Meet Rebecca Boxer

Q. What led you to the field of geriatrics?

There are a few reasons. I went into medicine because of my interest to help the underserved and advocate for equitable care. It became apparent during my training that older adults are an underserved population, especially those over 80. They have high care needs that can be difficult for our health care system to address effectively.

I enjoy working with families and caregivers trying to attain the best care for older adult(s) in their lives. Interdisciplinary team care is very rewarding. I also enjoy helping individual patients navigate complex medical needs stemming from the combination of aging, disease, pharmaceuticals and psychosocial challenges.

Q.How do outpatient geriatric clinical services work at UC Davis Health and our Healthy Aging Clinic?

The Healthy Aging Clinic geriatrics practice is growing! We have a multidisciplinary team that works in concert to assist in care and provide consultation to primary care physicians. For example, a physical therapist brings expertise to the evaluation of gait disorders, mobility and falls, and a social worker provides psychological support and troubleshoots issues of in-home support and caregiving. Pharmacists assist in management of complex medication regimens and polypharmacy. Importantly, our Dementia Care Program works closely with primary care providers to manage complex dementia care, and provides ongoing support to these patients and their support networks.

Q.You served as medical director of clinical trials at Kaiser Permanente Institute for Health Research in Colorado. How do you carry these experiences into your role here, and what are some research goals for the new division?

I oversaw a team operationalizing trials in the clinical setting — primarily Phase 3 oncology trials, but also GI and infectious disease. My role expanded during the pandemic, in that we rapidly partnered with regional hospital systems to bring COVID trials to hospitalized patients. We were able to pool resources between institutions and establish protocols for remote recruitment. Establishing a team with a shared vision during the pandemic was one of my most valued experiences.

From a research standpoint, my goal here is to build on the important work UC Davis aging researchers are already doing. Bring people from different departments and schools together who have similar interests and could benefit from each other’s innovation. This has already started with the Healthy Aging Initiative, Healthy Aging in a Digital World, and the Family Caregiving Institute. I would like to see the Division as an aging research home.

Q.How has the COVID pandemic affected older adults, and the practice of geriatrics?

It had a massive effect. Coping with the fear of life-threatening illness increased isolation and loneliness, which had a marked effect on health, happiness and vigor that still lingers. Many older adults still limit in-person interactions.

Of note, nursing home residents are some of the least likely to gain access to clinical trials. This is a problem, since older adults are often the most effected but the least studied. Thus, they’re excluded from the benefit of new medications and approaches. For more, see Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success. J Am Geriatr Soc. 2022 Mar;70(3):701-708. PMID: 35195276; PMCID: PMC8910690.

Q.What’s needed to reverse the shortage of geriatricians in the U.S.?

Although compensation has often been cited as an issue for the lack of residents choosing geriatric medicine (salaries are actually less for a fellowship trained geriatrician compared to a general internist), the reasons are more complex. Geriatrics is not “glamorous,” and a field where it’s “difficult to resolve patient problems.” We have a “fixit”culture, and geriatrics is much more nuanced — based in supportive care and maximizing quality of life.

The value of geriatrics practice to a health system is rapidly being recognized. To improve geriatric care, it will be necessary to increase incentives to attract physicians into the specialty, and also increase innovative educational approaches for all physicians to improve competence in care of the older adult. For more, see The Paradoxical Decline of Geriatric Medicine as a Profession. JAMA. 2023 Aug 22;330(8):693-694. doi: 10.1001/jama.2023.11110. PMID: 37540519.

Additionally, I can’t emphasize enough the importance of geriatrics-trained advance practice providers (APPs) as an important part of the future of geriatric health care. We are partnering with the School of Nursing to train and provide opportunity for APPs to join our team.

Q.Can technology play a role in mitigating the shortage?

Telehealth for geriatric consultation is of primary interest. For primary care physicians without local access to geriatric physicians, consultation can be very helpful to assist with care plans, reduce polypharmacy and manage multicomplexity. Wearables and remote monitoring are also helpful, usually for conditions such as heart failure, diabetes, and COPD. Wearables can also be useful in increasing and monitoring physical activity, which is key to maintaining function and independence.

Q.Cognitive impairment and dementia can complicate care, and multimorbidity and polypharmacy create their own constellation of variables. What art and science do geriatricians use to address these challenges in practice?

There are a few tenets I think are important:

• Listen to the patient and their support network (caregivers), especially for the cognitive impaired.
• Build trust with the patient and caregivers (very much part of #1).
• Do no harm, and provide a harm avoidance approach to care.
• Be willing to negotiate. Patients and their caregivers sometimes do not agree about, or want to adopt, the suggested plan of care. Provide explanations and alternatives, and align care with what matters most to the patient.
• It’s important to know the data and its limitations. Most research that guides evidence-based care did not include older adults (especially those 75 or older). This puts much of our standard approach for the management of chronic conditions on shaky ground. Knowing what matters to the patient, and the limits of evidence-based medicine, both feed into care decisions.
• Working as an interdisciplinary team provides the most comprehensive care.