Learning How to Help Shape Healthcare Policy That Improves Elder Care Through the Health and Aging Policy Fellows Program: Diane Meier, MD

Diane E. Meier, MD, a geriatrician, recently finished the Atlantic Philanthropies' prestigious Health and Aging Policy Fellows Program. She was one of nine professionals named a fellow this year. The honor is one among many for Dr. Meier, who is widely published and the recipient of numerous awards, including the MacArthur Foundation Fellowship (the so-called "genius award") and a five-year National Institute on Aging (NIA) Academic Career Leadership Award.

The Health and Aging Policy Fellows Program is designed to provide participants with the experience and skills necessary to help shape policy in ways that improve care for older adults. Physicians, nurses, pharmacists, clinical psychologists, social workers and others in the field who are committed to improving health and healthcare in later life, are interested in influencing health policy, and have leadership potential, are candidates for the highly sought-after fellowships.

This spring, during her fellowship, AGS News interviewed Dr. Meier, who is also Director of the Center to Advance Palliative Care (for more information, see www.CAPC.org), a national organization devoted to increasing the number and quality of palliative care programs in the United States. Under her leadership, the number of palliative care programs in U.S. hospitals has more than tripled in the last 10 years.

AGS News: What does the fellowship entail and how is it going?

Dr. Meier: I am participating in the residential track of the program, which allows fellows to live in Washington and participate in the policy-making process on federal and state levels either in the legislative or the executive branches of government. There is also a non-residential track which allows fellows to work on a policy project and brief placement or placements throughout the year at relevant sites.

Through the residential track, I am currently a fellow on the Senate Health, Education, Labor and Pensions (HELP) committee. In that context, I am working on various aspects of health policy including those concerning insurance rate setting; patent protection for new drugs; and direct-to-consumer advertising policy.

I am hoping to be able to use my experience to increase the sophistication of the palliative medicine field in influencing policy through a better grasp of the politics and the procedures necessary to policy-making.

I hope that I am also able to provide some real-world clinical knowledge and expertise for my remarkable colleagues on the committee's staff. I have been so impressed by the caliber, commitment to the public good, and amazing work ethic of congressional staffers. We doctors think we work hard! Much of the action now that health reform is law is on the implementation side in the executive branch of government. For example, there are pilot projects - such as the Independence at Home Act - designed to improve care for home-bound patients in ways that reduce their risks of hospitalization by providing well coordinated and well communicated primary and preventive care at home. If these prove effective in terms of improving quality of care while costing less, then the government will consider rolling them out nationwide.

AGS News: What have you learned through the Scholars program? And how do you plan to put your training to use?

Dr. Meier: I've learned, once again, the importance of relationships. In order to influence policy, attention to relationships is crucial; and such relationships take time and effort. Those of us in medicine need to understand that we can have real influence if we put the time and effort into identifying, meeting, and getting to know the key people in our field. Having worked with a Congressional committee I now understand who has seats at the table and contributes. There's a saying: "Be at the table or be on the menu." We must become healthcare professional-citizens and understand how to get involved in the development and advocacy necessary to help our patients. We need to change medical and nursing education to incorporate advocacy on behalf of the needs of our patients. We don't have the luxury of sitting it out if we want to help people now and in the future.

When I return to my position at Mount Sinai I will focus on mobilizing collaborations and connections among different groups. I will work on influencing new policy and the implementation of new laws. The Health in Aging Policy Fellows program has given me the vocabulary, the network, the connections and a real sense of how the game works.

AGS News: Could you talk about why you chose a career in geriatrics?

Dr. Meier: I was very close to my grandfather and spent summers at his farm in New Jersey. I adored him and learned to love ice cream and sunsets and gardening and to understand that all people were one, from him. While I was in medical school and as a trainee I always thought of him and how I would want a doctor to treat him if he were in the hospital. His memory helps me remember that every sick person and every old person is a fellow human being - who could have been my grandfather.

I graduated medical school in 1977, finished my residency in 1980, and then began a geriatric fellowship. I spent a lot of time on subspecialty rotations. The general medicine component - the broader field - was limited to the outpatient clinic one-half day a week, which is still the typical case in medical school training. Geriatrics was the one path that focused on whole-person care and providing high quality care. This made more sense to me cognitively.

AGS News: Could you tell us a bit about your experience on the first day of your internship and how it ultimately influenced your decision to go into geriatrics and palliative care?

On the first day of the internship, a patient assigned to my service was undergoing resuscitation after cardiac arrest. Running after my resident, we arrived at the bedside of this 89-year-old man, who had end-stage congestive heart failure. I watched as we shocked the patient repeatedly; tried four times to get a central line in; injected pressors directly into his heart; stuck the femoral artery for blood gases; and carried on chest compression for over an hour.

I felt as if I had failed the patient because I didn't know how to do the procedures or what I was expected to do as a first-day intern. I didn't know whether we were doing the right thing. It was a violent and traumatic experience. We left the patient naked and covered with tubes, paper, and bloodstained sheets. The patient's wife was seated outside the unit and I do not know if anyone spoke with her to explain what happened. Certainly no one explained it to me.

It is challenging to feel that the things that are important in healthcare are seen as marginal or not valued in the academic setting where I've worked for most of my career. Somehow this notion that we, as doctors and healthcare providers, have a responsibility to do more than the procedure is not a widely held stance. So for a long time, until I found a place for myself in geriatrics and palliative care I felt like I didn't belong. I'm sure other people share that feeling. It isn't talked about because it poses a challenge or threat to this whole healthcare system and the marketplace values driving it. It was lonely.

In my first real job at Mount Sinai in 1983, our chairman was Dr. Robert Butler. For me, he was a mentor who demonstrated how to be a citizen-physician - a physician concerned with the health of the public. Through him, I learned that the academic model - get grants, do research, publish - was necessary, but far from sufficient to the goal of assuring access to quality care for all Americans. Dr. Butler never pushed me to do anything I did not want to as a faculty member, but when I told him in 1994 that I was too busy to apply for the new Project on Death in America (PDIA) Faculty Scholars program, he refused to take "no" for an answer. Because of his mentorship and encouragement, in mid-career I found my true calling in palliative medicine.

AGS News: What advice would you offer someone considering a career or a career switch into geriatrics?

Dr. Meier: There is a reason geriatricians are the most satisfied with their work even though they are the least incentivized medical group financially. Geriatrics and palliative medicine offer what I was looking for when I decided to go to medical school in the first place. In this field, we are able to really connect with the patient and the patient's family and make the person's life better. It is incredibly rewarding and satisfying, and that is much better than money.

In my professional lifetime, I believe our society will begin to see people with geriatric training as the most valuable players. Geriatric populations are driving healthcare expenditures and if colleagues don't work with us, they won't be able to control costs. The incentives will switch. Rewards for quality will replace rewards for quantity. Our time is coming. I couldn't have said that before the health reform bill (which has a lot to offer geriatrics healthcare professionals and older adults) passed.

On a personal note, in geriatrics and palliative medicine, I am fortunate to have found an intellectual peer group of colleagues. Finding my peer group unleashed a lot of creative energy and optimism in me. I felt a sense of relief of not feeling alone. It was a power shift for me. Geriatrics and palliative medicine focus on meaning and purpose in life and in the practice of medicine - the purpose of our work - and that is a relief and a comfort to me.