Pioneers in Geriatrics – Passing It On

It all started at Boston City Hospital. I was uncertain about my medical abilities when I left medical school. My experience at this unique institution, working with a dedicated group of young physicians and nurses, with limited resources, taught me that I could indeed practice medicine. I was struck, however, with the discrepancies between what we were taught and the problems we encountered. We learned all about the latest research in immunology, infectious diseases, endocrinology, and other fields, but we spent every day trying to manage the problems of frail, often bed bound, elderly patients. Many patients were sent in from area nursing homes with pressure sores, muscle contractures, malnutrition, and delirium; our professors taught us little about these problems. Boston City did, however, have a unique program. They had several nurses who traveled to area nursing homes to help manage patients who we followed in our outpatient clinics. I accompanied these nurses to see my patients, gaining much from the experience. The nursing homes were all converted houses or small hotels with relatively unsafe environments and little in the way of sophisticated care. This was my introduction to Geriatrics. After two exhilarating years at Boston City, I was called by the United States Army to help care for the 101st Airborne Division, returning from Vietnam to their home base at Fort Campbell, Kentucky. During these 2 years, we had ample expertise in most medical specialties, but no one knew much about joint conditions, which filled our clinics. I decided to spend 1 year in rheumatology training and then to practice general internal medicine in a community setting, preferably in a health maintenance organization. After Fort Campbell, I returned to Boston City to be a chief resident in medicine. I then spent 1 year in rheumatology at the Boston University Medical Center, but my plans changed when I was offered the opportunity to spend a second year in Manchester, England, as a lecturer in rheumatology and honorary senior registrar at the Manchester Royal Infirmary. I leapt at this opportunity, and had a phenomenal clinical and educational experience at Manchester. My mentor was J.H. Kellgran, the first professor of rheumatology in the world and a superb clinician and educator. This was the last year before his retirement, and I spent the entire year at his elbow. I also benefited from the fact that rheumatology and rehabilitation were combined specialties in the United Kingdom, and I learned a great deal of rehabilitation during this year. Just prior to my leaving for England, Dr. Robert Gifford, my primary mentor during my medical school days and now the chief of General Internal Medicine at Yale, contacted me about a unit at Yale New Haven Hospital for which he was seeking a director. The Continuing Care Unit was established by Dr. Harold (Mickey) Willard in the late 1960s, with the goal of helping elderly patients, who had lost function during a hospitalization, gain enough mobility to return to their own homes. Dr. Willard established close relationships with area skilled nursing facilities, home health care agencies, and the State Area on Aging, before moving on to the University of Rochester. Although I was not actively seeking a position in geriatrics, this unit brought me back to those patients at Boston City whose problems so challenged me. Perhaps we could do something at Yale to improve their care. My optimism about this effort was enhanced by the two great leaders with whom I would work, Bob Gifford and Sam Thier, the new chairman of medicine at Yale. I returned to Yale in September, 1976. The first few weeks were challenging, as the chief residents in medicine refused to assign residents to this unit. My only request of Dr. Thier was to have the opportunity to teach residents about the care of older individuals. I will never forget the meeting that Sam called with his chief residents. He sat the residents down, lectured them on the importance of learning about the care of chronic diseases and the elderly, and told them to make sure that the residents were assigned to this unit on a daily basis. I was pleased to be able to justify Sam’s trust in me, when, 3 years later, the residents voted me their “House Staff Teacher of the Year. ” It was difficult for one person to build a viable program. I made every effort to take advantage of the From the Yale University School of Medicine, New Haven, Connecticut.