Elder Justice Roundtable: Education
What Training Is Needed for healthcare and Law Enforcement Professionals on Forensic Elder Abuse and Neglect Issues?
Presenter:
Gregory Paveza, Ph.D., M.S.W., Associate Professor, University of South Florida School of Social Work
First Responder:
Carmel Bitondo Dyer, M.D., A.G.S.F., F.A.C.P., Associate Professor of Medicine, Baylor College of Medicine, Director, Geriatrics
Program, Harris County Hospital District
Doctors, social workers, emergency medical technicians, nurses, lawyers, and other professionals need a better understanding of elder abuse and neglect to provide adequate assistance to their patients/clients. "What I want folks to begin to think about is ... Who needs to know what, and when do they need to know it?" said Dr. Gregory Paveza, associate professor at the University of South Florida School of Social Work.
Dr. Mosqueda pointed out that it is important to provide training at the right level. "One overarching theme, almost no matter what field, is [the application of a] pyramid approach—something Dr. Wright and I have used in designing training programs. [W]ho do you need to educate [and] at what level? . . . If you look at people who are geriatric experts, be they geriatric nurse practitioners, geriatricians, et cetera, that is a whole different level of expertise [for training purposes] than a medical student." Dr. Sanders echoed this point, suggesting that a consensus be developed for "What does the geriatrician need to know?" "What does the primary care physician . . . and the paramedic need to know at various levels?" Another suggestion was that education and training programs be evaluated to ensure their effectiveness.
In addition to training within each individual discipline, Dr. Mosqueda noted the importance of cross-discipline training, but said: "As physicians, we must admit that we are notoriously bad about going to multidisciplinary training." Dr. Paveza agreed, pointing out that it is difficult to get groups to cross-training, but that it is crucial to understanding the concerns of others who are part of multidisciplinary teams. Dr. Paveza noted that one way to increase attendance was to mandate training as part of license renewal.
Medicine
While this education initiative will not be an easy task, educating medical school students and physicians about elder abuse and neglect is paramount to the successful eradication of elder abuse and neglect. One way to get doctors to understand the medical importance of abuse is to compare it to chronic disease, said Dr. Mark Lachs, co-chief of geriatrics and gerontology at Cornell University's Weill Medical College. "This [abuse and neglect] has as much . . . mortality associated with it as all the other chronic diseases they normally treat . . . family violence victims of any age behave in the health system like people with chronic disease," he said.
To convince medical schools to teach students about elder abuse, geriatricians need to do more research, activists need to work to change policy, and elder deaths need to become "noteworthy," said Dr. Dyer, associate professor at Baylor College of Medicine, Texas. "Do you ever read about it in the newspaper—how somebody who was actively neglecting somebody [else] is prosecuted? Doctors are not reading that in the newspaper. It is not important," said Dyer. Many physicians regard elder abuse and neglect as "just a social issue."
Increased research, grants, and papers can convince medical school curriculum committees that elder abuse is an important medical issue, but that still will be a struggle. "When we developed the California training center for areas of all violence education ... we had people advocating at the University of California regents level, which mandates training in all of our University of California medical schools in order to get family violence on the curriculum of our seven California medical schools, and have not yet been successful ... that arena is not very promising," said Dr. Wendy Wright of the Children's Hospital in San Diego, California.
At present, there is no consensus on how to train physicians on elder neglect and abuse. "One thing would be to develop a consensus: What does a geriatrician need to know? I'm actually surprised it is not in the curriculum and in the examination ... what does a primary care physician, what does a paramedic need to know at various levels?" said Dr. Arthur Sanders, professor of emergency medicine at the University of Arizona.
Geriatricians can work state by state to make sure there are questions about aging on State board examinations, just as many States now include questions about violence on their nursing exams. Other policy changes can create financial incentives for schools to change their training. States can require medical schools that receive public funds to designate an elder abuse expert at the school. On a Federal level, Medicare can create incentives for medical schools to train more geriatricians, Dyer noted.
Doctors who already are licensed also need to be trained in elder abuse and neglect.
Physicians are required, under law, to report abuse. "There were physicians that were prosecuted in the child abuse arena for failing to report, and there is some value in that from a law enforcement perspective, to inspire others to come forward," said David Hoffman, assistant United States attorney in Philadelphia. Some doctors resist investigating elder abuse or neglect because of fear of testifying; others do so because they fear lawsuits or because they do not want to report colleagues to authorities.
"A lot of what we are facing are often really instances of medical malpractice which triggers off abuse, [including] misuse of medications, withholding of visits," said Dr. Carl Eisdorfer, chairman of the Department of Psychiatry and Behavioral Sciences at the University of Miami. To increase the chances for bringing such malpractice to attention, Dr. Eisdorfer suggested adopting the "impaired physician" model, in which physicians who have problems with substance abuse can be reported and "will get help rather than prosecutorial attention." In other cases, "doctors don't like to see lawyers because they have this vision of being cross-examined on the stand and getting involved and, if you do this, you may have to hire your own lawyer to protect you," said Dr. Eisdorfer. Attorneys and doctors need to be able to look at their colleagues' reports and judge whether abuse might be happening despite—or because of—their colleagues' efforts.
On a practical level, doctors tend to resist "interdisciplinary" or "multidisciplinary" training, preferring training developed specifically for physicians. "As physicians, we must admit that we are notoriously bad about going to multidisciplinary trainings," said Dr. Laura Mosqueda, director of geriatrics at the University of California-Irvine Medical Center, whereas nurses, social workers, and law enforcement officers are far more willing to participate.
To encourage doctors to attend multidisciplinary trainings, groups that offer them should also offer continuing medical education (CME) credits for doctors and continuing legal education (CLE) credits for lawyers, which are requirements for renewing a license to practice in many States. "It is a nice carrot, and sometimes both the physicians and the lawyers are looking for something out of the ordinary when they're going to do that, that is more than just the humdrum stuff that they may be doing every day and reading the journals on every day," said Dr. Ian Hood, deputy medical examiner, Philadelphia. In particular, quality assurance credits for continuing medical education are required, and difficult to obtain, said Dr Rosalie Wolf, executive director at the University of Massachusetts Memorial healthcare Institute of Aging.
Changing doctors' behavior is more than just a matter of giving CME credit, noted Dr. Sanders. He added: "There is a literature on changing physician behavior, and the trap is [that] you put on a CME course and you think people visit, or you send out a position statement from a professional society, and you think people are doing it . . . there are mechanisms of [changing behavior], some through regulation, some through feedback of physician leaders, various things like that."
Social Work
Social work students are not being taught even the most basic facts about the lives of older adults. "I don't know personally of any graduate schools of social work that offer curricula in elder abuse, and that is a big gap," said Joanne Otto, administrator of APS in Colorado. The National Association for Adult Protective Services Administrators is developing standards for training, but, so far, there are no Federal guidelines for training.
Ignorance of elder issues is pervasive in colleges, down to the very textbooks assigned to students. "As an example, several years ago at a meeting I went through a gob of textbooks, literally hundreds of textbooks on human development," said Paveza. "All of them had five chapters on child development, seven chapters on adult development, and a half-chapter on old age and development of the elder adult. We need to make sure that our professionals. . . at a basic level know about geriatrics, and know about aging, and what is the normal aging process." Medical residents and professional students also need to learn about basic aging issues, so they can identify adults who are showing unusual symptoms and answer the question, "What does a pattern begin to look like that should lead you to suspect that abuse and neglect is occurring?" said Dr. Paveza.
Law Enforcement
In some States, law enforcement personnel already are learning about elder abuse as part of their basic curriculum at the police academy. State legislatures in California and elsewhere have passed laws mandating training in elder abuse for law enforcement personnel and allocating the money to provide it, said Candace Heisler, consultant and trainer for the San Francisco District Attorney's Office.
In South Carolina, police academy instructors train recruits in legal issues surrounding elder abuse and indicators of abuse. Pictures of the physical impact of neglect on the body are particularly useful, said Randolph Thomas, police officer and law enforcement instructor at the Criminal Justice Academy in South Carolina. He commented: "Most of my police officers know what a gunshot wound is. They do not know what a pressure sore looks like, and when you start showing them pictures, they start to have a frame of reference. That may be the most important thing, just that cognitive framework that says, `Okay, this may or may not be abuse.' " Police officers want training and are capable of learning technical information about abuse and neglect. "They can tolerate a high level of sophistication, as long as it is done in laymen's terms," Thomas added.
Like many other entry-level workers, most police academy students are in their mid-20s and have difficulty sympathizing with and understanding older adults. Thomas said: "Somebody needs to teach them about the process of aging . . . . They need to know how this works, that not everybody who is 85 is impaired, and a lot of my officers think they are." Many of their complainants will be elderly and could be good witnesses if the officers knew how to work with them. "I have certainly seen a 23-year-old recently promoted to detective conduct a photo ID with an 85-year-old mugging victim in a way that was obviously not going to lead to a useful result, just because of a lack of knowledge about the kind of person the detective was dealing with," said Hood. Older adults are not always eager to work with young officers, either. Thomas commented that he sometimes hears older adults say "Send me back a real adult."
Unfortunately, the police need constant retraining. "Our State is turning over about 20, 25 percent of our police officers every year . . . It is a sign of a good economy," said Thomas. He stressed that training on elder abuse needs to be institutionalized and performed over and over again. Constant retraining can be exhausting for the trainers. "In our county. . . we have 26 different police departments. And with the high turnover, it just feels like you're lecturing to a parade sometimes," said Mosqueda. This problem is not limited to policemen. "It is also important in a lot of different fields we're addressing here: APS, nursing homes," said Dr. Erik Lindbloom, assistant professor at the University of Missouri. "Residency training, by design, has a 100-percent turnover over a 3-year period in internal medicine and family practice, for example," said Lindbloom.
California's training for police officers teaches basic awareness of aging issues, plus information on effectively reporting elder abuse, including scene preservation and evidence collection. "[This] translates into prosecutable cases where a crime can be shown and a perpetrator can be identified," said Heisler. In California, advanced training on these topics is especially important because State law "authorizes law enforcement to seize assets where a public guardian is going to pursue a conservatorship . . . and where they have a basis for concluding . . . a conservatorship would be appropriate," commented Heisler—that is, where the State takes over the care of an older victim of abuse or neglect.
California officials have developed a repository of training films on aging issues for distance learning through the State's Commission on Peace Officer Standards and Training (POST), Heisler said. These films are distributed to the 500-plus police departments in the State. "Through telecourses, we bring other prosecutors in, we bring law enforcement in to explain to them how you do these cases," said Heisler. The National Center for Elder Abuse in Washington, D.C., also plans to collect training materials for different disciplines, for a sort of national repository. Other California training courses also involve aging issues; the State's domestic violence training course includes a session on domestic violence in later life.
In Florida, an interdisciplinary team including a psychologist and geriatric nursing specialist has visited 25 percent of State police departments with a multimedia presentation on elder neglect and abuse, said Dr. Eisdorfer. In the future, trainers in South Carolina and Florida need to train more trainers. "It is pretty impractical to expect someone like Randy [Thomas] to continue traveling all over the State, all over the county, to do these presentations when we could be training people locally to do the same thing, [so they could] really take it under their wing as a cause at their medical school, at their agency, at their nursing home," said Dr. Lindbloom.
Prosecutors, however, are not nearly as well informed as law enforcement officials. "They do not have to receive training about this subject in law school, and they certainly do not have to have it for professional development in a prosecutor's office," said Heisler, although California's District Attorneys' Association offers a 3-day training course on the topic each year. The National College of District Attorneys has also added elder domestic violence and elder abuse to its roster of training courses.
Public Health Workers, Surveyors, First Responders, and Others
Public health workers also need education about elder neglect and abuse. "We have talked about how unresponsive hospitals are. Maybe we need to start educating the hospital administrators, the people in health policy and management who will run . . . local health departments, [who] can raise community awareness of this, and [who] are the people . . . running the outpatient clinics, the hospitals, the places where it might be seen, about what is needed to support the healthcare professionals [to] do both the detecting and reporting," said Dr. Catherine Hawes, professor at the Texas A&M University School of Rural Public Health.
Another group that needs training are "nurse surveyors and complaint investigators, and [employees of] State agencies who are charged . . . with investigating complaints in residential long-term care settings," said Dr. Hawes, and there is real importance in involving them on multidisciplinary teams.
Ms. Nerenberg suggested taking it one step farther to teach "health and social services providers, APS workers, some of the medical or health indicators they may need to know about." Ms. Connolly, with the U.S. Department of Justice, suggested training for firefighters, paramedics, ambulance EMTs, and other first responders, who often have no training in detection of elder abuse and neglect. She also suggested helping frontline responders develop internal screening protocols to analyze suspected elder abuse or neglect, document it, and, where appropriate make a report or referral to APS or law enforcement.
