Dr. Marilyn R. Gugliucci, MA, PhD, FAGHE, FGSA, AGSF, FNAOME, serves as President of the Gerontological Society of America (GSA). She is a Professor at the University of New England College of Osteopathic Medicine, where she directs both Geriatrics Education and Research and the U-ExCEL (UNE—Exercise and Conditioning for Easier Living) Fitness/Wellness Program for older adults. She also chairs a national GSA project, funded by AARP, focused on addressing ageism in health care. Book a free consultation today to get expert med school application help and improve your odds of getting into medical school.
1. What initially drew you to specialize in geriatrics, and what makes the field uniquely rewarding or challenging?
Let me provide some background. I was socialized to believe that aging was a positive occurrence. Throughout my childhood and adolescence, my grandparents were regarded with respect. My memories of them focused on the love they shared and the fun they had. The changes that evolved as they aged were not significant enough for me to categorize them as old. For example, even though my grandfather’s hair had turned white, it happened at the age of 25 - hardly an indicator of old age. My grandparents maintained their status as role models and mentors throughout my life. When my grandfather died at the age of 72 and my grandmother at the age of 79, it wasn’t old age that got them; they got sick. It happened to my brother when he was 6, an uncle at the age of 45, and a friend at 17. Old age, in my family, was not associated with death or decline. I was always, and continue to be, interested in being around older people.
Graduating with an exercise science/physiology degree made it possible for me to design and implement the University of New England College of Osteopathic Medicine (UNE COM) BodyWISE Center for Health and Fitness in 1989 that I directed for 17 years. We had approximately 500+ community members, 90% were 60 years of age and older, and we worked with 150 area physicians to coordinate the members’ care. BodyWISE offered programs in cardiac, stroke, and pulmonary rehabilitation and also used exercise as a modality for those who had joint replacements, diabetes, hypertension, and other chronic conditions. Essentially, BodyWISE was a medical-oriented gym (MOG), a recent term that was not invented back in the early 90s. In 1995 as a doctoral student, my focus was gerontology and my burning question was, “What is it like to grow older?” From 2000-2002, I was awarded an NIA Post-Doctoral Research Fellowship in Geriatrics at Boston University. Working with older people is my avocation and vocation. I have a passion in this field that continues to be fueled every day and burns just as bright as when I entered the field.
In 2006, I was invited by a UNE COM geriatrician to assist in implementing the UNE COM Department of Geriatrics, funded through a Health Resources and Services Administration grant. In 2024, the UNE COM (now) Division of Geriatrics was awarded the Academy for Gerontology in Higher Education Program of Merit for its robust and required geriatrics training and education (45+ hours) during the 1st and 2nd years of medical school. UNE COM’s geriatrics curriculum dedicates 80 percent of these curriculum hours to direct and experiential learning with and from older adults and the 12 hours of lecture include older adult participation. Of importance about our focus on geriatrics is that we are not trying to make students into geriatricians; instead, based on the demographics and how older adults are seen in every field of medicine, our graduates will be skilled in the care of older people.
There are numerous opportunities in this field to create new programs, enhance education opportunities, care strategies, and generate new research findings. The people who choose to work in this field are amazing; they collaborate, share ideas, welcome teamwork (Geriatrics is a team sport after all), and are creative/innovative in their approaches within the field of aging. It is a field you can work in until you die, as your aging process is part of the learning experience to be shared. Those who choose to be geriatricians are known to have the highest happiness quotient of all medical specialties. It is reported that geriatricians find their older adult patients a joy to work with—and if they aren’t, it is not because of old age, but rather the personality of the patient, which would be the case at any age in any medical profession.
What is most challenging in this field is the culture of aging within the US – it is viewed as synonymous with disease, decline, and withdrawal. This perspective on aging was actually created from the first theory of functional aging, referred to as the Disengagement Theory of Aging, in 1962 by Cummings and Henry. Essentially, this theory stated that it is mutually beneficial for older people to disengage from society and for society to disengage from older people—it is gradual and it is inevitable. As death is the ultimate disengagement, this theory essentially suggests that if you want to age functionally, you must die. This theory was debunked many years ago and yet it is still being taught by people who are not familiar with the field of gerontology or have bought into the negative stereotypes associated with aging that are prevalent in our society. What is concerning is that older adults have bought into the belief (the culture) that old age is synonymous with the disease/decline/withdrawal paradigm. However, the research shows that older adults are much happier in their older years than in their younger years or continue to be happy if they always have been. Growing older is not a death sentence, as our society purports!
The good news is that researcher Lars Tornstam reformulated Disengagement Theory, which is referred to as the Theory of GeroTranscendence. This theory describes a perspective shift from a more materialistic and rational view of life to a more transcendental one, leading to significant changes in the way of perceiving self, relationships with other people, and life as a whole … (Tornstam, L., Gerotranscendence: A Developmental Theory of Positive Aging, 2005). So, instead of disengagement, there is such a thing as positive self-solitude, which is a concept that many may relate to.
Ageism and certainly addressing ageism biases in health care is the current project I am working on in my role as president of the Gerontological Society of America (GSA) with funding from AARP. The Advisory Board is made up of higher education colleagues across the US and we are designing content to integrate into health professions programs in order to educate future health professionals about the detrimental effects of ageism in health care. Ageism has a financial cost of $63 billion a year, representing the excess costs associated with age-related biases and discriminatory practices in healthcare, leading to both undertreatment and overtreatment of older adults in the top eight healthcare conditions (Levy, B., Breaking the Age Code, 2023). There is no room for ageism in health care, as it causes iatrogenesis, which are health issues, including illness, injury, or adverse events (death) from medical care or treatment.
2. At what point in medical training should students start exploring geriatrics as a potential specialty. How can they gain early exposure?
a. At what point in medical training should students start exploring geriatrics as a potential specialty?
The simple answer is this can happen (1) during childhood, as grandparents are influential; (2) during high school/college from life experience with older people; or (3) in medical school, provided there are positive and multiple guided opportunities to understand the field of aging and geriatrics.
Actually, before I fully address this question, it will be helpful to provide some historical context about geriatrics content in allopathic (MD) and osteopathic (DO) medical colleges. At the time geriatrics competencies were first published by the American Geriatrics Society (2009), the majority of medical schools (MD and DO) offered zero to two hours of curriculum during the first two years of medical school, dedicated to learning about diseases and their treatments in older people. At this time, my medical school, the University of New England College of Osteopathic Medicine (UNE COM) was offering approximately 12 hours of geriatrics, ahead of the national data. To provide context, the term “geriatrics” (a noun) was defined as (1) the branch of medicine dealing with the diseases, debilities, and care of aged persons; (2) the study of the physical processes and problems of aging; gerontology; and (3) diagnosis and treatment of diseases and problems specific to the aged (Merriam-Webster Dictionary, 2009 and a similar definition from Blacks Medical Dictionary, 1995). Geriatrics was considered “slang” for an old person. Note in this definition there is no mention of health or wellness; it focuses on the “problems,” “diseases,” and “debilities” of “aged persons.” Old age already carried negative connotations in our western society and being elderly was associated with dying and death (See Disengagement Theory in Q 1 above). Fast forward, with the help of minimum geriatrics competencies and the rise of interprofessional care models (something geriatrics has always relied upon), more medical schools are integrating geriatrics curriculum; albeit there remains a paucity of learning opportunities in geriatrics at most US medical schools (Dawson et al., 2022). UNE COM has been fortunate to expand its geriatrics curriculum to 45+ hours (with 80% of the time spent in direct contact with older adults at their homes and all care settings) across the first two years of medical school (also known as the Pre-Clinical Years). UNE COM is one of three osteopathic medical schools in the US with such a robust geriatrics curriculum. In UNE COM’s American Geriatrics Society/Gerontological Society Student Chapter (aka AGS/GSA Student Chapter), we have 50-60 first-year students who become members of this nationally affiliated Student Chapter focused on Geriatrics and Palliative Care. To have such a high number of students each year who are interested in geriatrics is unheard of in medical school. With UNE COM’s reputation in geriatrics, it appears we are capturing the attention of students with interest in this field.
b. How can they gain early exposure?
Now, back to answering your question… Early exposure includes living with their grandparents, working in a nursing home or other care setting where older adults reside, or being part of a research team where there is interaction with older people. However, some students are “old souls”, they come wired for geriatrics, which is true in my case as I love being with older people (actually, at 71, I am an older person). Then there are students who don’t have any interest in geriatrics when they come to UNE COM, but by working directly with older people, they gain an appreciation for this population. We have found this to be true from our GEM (Geriatrics Education Mentor) program, in which students are assigned to an older adult and visit them in their home to complete five (5) assignments that include: (1) life history mutual sharing -students and the GEM, (2) geriatrics assessments -how to ask standardized questions and discuss outcomes with their GEM, (3) social, family, surgical, and medical history with medication management training with a PharmD student, (4) Osteopathic Structural/Physical Function Exam, and (5) Advance Directive and End of Life (Five Wishes) discussion. This longitudinal relationship building that occurs over the first 2 years of their medical school training, along with the other experiences provided at UNECOM appears to pique, and in some cases solidify, students interest in the field. Relationship building is a powerful experience.
The bottom line is, regardless of what field of medical a student plans to practice in, they will encounter older people; even in pediatrics, as one in four grandparents (this is a conservative number) are the primary carers of their grandchildren. If a pediatrician cannot work effectively with grandparents and keep them healthy as well, that child, who is their patient, will be at risk of needing foster care.
3. What skills or qualities do you believe are essential for success in geriatric medicine, and how can pre-meds start developing them now?
First, I hope those who are interested in geriatrics apply to medical schools that are supportive and provide a culture of “community” connection among students, with the faculty/administration and the community surrounding the medical school. The rigor of medical school is stressful enough, and having that sense of camaraderie with peers, engaging in the community (micro/meso/macro levels), providing services and support to those in need, and basking in a caring and nurturing environment is paramount so each student can be their best self in order to be the best physician they can be.
Let’s establish that all medical students need to be smart, be able to understand concepts and how to map them, do well on standardized tests, memorize in some cases but mostly be able to integrate learning across systems and apply them based on the nuances that are presented. They must be able to think on their feet and be creative—a diagnostic test provides information to consider, not a diagnosis. So presuming a student was accepted to medical school, the path they choose may twist and turn as they progress through each year, but eventually they will know what they definitely do not want to be and in their clinical education years (usually years 3 and 4) will hone in on a field or specialty based on passion. For any medical student or physician, the foundation is being humble, inquisitive, and an eager learner. Honing in on Knowledge, Attitude, and Skills (KAS) are the building blocks. However, the Essential Skills for Geriatrics (in my opinion) include:
- The ability to know and share their own heart: Knowing oneself and their essence of who they are deep inside is essential in order to convey and share a respectful engagement with older people and their family members.
- The ability to be “present”: As distractions are always part of a physician’s world, being fully engaged with each patient is a skill.
- Awareness of the importance of voice tone and body language in communication/meeting with patients: According to Mehrebian (1987), 93% of communication is achieved through voice and tone (38%) and body language (55%). Words are merely 7% of communication. If words and body language disagree, the research shows that people will trust the body language.
- The eagerness to solve mysteries: As Geriatrics Syndromes are multi-system issues, there is not one answer. A good geriatrician will gather information from the patient (or family if necessary) and systematically work through a multifaceted approach to understand and address the issues presented by older people.
- The ability to create a strong team and work with others in respectful ways: This includes being inclusive of the CNAs, social workers, nurses, NPs/PAs, food service workers, cleaning and maintenance staff, and anyone who is part of ensuring the comprehensive care for older people. The physician will often set the tone of the work environment and so having a mindful and respectful attitude for all who contribute, along with a good primary team, will create success.
- The ability to touch others and to give and receive hugs: It was stated in the Boston Globe that a person needs 4 hugs a day to survive and 8 to thrive. Many older people are isolated with little support. Having a physician who has this ability to feel comfortable with touch and hugging (always asking first) is so important. It is a form of non-verbal communication that can convey so much, providing the physician is “present.” In essence, to be a human “being” rather than a human “doing.”
4. What does the typical training path look like for becoming a geriatrician, from medical school through fellowship?
The basic answer is four years of medical school, 3 years residency (internal medicine or family medicine are the usual ones), and 1 year of geriatrics fellowship training. The bottom line is that the 4 years of foundational learning, depending on the medical school can either solidify or challenge ageism in health care. It can entrench a medical student in negative stereotypes and expectations about aging or it can challenge negative attitudes and enlighten medical students to create possibility lists for their older patients rather than problem lists (which they are taught to do). During the clinical years of medical school, when working with attendings, a medical student needs to be stalwart in their (positive) attitudes about aging, standing firm on addressing ageism in health care with fellow practitioners, providers, and staff. A culture shift to ensure all older persons who are in a medical setting are referred to as a person and not as a “geriatric patient” will be the first line of age-supportive communication—remember, geriatric (no “s”) is an adjective that often implies that someone or something has significant disorders—which brings us back to creating a problem list rather than a possibility list.
After graduating from medical school, hopefully the residency program has been vetted for its age supportiveness—Is the hospital an Age-Friendly Hospital? Is it HELP (Hospital Elder Life Program) certified? Is Age-Friendly Health Care (paying attention to the 4 Ms) part of the culture? The 4 Ms are: Matters Most (to the older person), Mobility, Mentation (includes cognition and depression), and Medications (poly-pharmacy). Actually, these 4 Ms are ageless and should be implemented with any person who is at the health care setting, as all are hopefully aging regardless of their chronological age. (Age-Friendly Health Systems- Age-Friendly Health Systems Join the Movement | Institute for Healthcare Improvement)
Once in the Geriatrics Fellowship Program (the Plus 1 specialty training), the trainee should feel like they found their “tribe” – physicians and staff with a passion for working with older adults. Again, the same applies regarding the hospital setting as above regarding its Age Friendly/supportive culture. There is also a NICHE certifications for hospitals—Nurses in the Care of Hospitalized Elders, that is good to look for as well
5. What are some common misconceptions students have about working with older adult Populations?
Based on the US culture of aging being synonymous with disease, decline, and withdrawal (death), students expect that working with older people will be depressing, that it is not “sexy” (exciting), and since older people are that much closer to death, a “why bother?” attitude could be present. The field of geriatrics is focused on high touch rather than high tech. It also relies on inter-professional approaches to care and teamwork among all staff at all levels. It is about relationship building, understanding what Matters Most to patients and being creative in providing avenues to help meet what Matters Most.
At UNE COM, I designed and implemented two unique Learning by Living Research Project tracks; both based on qualitative ethnographic/autobiographic research in which the students’ journals are the data. Each journal includes my comments and questions to help them dive deeper into reflection of their experiences through the pre-fieldwork, fieldwork and post-fieldwork phases of the project. Each student receives a copy of their final journal. It appears that UNE COM is the only medical school in the US and possibly globally that offers such programs.
(1) The Nursing Home Immersion Project (Established June 2005), in which medical students (who volunteer) are “admitted” to live the life of a nursing home resident for an extended period of time (24 hrs/day for 10-14 days), complete with a diagnosis and standard procedures of care from staff. I am considered to be the adult daughter. Upon entering the nursing home, students suddenly live as if they had a debilitating stroke. They lose the use of their dominant side and have to use a wheelchair (one-handed and one-legged), have a nasal cannula, are bathed and toileted, eat pureed foods and drink thickened liquids, and need to use the call bell to be transferred from chair to bed, etc. They may live in the dementia unit or on the long-term care floor, usually with a roommate. They participate in activities the residents engage in. They either receive OT and PT or are assigned to a resident who has a similar diagnosis to be part of their rehabilitation experiences. Miraculously, at the end of the 2 weeks, students are reluctant to leave the nursing home because they do not want to leave their friends. They have connected heart-to-heart with the residents and have found ways of communicating with residents who have limited speech. They have learned the power of silence, how to be in the moment with each person they spend time with and some realized that when they speak, it is no longer the other person’s story; it now becomes their story—they need to listen and not interrupt. Students are inspired by the resilience of some residents and are eager to find ways to connect with those they live with. The research is life-altering and has inspired a number of students to either become geriatricians or hone skills of working with older people beyond what is taught in medical school.
(2) The 48-Hour Hospice Home Immersion (established December 2014), in which 2nd year medical students volunteer with a student peer to live in an 18-bed (single rooms) in-patient acute care hospice home (considered the ICU of hospice) for 48 hours. They usually enter on a Friday afternoon and leave the hospice house on Sunday afternoon after a debriefing. In the time they are immersed, they provide patient care, family support, and post-mortem care. They are guided by and interact with an interprofessional staff team working closely with CNAs, nurses, NPs, social workers, and chaplains. Students experience at least 2 deaths and upwards of 10 deaths within the 48 hours (the average is 5 deaths). They have the opportunity to sit with patients and/or their families to hear their stories. All too often a person is transferred to the hospice home from a hospital or other care environment with unmanaged symptoms. Some patients have no idea they are dying, as the physician with whom they have been working failed to ascertain the person’s understanding; possibly the physician didn’t use direct or simple language. For example, one patient didn’t understand what the word metastases meant and didn’t feel comfortable asking. This too is a life-altering experience. Students expect to cry the entire 48 hours, and yet they realize how much life is in the home; when a person can no longer be cured of their disease, then healing is paramount. The students have noted how present they felt during the 48 hours, experienced the role of a person’s spirituality/religion at this time of life, and understood the power of touch and the importance of being present and listening with one’s whole being. To date, approximately 40 students have become palliative care physicians, and all who did this project thus far report skills in being able to discuss end of life and be comfortably present with a dying person (and their family).
The experiences, including skill and attitude development, attained from these two immersion projects cannot be taught in a lecture. How could one teach what it is like to no longer live in their home of choice due to challenges with Activities of Daily Living (ADLs) without experiencing this for an extended period of time? How can one teach what it is like to be present with those who are dying and, after their death, perform postmortem care? In closing, both of these projects happened because students approached me and said, “Dr. G., I want to learn how to talk with older people in a nursing home … Dr. G., I want to learn more about death, dying, and palliative care.” There are so many misconceptions about living in a nursing home and about death and dying, at UNE COM we figured out how to provide insights to dispel myths and fears in both of these environments with the help of our students.
6. What advice would you give to future doctors who want to make a meaningful impact in the care of aging populations?
Show up and be present. Share your heart, mind, and abilities in meaningful ways. Regardless if a person is an introvert (those who regain their energy by being quiet or needing alone time) or an extrovert (those who regain their energy by being with others). Both types of people have the ability for focused, mindful, and heartfelt connections with those they work with or provide care for.
Scan the environment in which you are practicing and allow yourself unfiltered idea generation (no guardrails). Talk with colleagues, determine high-need areas, and possibly ways you can address them. Regardless of your training in research, there are many medical students who have great research skills and can think through a project to design it. Attend conferences and be sure to network with others and join interest groups on topics that get you excited or that you want to learn more about. If you experience or observe a care procedure, practice model, or program that intrigues you, reach out to the originator and ASK for guidance. Imitation is the sincerest form of ”flattery"—for those committed to improving care of older adults or the systems that will aid in better care, the people in this field are eager to share and expand good works across the US and internationally.
In order to have a meaningful impact on the care of older people, it is important to include them in your thinking and how to design whatever it is you want to create. Be sure it applies to older people. Remember, if you met one older person, then you have met one older person! The heterogeneity of aging becomes more pronounced as people age biologically, physiologically, socially, and psychologically. Get input from older people you work with or have contact with; it will help expand the scope of thinking and help to ensure the implementation of the model/idea is applicable/appropriate for older people. The most powerful 3-letter word in the English language is…. Wait for it… ASK!
If you think about it, we barrage infants, toddlers, and children with questions as they are growing up. In essence, this is how we have been programmed to answer—making ASK the most powerful 3-letter word. Identify a need and ASK about it. How can we address this? What are your ideas? What do you think about XYZ as an approach? What do you think/feel is an effective way to deal with this issue or program? There is no end to the amount of questions one can generate to increase the care of older people—note each question is open-ended. During our younger years, people tend to ask closed questions that are easy to respond to: Can you say mommy/daddy? What animal is that? What does it say? But for a complex issue like having impact on the care of older persons, we need to ASK complex questions to get expansive answers… When there is a spark of excitement, that is the one to follow and try to address.
Inspira Advantage is proud to share insights from leaders like Dr. Marilyn R. Gugliucci, whose lifelong commitment to aging research and education helps inspire the next generation of physicians to deliver compassionate, thoughtful, and age-inclusive care.
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