Q&A with Cathleen Colon-Emeric: Mentorship and furthering the need for research in geriatrics

Friday, June 2, 2017

Cahtleen Colon-Emeric, MD, associate professor of medicine (Geriatrics), and Senior Fellow in Center for the Study of Aging and Human Development, received a Duke Health Scholars Award this spring.

This award is presented to faculty members who have an outstanding and established research path. Each award recipient receives substantial funding to further his or her research findings.

In this faculty Q&A, Dr. Colon-Emeric discusses her experiences with mentorship, her passion behind researching geriatrics, and the realities of being a clinical researcher. 

How did you become interested in studying geriatric medicine?
It was actually kind of serendipity. For a long time, I knew I wanted to do internal medicine since I loved its complexity. I love thinking about how different organ systems interact with each other, how dysfunction in one system affects the other, and so on. I did my medicine sub-internship knowing that I wanted to apply for internal medicine residency programs and I happened to be assigned to what was then the Francis-Scott Key Hospital (now Hopkins Bay View Hospital), which was home to the clinical campus of the National Institute of Aging. 

I was assigned to a geriatrics ward under one of the founding fathers of geriatrics medicine, William Greenough III, MD. I just absolutely fell in love with it. I fell in love with the patients and their stories. I fell in love with the clinical complexity. All of the geriatrics patients had multiple problems going on in multiple systems. I liked figuring out how to prioritize that and how to make everything balance out.

I loved dealing with families and the social situations. I liked coming up with a practical plan that fit my patients’ goals and needs. I was hooked. I decided that when I was applying to programs, I was going to look for ones that had a great geriatrics fellowship program in hopes of staying in the practice.

As a recipient of the Duke Health Scholars Award, how do you think its funding will aid your research?   
When I was told I was receiving the Duke Health Scholars Award, I was like "Wow! Now what am I going to do? I have all these opportunities." I'm in this point of my career now where I do a lot of mentoring with younger scholars. One of the challenges with mentees, particularly coming up in clinical research, is that clinical research can be very expensive and difficult to do.

The early career awards don't have a lot of dollars associated with them. They have salary support for the trainees, but there isn't enough funding for the projects. This will allow me some pots of money to help support my trainees, which is fantastic. We have to start thinking about the next generation of clinical researchers, which is particularly important for aging research since that pool of people is shrinking. Another thing it is going to help me to do is get some additional help from  project director and project support teams so I can focus on new ideas rather than continuing to maintain the current projects. I think it's going to allow me a lot of flexibility to be creative in my own research as well as help the junior residents. 

What inspired you to do research on osteoporotic hip fractures?
t was when I was a fellow taking care of patients at the Durham VA Hospital community living center. These were patients who were still getting rehabilitation. A whole bunch of them were still getting hip fractures and it was clear that it was a devastating event in their life. They went from being very functional and independent to being almost fully dependent and not being able to walk.

It started a cascade of other health problems and, frequently, it led to death. I wanted to understand more about the hip fracture syndrome in elderly people.  I ended doing a simple, chart review study as a fellow that grew and expanded into epidemiologic research during my advanced fellowship years. It ultimately led Ken Lyles, MD, and I to pitch a study to Novartis for secondary hip fracture prevention after hip fracture in older patients (Zoledronic Acid and Clinical Fractures and Mortality after Hip Fracture).

We found out that once you have a hip fracture, you have a 1 in 5 chance of having another broken bone within the next two years. That’s adding insult to injury. If we could prevent those injuries, we could really help patients have a better chance at recovering but there was a lot of concern that it was too late to prevent any fractures or that it wasn’t safe. There were concerns that the osteoporosis medication would interfere with the healing process. The study we pitched to Norvartis became a multi-national, randomized controlled trial that did prove that we could reduce secondary fracture after hip fracture.

Surprisingly, we also found out that we could reduce mortality after hip fracture. That was the first time anyone has ever proven that you could reduce mortality in hip fracture patients with osteoporosis medication. This has been confirmed in other studies.

Now, it has led to a worldwide push to get hip fracture patients treated properly for osteoporosis. Following that research, we did a number of other studies trying to figure out the mechanisms for mortality rate reduction as well as health service intervention studies to get the medications to actually be used in the field, skilled nursing facilities and in the VA system.

So that’s what I’ve been working for the last couple years. We have a big clinical program in the Durham VA hospital. We have 5 medical centers in the region with clinical services where we do eConsults after fractures and ensuring patients are appropriately tested and treated for osteoporosis. We are evaluating that to see if it would show a reduction in fracture rates and in other outcomes.

Another recent focus of mine is the screening process for osteoporosis in men. The guidelines are very clear for women—once you hit 65, it’s recommended that women get their bone density tested every couple years. The guidelines aren’t clear for men. It’s all over the map. Some say don’t test everybody. Some say test everyone and there’s everything in between.

We just finished up a study using VA national data to figure out whether not screening is effective for men if they haven't had a fracture yet. It turns out that the way we're operationalizing it, it doesn't seem to be effective. Mostly it’s because we're not selecting the right people for testing. And once we identify people who do have osteoporosis, they're not staying on therapy long enough to benefit. I'm currently working on trying to come up with new models of care for efficient male osteoporosis screenings work for fracture prevention.

What is it like to be a mentor?
It's really fun and rewarding! I learn as much or more from my mentees as they learn from me. They are always pulling me into new clinical areas so, for example, I have one right now who is an expert on feeding interventions for patients with advanced dementia. I have another one who is an expert on rehabilitation facilities.

And another one who specializes in transitional care interventions. So right now I'm learning about all of those areas, too. I think it's also fun to figure out each mentees’ needs. They all have special needs. They're all coming in from a different place of what they know and what they don't know. Trying to tailor how are you work with each mentee to meet their needs is a lot of fun. 

How does your mentorship experience from your days as a resident tie into your views of mentorship today?
Over the years, I’ve been blessed with fabulous mentors. Dr. Lyles has been an excellent mentor. Ken Schmader, MD, has also been a great mentor along with Harvey Cohen, MD. What I’ve learned from them is that you have to be available. You have to be willing to read that paper at 11 o’ clock at night or get feedback on your grant paper before it’s due next week. You also have to be encouraging, but honest and frank. You have to train your mentees that this is a tough business and they have to develop thick skin while being flexible and nimble.

When you were a mentee, did you ever feel like it was challenging to break through the tougher side of medicine and research?
There are always times when you get discouraged. You get your grant review back and it’s not what you hoped, or you get your paper rejected again. It’s learning from, not the mistakes so much, but rather the missteps and being persistent.

What important lessons have you learned from your mentors, particularly Ken Lyles?
One of the reasons why my mentorship relationship with Lyles worked so well is because we’re very different. We brought different skills to the table, and that’s why our relationship still continues to work. I still rely on him for skills that he’s really good at and he comes to me sometimes for help with skills that I’ve developed. What I’ve realized since I began mentoring others is that I have to develop those skills that I’ve been relying on from him for so long! In particular, he is great at networking. Ken Lyles knows everyone and he’s very gregarious.

I’m more of an introvert, so it’s much harder to do that. Right now, I realize it’s very important for me to push myself outside of my comfort zone because I can’t rely on Ken forever. Plus, I need to develop these skills not just for my own sake, but also for my mentees. I need to provide that level of networking for them too like Ken did for me. He has a way of stepping back and looking at the bigger picture, which is something I have to remind myself to do because it’s easy for me to become tangled in the details.

What are the hardest lessons you’ve learned throughout your career as a researcher?
I think the hardest lesson I've learned is that sometimes you dedicate three or five years to a clinical study—pour your heart and soul into it—and at the end of the day it's a negative study. The intervention doesn't do what you want it to do. Or the training program didn't result in better outcomes for the staff and patients. That's a little bit disheartening that it didn't work. Just like that old cliché with Thomas Edison and the 5,000 ways to not make a light bulb, it's like that in research. You have to learn from what doesn't work just as well as you learn from what does work. 

Do you think being a mentee now is different from when you were a mentee in medicine?
I think that the principles are the same but the funding lines are a lot tighter now than when I was a mentee. There’s more competition too. On the other hand, there are fewer geriatricians going into clinical research. I have a lot of mentees who are not necessarily in geriatrics, but are training in other specialties. It has been useful for me but it’s also frustrating because we haven’t able to attract as many geriatricians under research. 

Has the stagnant growth of geriatricians in research stunted opportunities for discoveries in geriatric medicine?
This is a national trend. It goes beyond Duke. The number of applicants for clinical geriatrics is going down every year. The number of geriatricians in research is going down every year, as well, so it’s kind of a double-whammy. The heart of this issue is multi-factorial of course. It’s partly funding issues and difficulty in doing clinical research with older, fragile populations. There are also issues with how will Medicare pay for geriatrics care and if it’s possible to make a living as a clinical geriatrician. There are a lot of market forces, cultural forces, as well as the realities of how difficult research is, contributing to all of that.

If you look at the surveys of physicians as well as physician or clinical researchers about their work and life satisfaction, geriatricians are always at the top of satisfaction even though we’re not necessarily the highest paid or most highly regarded specialty. It’s an incredibly rewarding field for those who choose to go into it. It’s just about overcoming some barriers to realize how great a field it is.  

What are your upcoming or current plans?
I’m going to submit a grant soon through the VA for a study about different models of care for primary osteoporosis screening for men. We have just recently submitted and are waiting to hear about funding decisions for a UH2 and UH3 NIH grant, which is a multi-million dollar center grant that I would co-lead with Heather Whitson. This project would be looking at physical resilience in older adults. This is an area that we’re really getting interested in as a Claude D. Pepper Center here at Duke.

We’re studying to see how many people bounce back after an acute illness or injury. Using my hip fracture patients as an example, how do we predict who is going to recover well and resume their daily activities and who’s not going to recover well and will need nursing home placement, physical therapy, or longer term care? We will be looking at multiple factors to find the underling reason after the insult such as stem cell generation, psychological state, and muscular skeletal health for intervention recovery.

In terms of what I will be doing with my mentees, I’m in the process of planning an intervention development workshop for older adults, which will be offered to the Pepper Center Scholars, my mentees, and open to the Duke CTSA KL2 scholars. It will be a fun workshop to plan, and it’s going to be great to work with the younger scholars.

This story was written by Tia Mitchell, communications intern for the Department of Medicine.