Geriatricians Raise Quality of Care for Aging
As the silver tsunami continues, older patients are living longer than ever. However, many endure a poor quality of life during their final years due to multiple, serious chronic disorders. Geriatricians at NewYork-Presbyterian/Weill Cornell Medical Center are raising quality-of-life standards by leading novel education and research initiatives. Randi R. Diamond, MD, is educating fellows by leading a palliative care global health initiative; Milagros D. Silva, MD, is conducting research aimed at improving palliative care for patients with limited English proficiency (LEP); and Ronald D. Adelman, MD, is educating medical students by changing the discourse around aging.
Fellows Gain Palliative Care Global Health Experience
Exposure to global health work can have a profound impact on the education of new physicians. Since 2013, Dr. Randi Diamond has traveled annually to rural Uganda to provide and teach palliative medicine at Naggalama Hospital — a 100-bed facility serving a catchment area of about 300,000 patients. This year, fellow Melissa Patterson, MD, in NewYork-Presbyterian/Weill Cornell’s Geriatrics Medicine Fellowship training program, and nurse practitioner Elizabeth Capano had the opportunity to join the team at Naggalama Hospital. Dr. Diamond provides fellows and other medical trainees with basic palliative medicine education, including pain assessments, non-pain symptom management, and communication with terminally ill patients, all in a global health setting.
“A global health experience is a desirable opportunity for fellows and viewed as a real draw to our training program. We work with a diverse population in New York City and figuring out how to navigate a new culture is very applicable,” says Dr. Diamond, who is also the Director of the Liz Claiborne Center for Humanism in Medicine at NewYork-Presbyterian/Weill Cornell Medical Center.
When Dr. Diamond first began her global health efforts six years ago, she hoped to bring her palliative care and geriatric expertise, but it quickly became clear that many aspects did not directly translate. Going to Uganda helps Dr. Diamond deliver high quality culturally competent care when she returns home. “It challenges me to think even more carefully about how I communicate with patients and to tailor that communication in the most culturally sensitive and individualized way.”
“When I go to Uganda, it makes me a better doctor when I return. It challenges my clinical and management skills and spurs creativity. It challenges me to see things from a new perspective and gives me a better understanding of what it feels like to be the one who is culturally different.”
— Dr. Randi R. Diamond
Now, Dr. Diamond often travels to Uganda twice per year to work with the palliative care team at Naggalama Hospital and communicates with the lead nurse throughout the year via email. Over the years, she noticed that palliative care in Uganda focuses on symptom management, but the communication of local health workers still needed further development. As a result, an educational intervention targeted at local health workers was born.
Alongside the nurse at Naggalama Hospital, Dr. Diamond and Weill Cornell Medicine medical student Lorien Menhennett developed educational modules that are based on video clips of real patient encounters in rural Uganda. “We tested them among rural health workers to see if they are an effective educational tool,” explains Dr. Diamond.
Pre- and post-test data are currently being evaluated, but preliminary findings show an increased level of comfort and confidence among rural health workers while communicating with seriously ill palliative care patients. Replication of a video-based educational intervention with real patient encounters has the potential to be implemented in other rural settings. “There is less opportunity for health workers in rural settings to practice communication skills because they are more isolated than colleagues doing similar work in urban settings,” says Dr. Diamond.
Dr. Diamond and the Ugandan palliative care nurse recently presented their educational program at the sixth International African Palliative Care Conference in Rwanda. “It generated a lot of interest among medical educators at the meeting from around continent. It fills an unmet need,” says Dr. Diamond.
To improve end-of-life care for a diverse and aging population, medical education that includes cultural competency is a top priority. Dr. Diamond is committed to teaching medical students and fellows first-hand about cultural competency and humility through her palliative care efforts in rural Uganda. “When I go to Uganda, it makes me a better doctor when I return,” she says. “It challenges my clinical and management skills and spurs creativity. It challenges me to see things from a new perspective and gives me a better understanding of what it feels like to be the one who is culturally different.”
Medical Interpreters Crucial to Palliative Care
America’s aging and increasingly diverse patient population presents many challenges related to communication and palliative care. All patients at New York-Presbyterian/Weill Cornell have free access to medical interpreters in person, by telephone or by video. “Providers are becoming more aware of not using family members, but we still have a way to go,” says Dr. Milagros Silva, who noted that doctors at Weill Cornell most frequently use Spanish and Chinese medical interpreters. “There are many different languages, people, and cultural backgrounds that come to the hospital and we often use medical interpreters because a lot of patients have limited English proficiency.”
In her study published in the Journal of Pain and Symptom Management, Dr. Silva and colleagues interviewed Spanish- and Chinese-speaking medical interpreters to obtain insight on how to best utilize their services during end-of-life care. The researchers conducted qualitative interviews with 12 Spanish or Chinese medical interpreters. Study findings revealed that although medical interpreters provide literal interpretation of the spoken word, they could also be utilized as cultural brokers to translate the meaning of words within a specific cultural context.
“For example, when we want to introduce hospice, there might not be a literal translation for do not resuscitate,” says Dr. Silva. “Often we use medical jargon, and the interpreter may not know how to translate unless we tell them what to say so that the patient may understand.” To maximize communication regarding end-of-life conversations, the authors recommend that providers conduct pre- and post-meetings with their medical interpreter.
“Providers are becoming more aware of not using family members as medical interpreters, but we still have a way to go.”
— Dr. Milagros D. Silva
Currently, Dr. Silva is interviewing hospitalists and internal medicine residents about their utilization of medical interpreters. “Preliminary analyses show that hospitalists and internal medicine residents know that medical interpreters help translate the medical word, but they do not know the nuances of their role and how they can help bridge the cultural gap.”
These findings build on previous work showing that language barriers influence end-of-life health quality and outcomes among patients with LEP. Specifically, when providers use a family or staff member instead of a professional medical interpreter, patients don’t fare as well. In a retrospective literature review spanning 54 years including a variety of languages published in the Journal of Pain and Symptom Management, Dr. Silva and colleagues found that patients with LEP had worse quality of end-of-life care when professional interpreters were not used.
The benefits of using medical interpreters are far-reaching and include improved patient-physician communication, increased cultural sensitivity, and improved patient satisfaction. “Eventually this leads to increased patient satisfaction because patients are getting the information they need based on cultural values and able to make informed decisions about their medical treatment,” says Dr. Silva.
Geriatric Education for Medical Students
Dr. Ronald Adelman, Co-Chief of the Division of Geriatrics and Palliative Medicine at NewYork-Presbyterian/Weill Cornell, is changing the medical education landscape on aging by using nontraditional means to illustrate concepts in the classroom. In his Division’s two-hour course, “Introduction to the Geriatric Patient,” students get a glimpse into a geriatrician life review through theatre production, actor’s studio, and small breakout sessions with older patients.
“We work with well-known actors and show students how ageism can be manifested. We also incorporate the life review so students get to know the patient in a much more holistic way,” says Dr. Adelman, whose research interests are in older patient-physician communication.
The course is offered to all first year medical students and includes a dramatic play depicting an older female patient with a daughter who is interfering in patient-physician communication. After the performance, an open actor studio format allows medical students to ask questions.
“We are introducing medical students to the older patient and fighting ageist stereotypes that exist in America,” says Dr. Adelman. “The students have many questions and it is a very useful interaction that explores how ageist bias can undermine a physician’s ability to diagnose underlying treatable medical conditions. It also gives students a sense of how to handle a third person in the medical encounter so the relationship between the doctor and older patient is not undermined.”
“We are introducing medical students to the older patient and fighting ageist stereotypes that exist in America.”
— Dr. Ronald D. Adelman
The impetus behind the course for first year medical students stems from Dr. Adelman’s research published in the Journal of the American Geriatrics Society on communication and the triad in the medical encounter. His work has shown that a successful physician-patient relationship allows for discussion of sensitive topics, alleviates patient stress, improves patient knowledge, and offers older patients greater access to healthcare services.
“We have found that the presence of a third person in the medical visit can change the interactional dynamics of older patient interviews, and influence the development of a trusting and effective physician-older patient relationship,” says Dr. Adelman.
Students are also exposed to an older patient from the Irving Sherwood Wright Center on Aging at NewYork-Presbyterian/Weill Cornell where a faculty member and the older patient are in a room with 10 medical students. Medical students have an opportunity to ask the same kind of questions they saw demonstrated in the play. “Students end up loving this most because meeting older people who are not necessarily healthy but still robust, independent, and articulate about their experience often dispels negative stereotypes,” says Dr. Adelman.
The class often inspires medical students to get involved in geriatrics in different ways. NewYork-Presbyterian/Weill Cornell has a medical student interest group in geriatrics as well as an eight-week summer research program. The unique summer program offers students training in research methodology, participation in an aging research project, exposure to clinical geriatrics practice and inpatient service, and the opportunity to present a research project at the American Geriatrics Society meeting. Students are mentored extensively to prepare them to give a talk, write a poster, and potentially publish their work.
Together Drs. Adelman, Diamond, and Silva are responding to the changing demographics of an aging population by creating unique medical education and research initiatives aimed at improving quality of care and advancing cultural competency skills.
Silva MD, Tsai S, Sobota RM, Abel BT, Reid MC, Adelman RD. Missed opportunities when communicating with limited English-proficient patients during end-of-life conversations: insights from Spanish-speaking and Chinese-speaking medical interpreters. Journal of Pain and Symptom Management. 2019 Oct 25. [Epub ahead of print]
Silva MD, Genoff M, Zaballa A, Jewell S, Stabler S, Gany FM, Diamond LC. Interpreting at the end of life: A systematic review of the impact of interpreters on the delivery of palliative care services to cancer patients with limited English proficiency. Journal of Pain and Symptom Management. 2016 Mar;51(3):569-80.
Greene MG, Majerovitz SD, Adelman RD, Rizzo C. The effects of a third person on the physician-older patient medical interview. Journal of the American Geriatrics Society. 1994;42(4):413-19.
Adelman RD, Greene MG, Ory MG. Communication between older patients and their physicians. Clinics in Geriatric Medicine. 2000; 16(1):1-24.