Clinical Champion Spotlight
This series highlights members of the GEDC community who are clinical champions for older adults in the emergency department.
Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He was the founding chair of the Geriatric EM committee of the International Federation of Emergency Medicine. He is the author of the website Geri-EM.com – a CME accredited program for geriatric emergency medicine education, now available at:Geri-EM Online
Don Melady, MD, likes his problems complex. It’s part of the reason why he has devoted much of his career as an emergency physician to improving emergency department care for older adults.
“During my clinical practice, I have just found providing medical care to older people to be interesting, intellectually challenging and emotionally rewarding,” Melady said. “There’s a term – “working at the top of your license” – meaning you’re using all of your skills, experience, knowledge, and attitudes to practice. When I’m working with older people in the ED, that’s what I experience.”
But Melady’s interest in solving complex problems isn’t the only reason he’s passionate about improving emergency department care for older adults. He grew up in a large Irish Catholic family in a small farming community where older people were an integral part of daily life. In fact, there was a point at which Melady had 32 aunts and uncles over the age of 70.
“Like most people involved in geriatric care, there often is a personal connection to older people, which one doesn’t always see in other areas of clinical practice,” Melady said. “Through my childhood, I had very close connections with older people and always felt very comfortable with older people in general.”
When he was a medical student, this connection led Melady to pursue extra coursework in the physiology of aging and geriatric neuropsychology to prepare for some of the challenges he would experience when providing care to older adults as an emergency physician.
Having practiced emergency medicine for 35 years, that extra effort has paid off in more ways than one. In 2011, Melady received an Innovation Fund Grant from the Ontario Government to create Geri-EM.com, a collection of e-learning modules that offer the knowledge clinicians in emergency departments and other care settings need to provide optimal care for older adults.
To date, the modules, covering topics ranging from medication management to cognitive impairment, have accounted for 25,000 hours of clinical, accredited learning.
“There’s no way I could ever have reproduced that impact in any other setting, to have educated 25,000 people for an hour, or 1,000 people for 25 hours,” Melady said. “That’s the equivalent of a university course. I’m so pleased that it filled what was clearly, and remains, a gap, even a void. There really is very little clinical education about older people that relates specifically to acute illness and injury.”
For example, the Geri-EM module on cognitive impairment educates clinicians about depression, delirium, and dementia. Conditions like dementia, which impacts as many as one in four people over the age of 75, can be overlooked during an emergency department visit because it isn’t the reason that a patient is presenting in the emergency department.
“[Emergency physicians] learn about the core things that bring people to the emergency department, and therefore we don’t learn about dementia,” Melady said. “It’s not on our radar in terms of clinical practice.”
And even though dementia might not be the reason that a patient visits the emergency department, the condition impacts the patient’s interactions with care providers and can make it difficult for care providers to get an adequate medical history. Dementia also impacts the patient’s ability to participate in care and to engage with care after the emergency department visit.
“Finding ways for our emergency departments and for all of our society to be more aware of dementia as a reality in many people’s lives is important if we’re going to be a successful emergency department, and if we’re going to be a successful society over the next 30 years,” Melady said.
In addition to the Geri-EM modules, Melady created a geriatric emergency medicine fellowship at Mount Sinai Hospital at the University of Toronto, where he is currently an associate professor of emergency medicine. The fellowship is the only one of its kind in Canada and one of only five in North America. To date, 13 fellows have completed the program and many have gone on to significant leadership positions both within their universities and provincial governments.
“It has been a way to spread the impact of this essentially new field of emergency medicine and to start seeding the field of emergency departments across Canada with specialists who have some real credentials and specialist knowledge in the field,” Melady said.
It’s through efforts like these that Melady hopes to impact more people than the patients who visit the emergency department. “If one wears one’s complexity hat and thinks not just about the patient in front of you; if you think about the patient as part of a complex constellation of people – family members, caregivers, neighbors, other clinicians, other members of the community; then the ripple effects for good practice are huge and touch many other people as well,” Melady said.
Dr. Don Melady is an emergency physician at Mount Sinai Hospital in Toronto, Canada and a founding member of the Geriatric Emergency Department Collaborative. He is the author of the website www.geri-EM.com – a CME accredited program for geriatric emergency medicine education – and the chair of the Geriatric EM committee of the International Federation of Emergency Medicine.