A one-time interim dean dedicated his career to improving how we care for older people.
You could say he’s been the Johnny Appleseed of geriatrics, sowing the seeds of quality and innovation in the care of elderly people wherever he’s worked. And it hasn’t gone unnoticed. In addition to myriad academic and hospital appointments, grants, and publications, Besdine’s 22-page CV includes such honors as Geriatrician of the Year (Gerontological Society of America), President’s Award (American Society on Aging), the Milo D. Leavitt Award for Eminence in Geriatric Education (American Geriatrics Society), and the Milton Hamolsky Lifetime Achievement Award for outstanding contributions to the field of Internal Medicine (American College of Physicians, Rhode Island Chapter). At Brown, where he served as interim dean of biology and medicine from 2002 to 2005, he has received the Brown Medical Alumni Association’s W. W. Keen Award and the Department of Medicine’s Beckwith Family Award for Outstanding Teaching. He and his wife, Terrie “Fox” Wetle, PhD, herself a renowned gerontologist and founding dean of Brown’s School of Public Health, are the ultimate power couple of the aging-research world.
In June 2018, Besdine announced he’s stepping down. Here, with his characteristic combination of pride and self-deprecation, understatement and irreverence, he looks back on a career well lived.
How did an almost-English major from Haverford end up becoming a doctor?
I grew up crawling around my father’s dental office. He worked with gold and made a lot of his own dentures. I was interested in the manual dexterity that required, and I really liked the way he interacted with people. But it wasn’t until high school that science really excited me. Then, in college, I led two lives. I met the criteria to be an English major, but I majored in biology, because I had decided to go to med school. I did a lot of biology research, which I liked a lot.
What did you like about it?
The quantitative dimension: reading the literature, investigating a problem, getting an answer. When it came time to decide what I was going to do after college, I struggled among graduate school in English, graduate school in biology, or medicine. I chose medicine because I thought it all of my interests. And I was so right.
Did anyone help you make that decision?
I followed my mentors’ advice. A good mentor helps people find their passion. And my mentors all said, “We are basic scientists and physicians and that is the noblest thing you can do.”
After graduating from the University of Pennsylvania’s medical school in 1965, you did your residency in internal medicine at Harvard and Beth Israel Hospital.
Yes, and I did my postdoctoral fellowships there, too. I was doing very basic immunology and immunochemistry, and doing it well enough that I got an NIH grant. I had my own 28 inches of laboratory bench space! Also around that time [1970], I co-authored an editorial in the New England Journal of Medicine about restricted heterogeneity of antibodies.
How did you make the leap from immunology to geriatrics?
I found I was not having as much fun at work as I saw people around me having. I liked getting grants funded, I liked getting papers published, but I wasn’t passionate about what I was doing. At the time I was moonlighting in a nursing home, and realized I was spending more and more time there. The residents whose medical care I found most exciting and challenging were those with multiple serious chronic illnesses (at least three or four, often six or more), were taking multiple medications (sometimes double digits), and had some degree of cognitive impairment. Getting it right took all the smarts and patience I had, and made me acquire even more.
I went to my chair of medicine, Howard Hiatt [subsequently dean of Harvard’s School of Public Health], and told him my dilemma. He said, “I met a man in Scotland I think you should go train with.” That was Sir Ferguson Anderson [1914–2001], the first endowed professor of geriatric medicine in Europe. I became his first American trainee, at the University of Glasgow. He was a wonderful human being. He captured my mind and heart.
What do you find so compelling about geriatrics?
It sounds trite, but I take great satisfaction in improving the human condition. Because of my parents, I grew up honoring and respecting underdogs, people who are suffering. Given the neglect of older people at the time I was coming into medicine, they were the obvious underdogs.
And clinically, geriatrics is exciting and challenging. General internists may take care of a patient with one problem. Our patients have nine coexisting conditions and 14 medicines and a fixed income. They can’t pay enough of the electric bill to be warm enough in the winter to avoid illness from cold exposure or cool enough in the summer to avoid illness from heat exposure. Some have difficult families, because the families see the distress of their beloved elder person, and they’re angry. They’re incredibly complex cases.
As a physician, you treat one patient at a time. But you’re also able to see how to make changes to care at the macro level, using data to improve policy. How did you learn that?
In 1995, while I was at UConn, I took a sabbatical. I wanted to be near Fox, who was deputy director at the National Institute on Aging in DC. She introduced me to Bruce Vladeck, the author of Unloving Care: The Nursing Home Tragedy. He was administrator of the Health Care Financing Administration [now the Centers for Medicare and Medicaid Services]and an icon of health care policy, especially as it relates to older people. I knew nothing about financing or policy, but Bruce told Fox, “I’ll give him a cubicle. We’ll find something for him to do.” So, for my introduction, I shadowed him for almost two months. We went to Capitol Hill, to briefings, to hearings, we went out in the field. As I like to say, I went everywhere with Bruce except home and the bathroom.
One day in the back of his chauffeured SUV, he said, “You know, this agency has never had a chief medical officer. I think you’d be good at that. How about it?” And I said, “Sure. What’s that?”
So I became HCFA’s first chief medical officer, as well as director of the Health Standards and Quality Bureau, a 1,200-person national entity with a billion-dollar-a-year budget responsible for improving and policing the quality of Medicare and Medicaid for 70 million people. I didn’t know enough to be scared. I had 22 people working in the front office to help me. That’s where I learned to manage people and programs.
Why did you take the job?
I was passionate about quality of care, and now I had a vehicle to put that passion into practice in the field. That year, 1995, was the 30th anniversary of the bill that led to Medicare and Medicaid. Bruce had been critical in getting Congress to implement 36 pages of legislation related to the quality of care in nursing homes. So I became responsible for quality of care the year that nursing home inspection and enforcement first went into practice.
How is it that you’re able to come at the issue through so many different angles—teaching, treating, researching, and thinking about policy?
I’m a left-handed male with mixed dominance. I mean, that I can read is remarkable.
In 2000, Fox came to Brown to start a program in public
health. You came, too, as the first Greer Professor of Geriatric Medicine, director of the division of geriatrics in the Department of Medicine, and director of the Center for Gerontology and Health Care Research (CGHCR) in the then-Public Health Program. What was appealing about coming to Brown?
In addition to the Greer professorship, what made it a done deal was that geriatrics at Brown was stagnant. There were two geriatricians doing mostly clinical work. Given the excitement and resources of the Greer professorship, the support of the Department of Medicine, and the chance to build excellence, how could anyone not jump? There are now 15 geriatricians, a dozen palliative docs, and six nurse practitioners in the division.
What also made it appealing was the CGHCR leadership. Some of the most exciting research in the United States related to improving quality of care for vulnerable older Americans was going on right here. I’ve mostly just done fine-tuning, but we have doubled the number of faculty and tripled the grant income since I came here. It was very gratifying when the American Health Care Association gave us $1 million in 2017 to establish the Center for Long-term Care Quality & Innovation. Vince Mor [PhD, professor of health services, policy, and practice] and Rosa Baier [MPH’04, associate professor of the practice of health services, policy, and practice] direct the Q&I Center, as I affectionately named it, whose goal is to identify, validate, and bring to scale promising innovations to improve care of vulnerable older people in long-term care—not just in nursing homes, but in the community as well.
In 2005 you received a $2 million grant from the Reynolds Foundation to integrate geriatrics into the med school curriculum from the very first year. In 2013 you received another $1 million to develop curricula to train doctors. Why is it important for all doctors to understand aging?
Every physician needs to understand the basics of geriatric medicine. The only specialties that do not deal with older adults are pediatrics and obstetrics. But pediatricians need to know about aging because a third of American children are raised principally or exclusively by grandparents. And the childbearing patients of obstetricians grow old, and many continue to get their care from their obstetricians. The care of older adults now is a major part of American medicine from both a clinical and financial perspective. In the future, older people will dominate the health care landscape by their sheer numbers and the complexity of their problems.
In 2012, you established a palliative care fellowship. How does palliative care connect with geriatrics?
Historically and to the present, geriatricians have had to be expert in palliative care to meet their elderly patients’ needs. Many of the current leaders in academic palliative medicine have come to the specialty through geriatrics. Our own Joan Teno [MD, MMSc’90, adjunct professor of health services, policy, and practice] is a fine example of that, having trained in geriatrics at George Washington and then come to Brown to do research, where she gravitated more and more to palliative medicine and end-of-life care. About 10 years ago, she made the transition to palliative clinical practice. The relatively new specialty of hospice and palliative medicine has evolved over the past few decades, and these specialists treat patients of all ages.
You’ve spoken for years now about what you call the “aging avalanche”—the fact that the number of Americans over the age of 65 is climbing. How are we doing in terms of training enough people to care for us as we age in great numbers?
Lousy. The number of certified geriatricians is actually trending down. My cohort is retiring and we’re not replacing ourselves one for one. Also, there are people who certified in 1988 who are giving up their certification. Because elderly patients take so much time, it becomes financially disadvantageous to be identified as expert in the care of older people. That’s another reason it’s important to teach all medical students about aging.
What qualities must the best geriatrician possess?
Be a really great clinician. Appropriately, but not excessively, like, respect, and honor old people.
In addition to the growth mentioned earlier, what are you most proud of from your nearly two decades at Brown?
Helping to make the Division financially viable, and also radically improving hospital care for elderly patients through co-management.
What do you mean by co-management?
Geriatrics co-management is a clinical program in which a geriatrician works alongside a surgical specialist.
What I already knew, but had never put into operation in a program, is that it’s always the same problems that kill or disable old people in hospitals, no matter what brings them in. They fall, they get nosocomial infections from catheters or from lines or from being sedated from a drug, they get delirious, they get a drug, they’re over-sedated, they aspirate, they get pneumonia, they get over-hydrated, they get heart failure, they get diuresis, they get kidney failure, and on the 13th hospital day, they die.
So [the late orthopedics chair]Michael Ehrlich and I agreed to try a model of care where an orthopedic surgeon and a geriatrician work side by side to care for a hip fracture patient. I told Mike, we can’t fix this with a fee-for service consultation program, where the geriatrician comes and evaluates the patient and leaves 14 recommendations on a page and a half, which nobody reads. The geriatrician needs to be able to write orders on your patients for everything but the care of the hip fracture. We have to manage the diabetes and the medications, manage the discharge plan, and so on. And someone else has to pay the salary and overhead costs of the geriatrician. Rhode Island Hospital was on board.
Not only did it improve results dramatically, it made us financially viable. Mortality decreased 70 percent. Discharges directly to home tripled, so now 15 percent of hip fracture patients avoid going into a nursing home, where they might get Clostridium difficile and die. Re-hospitalization rates were cut in half. Length of stay was reduced by 2.2 days. We’re doing this now for elderly patients who undergo trauma, joint replacement, colorectal and general surgery, and complex urology surgery.
For your whole career, including at Brown, you seem to have been in perpetual motion—creating programs, designing curricula, seeing patients, playing squash four times a week. Are you really, really retiring?
When I announced I was stepping down I didn’t have a plan. But [Provost] Rick Locke, [Chair of Medicine] Lou Rice, and [Dean of the School of Public Health] Bess Marcus all want me to stay around and be useful in the Division and the School. So I’ll work half time, maybe.
What will you do for fun?
Spend a lot of time with Fox sitting in our gazebo in the good weather and reading great books and laughing together.
Tell me something most people don’t know about you.
Well, everybody knows my wife is better than I am—a better manager, better strategic planner, better mentor, better driver, better everything. I speak of Fox as “my better three-quarters.”
What many people don’t know is that when I was a teenager I raced sports cars. I had a British racing green Austin Healey and a novice Sports Car Club of America competition license, and I raced at the Bridgehampton race track in the summer. I loved driving.
Looking back, how would you describe your leadership style?
I’m proud of only hiring outstanding physicians and teachers. I didn’t hire any stinkers. They are all trusting, respectful people, and they’re nice to each other. It’s no accident that [the Center for Gerontology and Health Care Research]is a great place to work. If you model kindness as a director, disrespectful people get embarrassed.
I’m also a strong believer in never meeting someone for the first time when you need something. When I became dean, I was glad to have already met a lot of people. My approach there was to occupy the high ground and recruit people to it, rather than give them orders.
How has becoming an “older American” affected your approach to your own health care?
I think I don’t do much differently, other than to follow my own excellent advice on living as healthily as possible, but I always have done that: eat Mediterranean, exercise often, manage my minor chronic diseases. And of course, avoid stress (good luck with that)!
What do you tell medical students to get them excited about geriatrics?
It’s some of the most rewarding work that a physician can do. You’re working at the top of your license every minute of the day. And people deserve to be well cared for until the end of their lives.
