2014, Copyright the Author Journal compilation © 2014, The American Geriatrics Society
0002-8614/14/$15.00
1180
HAZZARD
growing multidisciplinary SeniorCare program flourished in new inpatient and outpatient facilities. However, Petersdorf left for Harvard in 1979, my Howard Hughes support ended in 1980, and his successor could not support my position at Harborview. (I had to negotiate directly with the dean for a state-supported position as division head.) Finally, as Fretwell prepared to leave to initiate the program at Brown, I accepted the invitation from Victor McKusick, chairman of Medicine at Johns Hopkins (and HHMI adviser), to join his department to develop their aging program as his vice chairman at that venerable institution. With mixed feelings, we left our wonderful, leafy Seattle neighborhood in mid-1982.
Lessons Learned Do not wait for everything to be in place and guaranteed before starting an academic program in geriatrics—if you do, you will never begin one. Entrepreneurship, with its essential creativity and risk-taking, is critical for success in any new undertaking. Nevertheless, before accepting a position to lead a program in aging, carefully negotiate with an eye toward its enduring support. Leaders may leave, and institutional priorities may change, especially for programs that do not enjoy a self-sustaining financial base or, more ominously, will come to require ongoing cross-subsidy from other sources to sustain their teaching or clinical services. Think carefully before restricting the base of your program to a safety net hospital. Although “blood and guts” medicine may flourish there, patients at such institutions are generally younger; have undue socioeconomic and mental health burdens; and become sick, injured, and disabled before reaching old age, and more-prosperous citizens (and potential donors) generally try to avoid such institutions for their own care. Try to marry your research and clinical and educational programs in aging in a domain supported by the National Institute on Aging (NIA). Although I received a Geriatric Medicine Academic Award for program development from the NIA, in continuing to anchor my research in diseases supported by the NHLBI, I created a “schizophrenic” enterprise on an unstable funding platform. Although often difficult and painful, leaving an institution may facilitate your career development and allow for your dream of creating an aging program to be realized at a higher level at your new location. Likewise, your departure may enhance the prospects for the success of your successor as new terms are negotiated with her or him, a win-win outcome for our field.
JOHNS HOPKINS MEDICAL INSTITUTIONS (1982–86) Our 4 years in Baltimore passed quickly in a whirlwind of developments that in short order produced a major, wellbalanced academic program in aging at Johns Hopkins. This proved possible in that remarkable institution even while I devoted approximately 80% of my time and effort to supporting Victor McKusick in managing the Department of Medicine at the main medical campus in East Baltimore (his terse job description for me there: “Just be my alter ego”).
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During my recruitment, it became apparent that a dual strategy would be most productive in aging program development at Hopkins to most fully and rapidly realize its potential while efficiently leveraging my time and effort in the process. At the main campus (the “Mother Church”), I focused my principal efforts on the famed Osler medical service and residency program and its home in the small, academic division of (general) internal medicine. From that modest site, I launched a small geriatric assessment clinic and became immersed in divisional activities that provided a geriatric beachhead from which several outstanding fellowship candidates and future leaders migrated to our field. Nevertheless, the greater opportunity for success at Hopkins clearly lay in joining forces with the programs and faculty based in southeast Baltimore on the sprawling campus of the Hopkins-affiliated Baltimore City Hospital, site of the Gerontology Research Center, and the intramural program of the NIA with its famed Baltimore Longitudinal Study of Aging. There a 3-year fellowship training program was quickly initiated (in which Hopkins geriatric fellows were prepared for academic clinical and research careers). Hopkins subsequently acquired the entire 113acre site (now called the Hopkins Bayview Campus) and built a new hospital, a model geriatric care pavilion, and a spacious research and teaching building. Colleagues at that site who were critical to its success included Reubin Andres, clinical director of the Gerontology Research Center and inventor of the glucose/insulin clamp, John Burton (a geriatrician’s geriatrician, who immediately began to assemble a magnetic clinical, teaching, and fellowship program), and Andy Goldberg (another previous Bierman trainee) recruited from St. Louis as research director. Goldberg soon became a critical leader in our new NIA Teaching Nursing Home Program Project and director of a new General Clinical Research Center adjacent to the Gerontology Research Center. Each year, more Hopkins students, fellows, and residents began to populate the geriatric fellowship at Bayview. This became a vehicle for the career development of such future academic geriatric leaders as Walt Ettinger, Linda Fried, Jeff Williamson, and Jeremy Walston. Hopkins Bayview also became a fountainhead of innovative models for geriatric care, such as the Hopkins Hospital at Home program. Those years also marked publication of the first edition of the McGraw-Hill textbook, Principles of Geriatric Medicine and Gerontology, with Reubin Andres, Ed Bierman, and me as founding editors (now entering its seventh edition under the senior editorship of Jeff Halter, another Seattle VA metabolism fellow as protege of Dan Porte). My role in all of this frenzy-of-aging activity is perhaps summarized in metaphorical terms: I was but a seed crystal added to an already supersaturated solution for the program that rapidly crystallized during my first 3 years in Baltimore, which veritably flew by before Jack Stobo succeeded Victor McKusick as chairman. At that juncture, as I was contemplating my future, I met with my admired Dean, Dick Ross, and he flattered me by offering to create a separate Department of Geriatrics if I would stay, but recalling my months in Oxford and the isolation of geriatrics in its own department there, and from my experience as Victor’s only vice-chairman, I passed on his offer
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because I had developed the itch to try for a third time to build an academic program in gerontology and geriatric medicine—this time from the apex of the AHC as chairman of its largest unit: the Department of Medicine.
Lessons Learned In negotiating for support of your plan for geriatrics program development at your next AHC, seek solid funding for your own position from institutional leaders as evidence of their commitment to your success. For me in Baltimore, although clearly appreciating not having to obsess about funding myself from grants (my position as vice-chairman was tenured and supported equally from departmental and hospital sources), more important toward achieving my objectives was the strong partnership with my boss from the office adjacent to his as chairman of the largest department at the medical center. Sharing the power and influence of his position had most efficiently leveraged my time, energy, and institutional resources in rapidly assembling an integrated aging program at Hopkins. This exhilarating experience taught me an important leadership principle: to amplify my efforts most effectively, I needed to focus on recruiting the best talent to the program and then largely leaving them alone to pursue their ideas with my support while not squelching their creativity through micromanagement. As John Wooden wrote, as critical to his incomparable success in building the basketball program at the University of California at Los Angeles, there is no limit to what you can accomplish if you don’t mind who gets the credit. Teamwork, collaboration, and synergism among the leaders of your program will be essential to its success. Especially crucial to a program at an institution such as Hopkins as a community icon of excellence is a dynamic, charismatic, dedicated geriatrician to lead its clinical and educational activities, in the process attracting respect and discretionary support from grateful institutional donors. I cannot give enough thanks and credit to John Burton in this regard. If you feel an itch, scratch it! But not too fast. Proceed deliberately; think, plan, and seriously evaluate the pros and cons of the opportunity. Before agreeing to develop an academic aging program at a given location, you would be well advised to conduct a systematic SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis in formulating your strategy for success. If you are serious in this process, you will probably experience many sleepless nights along the way. Then, before you finally agree to accept the position, negotiate carefully, assertively, patiently, and deliberately!
WAKE FOREST UNIVERSITY (BOWMAN GRAY) SCHOOL OF MEDICINE (1986–99) In pursuing my dream at Wake Forest, I took 10 months and made 13 trips to Winston-Salem to negotiate my appointment as Chairman of Internal Medicine. Before I finally shook hands to seal the deal with Dick Janeway, CEO and Dean of the Bowman Gray School of Medicine of Wake Forest University, I had become convinced of his
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full support and deep understanding of the rationale and timetable of my plan to conduct a unique experiment there: To “gerontologize” the academic health center (to weave aging into the very DNA of Wake Forest—to build and sustain the program) and to do so from the chair of the largest department at the medical center (and university). To facilitate our final agreement and add concrete evidence of his commitment to this program, Janeway enlisted the support of his closest and most powerful adviser on the medical school Board of Visitors—for whom a new J. Paul Sticht Center on Aging would be built squarely in the middle of the medical center campus—and Paul Sticht himself testified to his personal support for this initiative by sharing his own story of frustration in trying to facilitate the medical care of his parents in their old age. In our discussions, I convinced both of them that we should pursue my unprecedented dream at Wake Forest by rebuilding and inflecting the existing department toward a more balanced model, enhancing its reputation as a superior clinical and teaching institution through selective recruitment of faculty with aging interests to important positions throughout our department. This would begin with investments in the human infrastructure critical to its long-term success. These would be focused in an expanded and more academic Section of General Internal Medicine (to include a nidus of academic physicians in Gerontology and Geriatric Medicine), as well as in faculty in each of our subspecialty sections, and we would progressively feature aging and geriatrics in our medical student, residency, and fellowship training programs. To strengthen the financial infrastructure of this program, while deliberately pursuing this opportunity and capitalizing upon my experience at Hopkins, I had carefully conducted a SWOT-like analysis of the environment in Winston-Salem. This led to receiving Janeway’s crucial pledge of support for a new internal medicine fiscal plan that would allow distribution of departmental “taxes” among our sections in a manner that supported the clinical, educational, and research programs in which all were united in our commitment to aging and geriatrics. Although this long period of inquiry and negotiation was new to me and often uncomfortable, at the conclusion of this extended “mating dance,” Dick Janeway, a powerful Winston-Salem financial wizard and business leader, congratulated me on having negotiated so cleverly in this marathon process. This was high praise and a good start to our long partnership in this unprecedented enterprise. Thus the experiment began on a sound footing—ironically, perhaps, on April Fool’s Day 1986. The following 12 years comprised the apogee of the arc of my career in academic gerontology,1,2 a position later summarized in an essay arguing that chairing a Department of Internal Medicine was the best job in academic medicine3—one especially gratifying, unifying when directed toward building a program for elderly adults that was effective, efficient, evidence-based, and focused on the needs of each older person. The path I followed during those years at Wake Forest proceeded along parallel, largely separate tracks—locally and (more quietly) nationally. On the local front, and especially in the first 3 years, I concentrated on rebuilding the department, starting with its Section of General Internal
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Medicine at the base of the pyramid of our residency, and “gerontologized” department. Wake Forest soon competed successfully for a new General Clinical Research Center and received a starter grant from the John A. Hartford Foundation in 1987 to formally initiate the J. Paul Sticht Center on Aging. Walt Ettinger arrived from Hopkins that year to head General Internal Medicine and soon launched a 3-year fellowship in gerontology and geriatric medicine in partnership with Curt Furberg in a new Department of Public Health Sciences. Soon thereafter, we received one of the first Claude D. Pepper Older Americans Independence Center grants from the NIA in collaboration with the Department of Health and Exercise Science at the Wake Forest Reynolda Campus together with our counterparts at the University of Tennessee at Memphis. Meanwhile, critical recruits in cardiology, infectious diseases, endocrinology, gastroenterology, hematology and oncology, nephrology, pulmonary and critical care, and rheumatology all enriched our aging research program under the umbrella of the J. Paul Sticht Center on Aging, and Wake Forest rose progressively in the ranks of academic health centers in the “NIH Derby.” As our department became stronger, and its academic reputation grew, I devoted more of my time to extramural activities, using my position as the first geriatrician to chair a department of internal medicine to advocate for our field on the national level in the Association of Professors (chairs) of Medicine. I also exploited my decade deeply involved in activities of the American Board of Internal Medicine (ABIM) to advance our cause, notably in a groundbreaking joint effort with the American Board of Family Practice that defined geriatrics as an “added qualification” and crafted a single certifying examination for candidates from both fields. On the board of the American Geriatrics Society (AGS) and as President and Chairman of the Board, I championed recognition of geriatrics as a primary care discipline. Most controversial, I also led a campaign to reduce the required duration of geriatric fellowships from 2 years to 1 year to attract more family physicians and internists to become trained and certified in our field.4 At the same time, I continued to advocate for support of the advanced academic preparation of future leaders through additional training and experience as educators and especially as researchers. When finally implemented by the ABIM and ABFP, the 1-year fellowship option effectively doubled the annual number of newly certified geriatricians but, predictably, simultaneously decreased the number pursuing even a second year of academic fellowship training (currently elected by only 7% of first-year fellows—especially concentrated at centers of excellence such as those recognized by the Hartford Foundation). In such extramural activities throughout my career, I have remained most committed to promoting the orderly career development of clinical investigators in aging and geriatrics (through my infamous “17-year plan”5). Here I have concentrated my efforts in programs supporting the “best and the brightest” future leaders of our field along the continuum of rigorous academic career development. This has been focused especially at two points of their greatest vulnerability to becoming lost to our field: beginning faculty shortly after completion of their clinical
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training (T. Franklin Williams awards for medical specialists (through the Alliance for Academic Internal Medicine) and Dennis Jahnigen awards for nonmedical specialists through AGS, both supported by the NIA, Hartford Foundation, and Atlantic Philanthropies, Inc.—and for those at later stages in career development but not yet independently funded by R-01 grants (Paul B. Beeson Career Development Awards in Aging Research—grants enriched in time, funds, and peer support at annual meetings (supported by the NIA and the Hartford and Starr Foundations and administered by the American Federation of Aging Research)). These parallel intramural and extramural activities, together with my local responsibilities in leading our Department of Internal Medicine, all became more frenzied as construction of the J. Paul Sticht Center on Aging (and Rehabilitation) neared completion in 1997—having quintupled in size and scope over a decade to include a geriatric ambulatory care clinic, an inpatient Acute Care of the Elderly unit, an adult–geriatric psychiatry unit, and two floors of rehabilitation facilities. In anticipation of increased demand for aging clinical and teaching services, Paul McGann and Jeff Williamson had been recruited to expand the clinical fellowship and care programs, and a grand opening celebration was planned for April of that year. By then, however, my “dowry” for building the Department of Internal Medicine and the Sticht Center had long since been exhausted, not all programs were flourishing, clinical margins had diminished, Ettinger had earned his MBA and gravitated toward executive leadership of academic health centers, and the financial position of the institution and our internal medicine department had become precarious. So not long after the center opened, my transition to the next stop in our nomadic academic lives had begun—which by the new millennium had brought us full circle back to Seattle, the University of Washington, and the same wonderful neighborhood that we had left nearly 3 decades before.
Lessons Learned “Gerontologizing” an academic health center through its Department of Medicine or a Center on Aging can leverage your efforts and resources to imbed aging into the culture, a transformation that will endure long after you have departed. To everything there is a season, and mine as Internal Medicine chairman at Wake Forest had nearly exceeded three U.S. presidential terms when the Sticht Center opened, so leave the stage before you are escorted to the wings—or in the immortal words of Kenny Rogers borrowed from the world of poker, “Know when to hold ’em and when to fold ’em.” In leaving, you may enhance the prospects for the success of your successors in continuing to build an aging program beyond your wildest dreams: The program at the UW today is stronger for my having left when I did. The program at Hopkins is stronger for my having left when I did.
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Nowhere is this principle better exemplified than at Wake Forest, where upon returning after 13 years, I recognize that geriatrics and gerontology and the Sticht Center on Aging (and Rehabilitation) enjoy an important institutional position of power and influence at all levels. The Wake Forest Baptist Medical Center and the Wake Forest School of Medicine have been truly “gerontologized.” Now more than ever, I am convinced that impulsively accepting Bob Petersdorf’s offer in 1975 was the best professional decision I ever made!
EPILOGUE: LOOKING AHEAD Having recounted the highlights of my nearly 4 decades in academic geriatrics, I conclude with remarks on how geriatricians as “supraspecialists” should address the urgent challenges facing our field to improve the care and quality of life of older persons through our efforts in research, education and training, clinical care, and public policy and advocacy. Our research must be creative even as it is practical and evidence based, with the care and welfare of older persons at the center of our critical and creative science. All of the National Institutes of Health and its centers— not just the NIA—must be engaged in this campaign in Bethesda and Baltimore as well as at AHCs across the United States. Our education and training programs must continuously escalate in sophistication and effectiveness in all of the relevant disciplines, many extending to the interdisciplinary and community settings most essential to ensuring a seamless continuum of care for older persons. Palliative care should be embraced as a natural part of this continuum. Two-year, integrated fellowships in both sister disciplines should be developed, an efficiency that should allow for some academic training in both. Geriatrics is a team sport, and understanding its nuances and complexities is essential to its effective practice and teaching. We should capitalize on the talents and contributions especially of the preponderance of women
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attracted to our field, for they (and their male geriatric colleagues) embrace and personify those attributes. Our “supraspecialty” must become ever broader in its scope and influence as the approaching tsunami of elderly Americans draws nearer and their earned entitlements in Social Security and especially Medicare become increasingly urgent fiscal and political challenges. A cadre of geriatricians with the requisite personal attributes, training, and experience in management, policy, government, and politics must be prepared to lead the necessary transformation of the U.S. healthcare system to meet the needs of these citizens. Even as these challenges grow, geriatricians become ever fewer in numbers as fewer than 1% of U.S. medical graduates elect to become certified through 1-year fellowships, and of those, few pursue additional training to become future educators, researchers, and leaders. Hence, leverage on the contributions of each of these physicians will become increasingly critical—even as we persevere in our efforts to attract the “best and the brightest” to our ever-more-urgent cause.
ACKNOWLEDGMENTS Conflict of Interest: The author certifies that there are no financial, personal, or other conflicts of interest with this paper. Author Contributions: Dr. Hazzard is solely responsible for all aspects of this manuscript, which appears only in this journal. Sponsor’s Role: None.
REFERENCES 1. Hazzard WR. Academic gerontology—or the aging of academicians. Clin Res 1984;32:3–8. 2. Hazzard WR. Academic gerontology—or the aging of academicians: Implications for aspiring academic geriatricians. J Am Geriatr Soc 1994;42:1123– 1127. 3. Hazzard WR. I love this job: Notes of an internal medicine chairman. Acad Med 1998;73:228–229. 4. Hazzard WR. Geriatric fellowship training: A revisionist proposal. J Am Geriatr Soc 1992;40:1175–1177. 5. Hazzard WR. A report card on academic geriatrics in 1991: The struggle for academic respectability. Ann Intern Med 1991;115:229–230.
