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Geriatric Emergency Medicine (GEM)

Author

Jose Orozco, MSIII
University of California Riverside School of Medicine

Faculty Editors

Katren Tyler, MD, FACEP
Associate Professor, Associate Program Director, Department of EM
Geriatric Emergency Medicine Fellowship Director
Vice Chair for Faculty Development, Wellness and Outreach
UC Davis Health System

Don Melady, MSc(Ed), MD, CCFP(EM), FCFP
Emergency Physician, Geriatric Lead, Schwartz/Reisman Emergency Centre 
Mount Sinai Hospital, Toronto
Assistant Professor, Faculty of Medicine
University of Toronto

Michael Stern, MD
Assistant Professor of Medicine in Emergency Medicine
Chief, Geriatric Emergency Medicine
Co-Director, Geriatric Emergency Medicine Fellowship
New York Presbyterian Hospital/Weill Cornell Medical Center

Kevin Biese, MD, FACEP, MAT
Associate Professor of Emergency Medicine and Internal Medicine
Division of Geriatrics
Vice-Chair of Academic Affairs
Co-Director Division of Geriatrics Emergency Medicine
UNC Chapel Hill

Lauren T. Southerland, MD
Director of Geriatric Emergency Care
Department of Emergency Medicine
The Ohio State University Wexner Medical Center

Special thanks to our 1st edition writing team

Krystle Shafer, MD
Katren Tyler, MD, FACEP
Don Melady, MSc(Ed), MD, CCFP(EM), FCFP
Michael Stern, MD
Kevin Biese, MD, FACEP, MAT
Lauren T. Southerland, MD

INTRODUCTION

Description of the specialty
An overall increase in life expectancy and the demographic bubble of the baby boomers is reflected in increasing numbers of older patients (65 and over) presenting for emergency care. The field of geriatric emergency medicine evolved to fill the needs of this group of people in times of serious illness or injuries. Older patients are generally more complex than younger patients, with physiologic, pharmacologic, and pathologic differences, as well as social needs that may differ from younger patients. In addition, there are specific geriatric syndromes that often go unrecognized in emergency departments. As a result of this growing patient population, fellowship training is an important component of the emerging subspecialty of geriatric EM.

History of the specialty/fellowship pathway
The American Board of Internal Medicine and the American Board of Family Medicine offer ACGME accredited fellowships with a match process and board exam. These programs generally do not offer training to emergency medicine applicants. 

Therefore, geriatric EM fellowships were created to provide fellowship-level geriatric knowledge and training to EM residency-trained physicians.  They are a relatively new fellowship pathway within emergency medicine; the first geriatric emergency medicine fellowship started at Beaumont in Michigan, with the second at New York Presbyterian in 2005. Most of the GEM fellowships combine attending-level EM clinical care with the patient care and coursework of an existing geriatric medicine fellowship. Additionally, in April 2017, the Geriatric Emergency Department Accreditation (GEDA) program was formed by the American College of Emergency Physicians (ACEP). This program is an ACEP-governed national accreditation program that is designed to improve the care of geriatric patients presenting to the emergency department. This program offers three levels of accreditation, which is based on the emergency department’s commitment to senior-specific care.

Why residents choose to follow this career path
EM residents choose this career path when they are interested in furthering their clinical proficiency in the acute care of the older patient. It may also be a choice for those interested in research topics relevant to the development of health care for the emergency geriatric population. 

How do I know if this path is right for me?
Are you interested in improving care for the elderly who seek medical attention in the emergency department? Are you interested in participating in research related to the field of geriatric emergency medicine, or leading hospital committees that address elderly issues? Would you like to create an emergency department geriatric service? How about participating in and leading hospital committees that address elderly issues? Do you like working in multidisciplinary teams? If so, then this may be the fellowship for you. 

Career options after fellowship
A diversity of career options exist such as geriatric emergency medicine program director/assistant program director, GEM medical director, involvement in multidisciplinary geriatric initiatives, GEM research, GEM education for emergency medicine residents and faculty, as well as medical students. 

Geriatric emergency departments have developed in community based EDs across the country. Many of the community health systems with geriatric EDs are actively seeking GEM expertise, providing opportunities for GEM-trained physicians to practice lead after graduation.

Splitting time between departments
Your specific schedule depends on final appointment, local opportunities, hospital culture, and individual circumstances. Geriatric EM-trained physicians have worked in community settings, skilled nursing facilities, and other split positions. 

Academic vs. community positions
Geriatric emergency medicine can be practiced at both community and academic institutions. The choice of academic vs. community is usually dependent on the applicant’s desire for education or research opportunities, as larger academic institutions tend to have better access to funding, research staff, research facilities, and students, residents, and fellows.   

Many community geriatric EDs exist across North America, and community geriatric emergency practice offers the opportunity to affect the lives of thousands of patients.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs

The current programs, in order of establishment, are:

Research fellowship with options for a geriatric focus:

Differences between programs
With the exception of the University of Arizona, which is purely a research program, these fellowships are similar in their diverse geriatric multidisciplinary clinical training. They vary in the types of research and advanced degree opportunities available. Please refer to individual program websites for additional details. 

Length of time required to complete fellowship
1-2 years. The 2-year program should have an advanced degree, such as a master’s-level program.

Skills acquired during fellowship
Geriatric emergency medicine fellows receive interdisciplinary training regarding the care of the geriatric patient across multiple in- and outpatient settings. Fellows are provided with an opportunity to become more competent in categories such as knowledge of the field, communication skills, and patient care/procedures. For further details, please refer to the individual GEM Fellowship programs’ websites.

Typical rotations/curriculum
Clinical, research, administrative, and clinical educator rotations and curriculum are the foundation of these fellowships. Most programs offer opportunities for obtaining an advanced degree and/or mentored research projects. 

Board certification afterwards?
Currently, GEM fellowships are non-ACGME-accredited. However, beginning in 2014, SAEM has approved several of these non-ACGME-accredited GEM Fellowships. While obtaining a certification may not be necessary, it is highly encouraged as it provides an opportunity to become a more qualified and experienced candidate. 

Average salary during fellowship
Because this is not an ACGME-approved fellowship for EM physicians, the fellowship salary is typically much more competitive as compared to the typical PGY-4/5 salary. 

PREPARING TO APPLY

How competitive is the fellowship application process?
Because this is not an ACGME fellowship, it is hard to gauge how competitive this fellowship is. There are limited fellowship programs available but the application pool is typically small. 

Requirements to apply
Applicants must be either in their final year of EM residency, EM board eligible or EM board certified physicians. Applicants must also be able to obtain a medical license in the state in which the fellowship is based. 

Research requirements
Research is not required but may certainly strengthen your application, especially if you perform research in topics relevant to the field. 

Suggested elective rotations to take during residency
Some examples of elective rotations to consider include geriatric outpatient clinics, inpatient consult services that specialize in geriatrics, palliative care services, geriatric psychiatry units, and/or outpatient geriatric clinics.

Suggestions on how to excel during these elective rotations
The best way to excel during these rotations is to work hard, come in early and stay late, read every day and expand your knowledge base, be courteous to all, remain enthusiastic throughout the entire rotation, be mindful of ethical situations, and be a team player. 

Should I complete an away rotation?
An away rotation at one of the institutions listed that sponsor this fellowship may be a good idea to help you “try out” the program and let the program get to know you. Assuming you do well during this rotation, it could be a nice way to help you stand out from other applicants. 

What can I do to stand out from the crowd?
The best way to stand out from the crowd is to develop a CV that through various activities clearly demonstrates your interest in GEM and also demonstrates your leadership ability. Anything showing interest early on in GEM is a great way to be remembered. 

Should I join a hospital committee?
Yes, assuming you are able to hold a leadership position and be an integral part to the committee. 

Publications other than research
Publications other than research, such as blog posts, EM Resident articles, podcasts, etc., are strongly encouraged especially in topics related to the GEM field. These are excellent opportunities to educate yourself and fellow EM physicians while also helping to increase your visibility to the small but vibrant GEM community. 

How many recommendations should I get? Who should write these recommendations?
Traditionally you should obtain 3 letters of recommendations, 1 of which should be from your past or current residency program director. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Absolutely. The key is to continue your involvement in this field and continue to develop your CV. The more involvement, the more it shows interest and will aid your chances for the fellowship. 

What if I’m a DO applicant?
There are no known barriers to DO applicants. 

What if I am an international applicant?
International applicants are strongly encouraged to contact each program individually. International applicants will at minimum need to have the appropriate visa, medical licensure, complete a core residency-training program, and have passed all 3 USMLE steps. If you are applying to a program accredited by ACGME, you must also meet all ACGME requirements. Of note, there is a Canadian program listed above that is open to American candidates and the license process for a training position is relatively straightforward.

Also of note for international candidates, the Global Emergency Medicine Literature Review Task Force developed a definition of Global EM with the goal of this definition to: a) clarify the role and importance of GEM within the wider field global health, b) delineate opportunities for GEM research and funding, c) advance knowledge dissemination and implementation of GEM advancements worldwide, d) standardize training of providers specialized in GEM, and e) promote professionalization of GEM. While this obviously doesn't pertain to U.S.-based GEM fellowships, it does speak to the opportunities that are newly developing worldwide (Canada and Australia, for example).

APPLICATION PROCESS

How many applications should I submit?
Apply to all programs you would seriously consider attending if offered a fellowship position. 

How do I pick the right program for me?
The fellowship program you choose should provide the resources to help you obtain your career goals and aspirations. It should also be in a location where you and your family will feel comfortable spending the next 1-2 years. Finally, during your interview, you should feel comfortable and see yourself fitting in. 

Common mistakes during the application process

  • Missing application deadlines.
  • Choosing letter of recommendation writers who do not know you well or are not strongly supportive of your aspirations in geriatric emergency medicine.
  • Grammatical errors in your application and/or personal statement.
  • Having a CV that does not clearly show your interest in GEM.
  • Having a CV that does not have any activities that display your leadership capabilities.

Application deadlines
Please contact each program individually regarding their application process and application deadlines. It is best to inquire approximately 1 year (July) prior to your intended fellowship start date. 

Tips for writing your personal statement
Do not fall into the trap of repeating your CV in your personal statement. Instead, use this avenue to explain why you are interested in a geriatric emergency medicine fellowship and how you plan to use this training for your future career. The best personal statements read as a story. Thus, if there is a particular patient who sparked your interest in the field, now is the time to talk about it. Let your personality shine through in your statement, and use this is an opportunity to positively separate yourself from the other the applicants. 

Is this a match process?
No. 

What happens if I don’t obtain a fellowship position?
If you do not obtain a fellowship position, take a hard look at your application to identify areas of weaknesses. It may be helpful to have your residency program director look over your application with you to help identify these areas. You may also consider asking the GEM programs that you applied to for advice on how to make your application stronger. Spend the next year addressing these weaknesses and apply again. Worst-case scenario, you can build a niche within this field with research and other publications as well as a clinical educator. 

INTERVIEW PROCESS

How do I stand out from the crowd?
The best way to stand out from the crowd is by letting your personality shine through. Don’t be overly talkative, but also do not be the shy candidate who is hard to engage in conversation. Come prepared with questions about the program that are not easily answered by looking at the program’s website. Have a clear vision about your reasoning for wanting to complete this fellowship and regarding your future career goals. 

What types of questions are typically asked?

  • Why are you interested in geriatric emergency medicine?
  • Why are you interested in GEM at our specific institution?
  • What are your 5- and 10-year career goals?
  • What can we expect from you in your first 90 days?
  • Tell me more about [blank] that you list here on your CV.

How many interviews should I go on?
It is recommended to attend all interviews that are offered. Remember that missing an interview can be seen as both irresponsible and unprofessional. 

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Kahn J, Magauran Jr BG, Olshaker JS. Geriatric Emergency Medicine. New York, NY: Cambridge University Press; 2014.
  • Murdoch I, Turpin S, Turpin B, MacLullich A, Losman E. Geriatric Emergencies. India: Wiley-Blackwell; 2015.
  • Mattu A, Grossman S, Rosen P. Geriatric Emergencies: A Discussion Based Review Book. Wiley-Blackwell.

Important skills to practice while in residency to prepare for fellowship
Skills to practice to prepare for fellowship include proficiency in clinical care of elderly patients, administrative and leadership skills, research skills, interpersonal and communication skills, and clinical educator skills. 

Tips on how to succeed as a fellow
Fellowship is a unique time to continue expanding your clinical skills under the guidance of a faculty mentors as you transition from being a resident to an attending. Take advantage of all opportunities offered. Work hard and become an expert in this field all while maintaining a balance with your personal life. 

CONCLUSION

Additional resources

National organizations

  • Academy of Geriatric Emergency Medicine (AGEM) -Academy of Society for Academic Emergency Medicine
  • GEMS – Geriatric Emergency Medicine Section (ACEP)
  • The American Geriatrics Society

Conferences

  • ACEP and GEMS sections
  • SAEM and AGEM section (especially great networking dinner)
  • American Geriatric Society meeting
  • Geriatric Emergency Medicine Conference (held in the U.K.): http://em3.org.uk/gemcon/#gemcon16
  • Local geriatrics conferences, including Maine Geriatrics Conference and UCLA Intensive Course in Geriatrics

How to find a mentor
FOAMed resources are a great way to get in touch, and residents should reach out to fellowships. We encourage residents to seek out geriatric EM clinician mentors within their own institutions, during away electives, and/or at conferences, especially at ACEP (Geriatric Emergency Medicine Section) and SAEM (Academy of Geriatric Emergency Medicine).