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Geriatric education for the physicians of tomorrow
Archives of Gerontology and Geriatrics 49 Suppl. 2 (2009) S17–S20
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Geriatric education for the physicians of tomorrow Barry D. Weissa, *, Mindy J. Fainb a Department b Department
of Family and Community Medicine, University of Arizona, College of Medicine, Tucson, AZ 85719, USA of Medicine, Geriatrics Section, University of Arizona College of Medicine, Tucson, AZ 85724-5069, USA
article info
abstract
Keywords: Current training programs Geriatrics training Reimbursement for geriatric care Geriatric education to physicians
The world’s population is aging and there is need for more geriatricians. Current training programs, however, are not producing a sufficient number of geriatricians to meet that need, largely because students and residents lack interest in a career in geriatrics. A variety of reasons have been suggested to explain that lack of interest, and several changes in geriatrics training might increase the number of medical trainees who choose a career in geriatrics. These changes include recruiting medical students who are predisposed to geriatrics, loan forgiveness programs for those who enter careers in geriatrics, increased reimbursement for geriatric care, providing geriatric education to physicians in all specialties throughout their training, and refocusing geriatrics training so it includes the care of healthy vigorous older adults, rather than an exclusive focus on those with debility and chronic or fatal illnesses. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. The aging population The population of the world is aging. Statistics from the United Nations indicate that in just 40 years from now, well within the careers of current medical trainees, the world’s population will include nearly two billion people over age 60. One out of every five people will be 60 years or older, and, worldwide, older adults will outnumber children (Department of Economic and Social Affairs, 2002; United Nations Program on Aging, Online). The fastest-growing segment of the older population will be the oldest old, people over 80, who will represent 20% of the world’s population over 60. Between 2005 and 2050, the number of people over 100 years of age will have increased by a factor of 14 to reach nearly 4 million (United Nations Program on Aging, Online). 2. The growth of geriatrics in medical education The aging of the population has long been recognized by medical educators. Indeed, many current medical school faculty members, some now in senior leadership positions, became aware of the aging population and the so-called “geriatric imperative” nearly 30 years ago with the publication of books and reports on the topic (Somers and Fabian, 1981). Over the next several decades, medical school departments around the world, primarily in family medicine and internal medicine, but also in other disciplines, began developing curricula and special training programs in geriatrics. By 2004, in the US, there were national accreditation requirements that a geriatric * Corresponding author. Tel.: +(1-520) 626 6975; fax: +(1-520) 626 6134. E-mail address: [email protected] (B.D. Weiss). 0167-4943 /$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
component be included in residency training for a large numbers of specialties and subspecialties (Table 1) (Institute for Health Policy and Health Services Research, 2004). Though the intensity and content of geriatric education varied between specialties, the extent of the effort demonstrates that medical educators understood the need for trainees to learn about geriatrics. This effort was accompanied by development of post-residency geriatric medicine fellowships and a national certification in geriatric medicine offered jointly by the American Board of Internal Medicine and the American Board of Family Medicine (Accreditation Council for Graduate Medical Education, 2006a,b). The extent and scope of geriatric training has continued to increase. Although few medical schools in the US have a dedicated department of geriatrics, the growth of geriatrics training in residency programs has nonetheless persisted. More than 95% of family medicine residency programs in the US now have a required curriculum, not just a curricular component, in geriatrics (Bragg et al., 2006). Internal medicine residency programs have also increased their geriatric training, with at least 91% of programs requiring dedicated geriatric training of two weeks or more (Warshaw et al., 2006). In the United Kingdom, results of a 2006 survey of school deans revealed that geriatrics is taught in nearly all UK medical schools (Bartram et al., 2006). Other examples of geriatrics training programs can be found around the world, in Africa (Louw, 1997; King et al., 2005; Ferreira, 2006), South America (Garcez-Leme et al., 2005; Bos et al., 2007), Europe (Bonin-Guillaume et al., 2005), the Middle East (Abyad, 2004; Leibovitz et al., 2004), and Asia (Fukuchi, 1992; Emlet and Hokenstad, 2001) though in some areas geriatrics education is still limited (Bassan et al., 2006; Flaherty et al., 2007).
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B.D. Weiss, M.J. Fain / Archives of Gerontology and Geriatrics 49 (2009) S17–S20 Table 1 Specialties with geriatric training requirement in the USA as of 2004 Specialty
Year requirement began
Anesthesiology
2001
Emergency medicine
2001
Family medicine
2001
Internal medicine (general)
2003
Internal medicine (all subspecialties)
1999
Neurology (pain management)
2000
Neurology (vascular neurology)
2002
Orthopedic surgery
2003
Physical medicine and rehabilitation
2003
Psychiatry
2001
Surgery (critical care)
2001
Urology
2003
Source: http://www.adgapstudy.uc.edu/Files/ADGAP%20Table%204_2a.pdf http://www.adgapstudy.uc.edu/Files/ADGAP%20Table%204_2b.pdf
3. Where are the geriatricians? Despite the growth of geriatrics education programs, there is still a worldwide shortage of geriatricians. Data from the US are readily available, where news reports indicate that as recently as 2006, there was only one geriatrician for every 5,000 Americans over age 65 (Gross, 2006). It is estimated that by 2030, as many as 36,000 geriatricians will be needed to care for the aging US population (Alliance for Aging Research, 2002), a number that cannot possibly be reached given the small number of current geriatricians and the current lack of interest in geriatrics by medical students and residents. The American Board of Family Medicine has reported that of the nearly 75,000 family physicians in the US, only just over 2,000 (<3%) of them were certified in geriatrics and few new family physicians obtain certification each year (331 did so in 2008) (American Board of Family Medicine, Online). Indeed, the number of family physicians seeking certification in geriatric medicine each year is barely larger than the number seeking certification in sports medicine, which is perhaps surprising, or even inappropriate, given the demographic changes of an aging population. In internal medicine, reports indicate that nearly onethird of geriatric fellowship positions in the US go unfilled, even since the introduction of the option of shortening fellowship training to one year, and only a minority of the remaining positions are filled by graduates of US medical schools (Brotherton and Etzel, 2006; Hirth et al., 2008). 4. Why not geriatrics? Why are so few young physicians interested in geriatrics? A variety of reasons have been cited. One recent study suggested that trainees simply underestimate the magnitude of the need for geriatricians in the coming decades. Only two thirds of family medicine residents in that study expected that geriatrics would be a significant part of their practice (Helton and Pathman, 2008), when the reality is that for most primary care physicians, geriatrics will form the bulk of their practice in the coming decades. Another reason is low compensation, cited by the Institute of Medicine (2008) as an important cause for the lack of interest in geriatrics, as compensation is known to influence specialty choice (Ebell, 2008). Medical students in the US graduate from medical school and enter residency with average debt exceeding $200,000; a figure that is rising at a rate of 6–7%/year (Jolly, 2007). This debt load
makes it difficult to devote extra years to a geriatrics fellowship, during which salaries are low, followed by practice as a geriatrician, for which compensation is lower than it is for internists and family physicians that do not complete geriatrics fellowships (American Medical Group Association Compensation Survey Data, 2007). But, the problem may go deeper than just salaries and awareness of demographic changes. Rather, it may involve the way we teach about geriatrics. Indeed, studies from around the world have shown that medical students and residents have a negative view of and low interest in geriatric medicine. For example, a survey of medical students in Australia showed that very few were considering a career in geriatrics and most students said they would prefer not to treat the elderly. The reason, they said, after experiencing geriatric practice during their training, is that geriatric medicine is a “low-tech” specialty that is mostly concerned with psychosocial and placement issues rather than curing illness (Le Couteur et al., 1997). Several studies have shown that these negative views become even more negative as trainees have more exposure to geriatrics. One study showed that attitudes about geriatrics deteriorate during training, with students entering medical school having more favorable attitudes toward geriatrics than more advanced students and residents (Kishimoto et al., 2005). Another study showed that among trainees who had an interest in geriatrics and chose to enter geriatric fellowship program, attitudes about older people became less positive during fellowship training (Lee et al., 2005). An argument can thus be made that we are doing something wrong in our geriatrics training. Establishing geriatric curricula, program requirements, and fellowship programs is simply not enough. If our medical student, residency, and fellowship programs are “turning off” trainees to a career in geriatrics, we need to rethink the way we provide geriatric education. 5. What should be different? How can we encourage more physicians to enter the field of geriatrics? First, we need to commit to the need for geriatricians. Some have argued that the lack of geriatricians is not important, and that any primary care physician can provide geriatric care because most primary-care training programs now include some geriatrics training. However, research shows that they don’t provide it as satisfactorily. For example, when compared to fellowship-trained geriatricians, generalist physicians are more likely to prescribe inappropriately, and are less likely to proactively assess patients for common geriatric syndromes (Phelan et al., 2008). Second, we should institute a program of loan forgiveness for physicians who choose geriatrics, a policy that has been successful in encouraging physicians to choose rural practice areas. A loan forgiveness program has the potential to increase the number of graduates entering geriatrics. Additionally, changes in reimbursement incentives that place value on complex office-based care of older adults would greatly aid in feeding the pipeline of geriatricians. Third, we need to fully recognize that all physicians, regardless of specialty, will be providing care for markedly increasing numbers of older patients. Medical training should prepare all physicians for this future, starting with the first day of medical school. Some philanthropic foundations have already begun to make a difference, funding programs that provide geriatric training for all physicians (Kuehn, 2009). For example, in the US the Donald W. Reynolds Foundation has provided significant funding to over 40 medical schools to develop and implement geriatrics curricula. Similarly, the John A. Hartford Foundation supports the American Geriatrics Society’s Geriatrics for Specialists Initiative to enhance geriatric training, with a focus on surgeons and related specialty physicians. As part of this effort, in 2007 the
B.D. Weiss, M.J. Fain / Archives of Gerontology and Geriatrics 49 (2009) S17–S20
Association of American Medical Colleges (AAMC), supported by the Hartford Foundation, established a minimum set of 26 geriatric competencies for all medical students. Other specialties continue to develop and implement similar geriatric competencies for residents and practicing physicians. These efforts are essential steps towards assuring broad-based physician competency in the care of older adults, and they require expanded national support. Fourth, medical schools, the pipeline for future geriatricians, need to do a better job of recruiting students with a potential interest in primary care, which, in most cases, is the conduit into geriatric medicine. Just as entry into primary care residencies can be increased by recruiting medical students with a predisposition to primary care practice and humanistic medicine (Phillips et al., 2009), such recruitment can also facilitate entry of students and residents into future geriatric careers. Fifth, although traditional block rotations in geriatrics provide trainees with exposure to key facets of geriatric practice, medical schools and residency programs should also integrate geriatric principles of care throughout training. Students and residents should be exposed to faculty with expertise in geriatrics in most, if not all, rotations, including medical and surgical subspecialties, and in continuity practices, to reinforce geriatric principles of care. Creating the cadre of faculty with the necessary expertise can be accomplished through faculty development programs. Such longitudinal exposure to geriatric training will complement traditional block rotations that don’t give residents and students the opportunity to follow patients long enough to see them improve from the setbacks experienced during hospitalization, nor the opportunity to experience the satisfaction and reward of helping patients and families though the difficult times and declines that occur when serious or fatal illnesses develop. Finally, we need to refocus geriatric training so that the emphasis is not solely on chronically ill and debilitated patients needing geriatric assessment, patients who are dying, demented, institutionalized, or needing support from poorly funded social service agencies. While care of such patients needs to be a part of geriatrics training, sole focus on such debilitated patients cannot always sustain a satisfying career, any more than an oncologist’s career would be satisfying if the oncologist’s patients never experienced a cure or remission from cancer. Rather, trainees need to know and see that most older adults are healthy and live in the community, not in nursing homes. They need to know, in contrast to what they see in the patient mix of current training programs, that only a minority of older adults, even at age 80 or 90, have dementia (Plassman et al. 2007). They need to know that older adults, including those in their 70s, 80s, and 90s, maintain active lifestyles and even run in marathons (Browne, 2000; Potter, 2009). Students and residents should be exposed to these healthy older individuals, as such exposure would likely change the trainee’s perception of geriatrics. We should teach them the knowledge and skills to keep such individuals healthy and active. These skills are not learned in nursing homes and hospices, which are the site of many current geriatric training experiences. Such training is of critical importance in our aging society, in which our goal as physicians should be to help seniors live healthier, longer, and more independent lives.
Conflict of interest statement Both Dr Weiss and Dr Fain receive grant funding from the Donald W. Reynolds Foundation and from the US Health Resources and Services Administration to support development and operation of geriatrics education programs. These organizations had no role whatsoever in preparation of the manuscript.
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References Abyad, A., 2004. Geriatrics in the Middle East. Middle Eastern J. Age Aging http://www.me-jaa.com/content0.htm Accreditation Council for Graduate Medical Education, July, 2006a. Program requirements for fellowship education in family medicine-geriatric medicine. http://www.acgme.org/acWebsite/downloads/RRC_progReq/125pr0706.pdf Accreditation Council for Graduate Medical Education, July, 2006b. Program requirements for fellowship education in internal medicine-geriatric medicine. http://www.acgme.org/acWebsite/downloads/RRC_progReq/151pr707_ims.pdf Alliance for Aging Research, 2002. Medical Never-Never Land: 10 Reasons Why America is Not Ready for the Coming Age Boom. Alliance for Aging Research, Washington, DC. American Board of Family Medicine. Diplomate Statistics: Certification/Recertification Exam Statistics. https://www.theabfm.org/about/stats_exams.aspx American Medical Group Association Compensation Survey Data, 2007 Report. http://www.cms.hhs.gov/AcuteInpatientPPS/Downloads/AMGA_ 2007%20Report.pdf Bartram, L., Crome, O., McGrath, A., Corrado, O.J., Allen, S.C., Crome, I, 2006. Survey of training in geriatric medicine in UK undergraduate medical schools. Age Ageing 35, 533–535. Bassan, N.D., Soldano, O.R., Vinuesa, M.A., Venezia, S.M., DeSipio, A., 2006. Geriatric medical education: an unclosed loop. Rev. Fac. de Cien. Med. ´ Univ. Nac. Cordoba, 63, 71–75. Bonin-Guillaume, S., Kressig, R.W., Gavazzi, G., Jacques, M-C., Chevalley, T., Pautex, S., Vischer, U., Zekry, D., Michel, J-P. 2005. Teaching the future teachers in geriatrics: the 10-year success story of the European Academy for Medicine of Aging. Geriatr. Gerontol. Intern. 5, 82–88. Bos, A.J.G., Pedilna, D.V.P., Bos, A.M.G., Gomez, F., 2007. Gerontology-specific graduation programs in Brazil and Columbia. Gerontol. Geriatr. Educ. 27, 65–77. Bragg, E.J., Warshaw, G.A., Arenson, C., Ho, M.L., Brewer, D.E., 2006. A national survey of family medicine residency education in geraitric medicine: comparing findings in 2004 to 2001. Fam Med. 38, 258–264. Brotherton, S., Etzel, S., 2006. Graduate medical education, 2005–2006. J. Am. Med. Asooc. 296, 1154–1169. Browne, A., 2000. Age need not weary the marathon runner. The Observer. April 6. http://www.guardian.co.uk/uk/2000/apr/16/anthonybrowne.theobserver Department of Economic and Social Affairs, Population Division. 2002. World Population Ageing: 1950–2050. United Nations. http://www.un.org/esa/population/ publications/worldageing19502050/. Ebell, M.H., 2008. Future salary and US residency fill rate revisited. J. Am. Med. Assoc. 300, 1131–1132. Emlet, C.A., Hokenstad, M.C., 2001. Geriatric home- and community-based care training project for transitional societies from central and eastern Europe through Asia. Gerontol. Geriatr. Educ. 21, 55–64. Ferreira, M., 2006. Geriatric medicine in South Africa: a Cinderella subspecialty? S.A. Fam. Practice 48, 18. Flaherty, J.H., Liu, M.L., Ding, L., Dong, B., Ding, Q., Li, X., Xiao, S., 2007. China: the aging giant. J. Am. Geriatr. Soc. 55, 1295–1300. Fukuchi, Y., 1992. Gerontological education in Japan: geriatric education and training. Nippon Ronen Igakkai Zasshi 29, 368–371. Garcez-Leme, L.E., Leme, M.D., Espino, D.V., 2005. Geriatrics in Brazil: a big country with big opportunities. J. Am. Geriatr. Soc. 53, 2018–2222. Gross, J., 2006. Geriatrics lags in age of high-tech medicine. New York Times. October 18. www.nytimes.com/2006/10/18/health/18aged.html?_r=2&pagewanted=1 Helton, M.R., Pathman, D.E., 2008. Caring for older patients; current attitudes and future plans of family medicine residents. Fam. Med. 40, 707–714. Hirth, V.A., Eleazer, G.P., Dever-Bumba, M., 2008. A step toward solving the geriatrician shortage. Am. J. Med. 121, 247–251. Institute for Health Policy and Health Services Research–Directors of Geriatric Academic Programs (IHPHSR-ADGAP) Database Project. Table 4.2 2004. http://www.adgapstudy.uc.edu/Home.cfm Institute of Medicine, April 2008. Retooling for an Aging America: Building the Health Care Workforce. National Academies Press, Washington, DC. http://www.iom.edu/CMS/3809/40113/53452/54320.aspx Jolly, P., 2007. Medical School Tuition and Young Physician Indebtedness. An Update to the 2004 Report. Association of American Medical Colleges. Washington, DC. https://services.aamc.org/publications/showfile.cfm?file= version103.pdf&prd_id=212&prv_id=256&pdf_id=103 King, S.V., Gachuchi, M., Ice, G., Cattell, M., Whittington, F., 2005. Gerontology education and research in Kenya: establishing a US-African partnership in aging. Gerontol. Geriatr. Educ. 26, 117–135. Kishimoto, M., Nagoshi, M., Williams, S., Masaki, K., Blanchette, P.L., 2005. Knowledge and attitudes about geriatrics of medical students, internal medicine residents, and geriatric medicine fellows. J. Amer. Geriatr. Soc. 53, 99–102. Kuehn, B.M., 2009. effort under way to prepare physicians to care for growing elderly population J. Am. Med. Assoc. 302, 727–728. Le Couteur, D.G., Bansal, A.S., Price, D.A., 1997. The attitudes of medical students towards careers in geriatric medicine. Australasian J. Ageing 16, 225–228. Lee, M., Reuben, D.B., Ferrell, B.A., 2005. Multidimensional attitudes of medical
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residents and geriatrics fellows towards older people. J. Am. Geriatr. Soc. 53, 489– 494. Leibovitz, A., Baumoehi, Y., Habot, B., 2004. Geriatric medical education in Israel. Gerontol. Geriatr. Educ. 25, 33–42. Louw, S., 1997. Geriatric medicine in South Africa – the onus is on medical schools. SA Med. J. 87, 1099–1100. Phelan, E.A., Genshaft, S., Williams, B., LoGerfo, J.P., Wagner, E.H., 2008. A comparison of how generalists and fellowship-trained geriatricians provide “geriatric” care. J. Am. Geriatr. Soc. 56, 1807–1811. Phillips, R.L., Dodoo, M.S., Petterson, S., Xierali, I., Bazemore, A., Teevan, B., Bennett, K., Lagagneur, C., Rudd, J., 2009. Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices? The Robert Graham Center. Washington DC. Plassman, B.L., Langa, K.M., Fisher, G.G., Heeringa, S.G., Weir, D.R., Ofstedal, M.B., Burke, J.R., Hurd, M.D., Potter, G.G., Rodgers, W.L., Steffens, D.C., Willis, R.J.,
Wallace, R.B., 2007. Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology 29, 125–132. Potter, L., 2009. Glad to be grey. The Guardian. June 20. http://www.guardian.co.uk/ society/2009/jun/20/fauja-singh-marathon-runners Somers, A.R., Fabian, D.R., 1981. The geriatric imperative: an introduction to gerontology and clinical geriatrics. Appleton-Century-Crofts. New York. United Nations Program on Aging. Online. The Aging of the World’s Population. Population Division, Department of Economic and Social Affairs, United Nations Secretariat. http://www.un.org/ageing/popageing.html Warshaw, G.A., Bragg, E.J., Thomas, D.C., Ho, M.L., Brewer, D.E., 2006. Association of Directors of Geriatric Academic Program. Are internal medicine residency programs adequately preparing physicians to care for the baby boomers? A national survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce study. J. Am. Geriatr. Soc. 54, 1603–1609.
Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Geriatric education for the physicians of tomorrow Barry D. Weissa, *, Mindy J. Fainb a Department b Department
of Family and Community Medicine, University of Arizona, College of Medicine, Tucson, AZ 85719, USA of Medicine, Geriatrics Section, University of Arizona College of Medicine, Tucson, AZ 85724-5069, USA
article info
abstract
Keywords: Current training programs Geriatrics training Reimbursement for geriatric care Geriatric education to physicians
The world’s population is aging and there is need for more geriatricians. Current training programs, however, are not producing a sufficient number of geriatricians to meet that need, largely because students and residents lack interest in a career in geriatrics. A variety of reasons have been suggested to explain that lack of interest, and several changes in geriatrics training might increase the number of medical trainees who choose a career in geriatrics. These changes include recruiting medical students who are predisposed to geriatrics, loan forgiveness programs for those who enter careers in geriatrics, increased reimbursement for geriatric care, providing geriatric education to physicians in all specialties throughout their training, and refocusing geriatrics training so it includes the care of healthy vigorous older adults, rather than an exclusive focus on those with debility and chronic or fatal illnesses. © 2009 Elsevier Ireland Ltd. All rights reserved.
1. The aging population The population of the world is aging. Statistics from the United Nations indicate that in just 40 years from now, well within the careers of current medical trainees, the world’s population will include nearly two billion people over age 60. One out of every five people will be 60 years or older, and, worldwide, older adults will outnumber children (Department of Economic and Social Affairs, 2002; United Nations Program on Aging, Online). The fastest-growing segment of the older population will be the oldest old, people over 80, who will represent 20% of the world’s population over 60. Between 2005 and 2050, the number of people over 100 years of age will have increased by a factor of 14 to reach nearly 4 million (United Nations Program on Aging, Online). 2. The growth of geriatrics in medical education The aging of the population has long been recognized by medical educators. Indeed, many current medical school faculty members, some now in senior leadership positions, became aware of the aging population and the so-called “geriatric imperative” nearly 30 years ago with the publication of books and reports on the topic (Somers and Fabian, 1981). Over the next several decades, medical school departments around the world, primarily in family medicine and internal medicine, but also in other disciplines, began developing curricula and special training programs in geriatrics. By 2004, in the US, there were national accreditation requirements that a geriatric * Corresponding author. Tel.: +(1-520) 626 6975; fax: +(1-520) 626 6134. E-mail address: [email protected] (B.D. Weiss). 0167-4943 /$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.
component be included in residency training for a large numbers of specialties and subspecialties (Table 1) (Institute for Health Policy and Health Services Research, 2004). Though the intensity and content of geriatric education varied between specialties, the extent of the effort demonstrates that medical educators understood the need for trainees to learn about geriatrics. This effort was accompanied by development of post-residency geriatric medicine fellowships and a national certification in geriatric medicine offered jointly by the American Board of Internal Medicine and the American Board of Family Medicine (Accreditation Council for Graduate Medical Education, 2006a,b). The extent and scope of geriatric training has continued to increase. Although few medical schools in the US have a dedicated department of geriatrics, the growth of geriatrics training in residency programs has nonetheless persisted. More than 95% of family medicine residency programs in the US now have a required curriculum, not just a curricular component, in geriatrics (Bragg et al., 2006). Internal medicine residency programs have also increased their geriatric training, with at least 91% of programs requiring dedicated geriatric training of two weeks or more (Warshaw et al., 2006). In the United Kingdom, results of a 2006 survey of school deans revealed that geriatrics is taught in nearly all UK medical schools (Bartram et al., 2006). Other examples of geriatrics training programs can be found around the world, in Africa (Louw, 1997; King et al., 2005; Ferreira, 2006), South America (Garcez-Leme et al., 2005; Bos et al., 2007), Europe (Bonin-Guillaume et al., 2005), the Middle East (Abyad, 2004; Leibovitz et al., 2004), and Asia (Fukuchi, 1992; Emlet and Hokenstad, 2001) though in some areas geriatrics education is still limited (Bassan et al., 2006; Flaherty et al., 2007).
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B.D. Weiss, M.J. Fain / Archives of Gerontology and Geriatrics 49 (2009) S17–S20 Table 1 Specialties with geriatric training requirement in the USA as of 2004 Specialty
Year requirement began
Anesthesiology
2001
Emergency medicine
2001
Family medicine
2001
Internal medicine (general)
2003
Internal medicine (all subspecialties)
1999
Neurology (pain management)
2000
Neurology (vascular neurology)
2002
Orthopedic surgery
2003
Physical medicine and rehabilitation
2003
Psychiatry
2001
Surgery (critical care)
2001
Urology
2003
Source: http://www.adgapstudy.uc.edu/Files/ADGAP%20Table%204_2a.pdf http://www.adgapstudy.uc.edu/Files/ADGAP%20Table%204_2b.pdf
3. Where are the geriatricians? Despite the growth of geriatrics education programs, there is still a worldwide shortage of geriatricians. Data from the US are readily available, where news reports indicate that as recently as 2006, there was only one geriatrician for every 5,000 Americans over age 65 (Gross, 2006). It is estimated that by 2030, as many as 36,000 geriatricians will be needed to care for the aging US population (Alliance for Aging Research, 2002), a number that cannot possibly be reached given the small number of current geriatricians and the current lack of interest in geriatrics by medical students and residents. The American Board of Family Medicine has reported that of the nearly 75,000 family physicians in the US, only just over 2,000 (<3%) of them were certified in geriatrics and few new family physicians obtain certification each year (331 did so in 2008) (American Board of Family Medicine, Online). Indeed, the number of family physicians seeking certification in geriatric medicine each year is barely larger than the number seeking certification in sports medicine, which is perhaps surprising, or even inappropriate, given the demographic changes of an aging population. In internal medicine, reports indicate that nearly onethird of geriatric fellowship positions in the US go unfilled, even since the introduction of the option of shortening fellowship training to one year, and only a minority of the remaining positions are filled by graduates of US medical schools (Brotherton and Etzel, 2006; Hirth et al., 2008). 4. Why not geriatrics? Why are so few young physicians interested in geriatrics? A variety of reasons have been cited. One recent study suggested that trainees simply underestimate the magnitude of the need for geriatricians in the coming decades. Only two thirds of family medicine residents in that study expected that geriatrics would be a significant part of their practice (Helton and Pathman, 2008), when the reality is that for most primary care physicians, geriatrics will form the bulk of their practice in the coming decades. Another reason is low compensation, cited by the Institute of Medicine (2008) as an important cause for the lack of interest in geriatrics, as compensation is known to influence specialty choice (Ebell, 2008). Medical students in the US graduate from medical school and enter residency with average debt exceeding $200,000; a figure that is rising at a rate of 6–7%/year (Jolly, 2007). This debt load
makes it difficult to devote extra years to a geriatrics fellowship, during which salaries are low, followed by practice as a geriatrician, for which compensation is lower than it is for internists and family physicians that do not complete geriatrics fellowships (American Medical Group Association Compensation Survey Data, 2007). But, the problem may go deeper than just salaries and awareness of demographic changes. Rather, it may involve the way we teach about geriatrics. Indeed, studies from around the world have shown that medical students and residents have a negative view of and low interest in geriatric medicine. For example, a survey of medical students in Australia showed that very few were considering a career in geriatrics and most students said they would prefer not to treat the elderly. The reason, they said, after experiencing geriatric practice during their training, is that geriatric medicine is a “low-tech” specialty that is mostly concerned with psychosocial and placement issues rather than curing illness (Le Couteur et al., 1997). Several studies have shown that these negative views become even more negative as trainees have more exposure to geriatrics. One study showed that attitudes about geriatrics deteriorate during training, with students entering medical school having more favorable attitudes toward geriatrics than more advanced students and residents (Kishimoto et al., 2005). Another study showed that among trainees who had an interest in geriatrics and chose to enter geriatric fellowship program, attitudes about older people became less positive during fellowship training (Lee et al., 2005). An argument can thus be made that we are doing something wrong in our geriatrics training. Establishing geriatric curricula, program requirements, and fellowship programs is simply not enough. If our medical student, residency, and fellowship programs are “turning off” trainees to a career in geriatrics, we need to rethink the way we provide geriatric education. 5. What should be different? How can we encourage more physicians to enter the field of geriatrics? First, we need to commit to the need for geriatricians. Some have argued that the lack of geriatricians is not important, and that any primary care physician can provide geriatric care because most primary-care training programs now include some geriatrics training. However, research shows that they don’t provide it as satisfactorily. For example, when compared to fellowship-trained geriatricians, generalist physicians are more likely to prescribe inappropriately, and are less likely to proactively assess patients for common geriatric syndromes (Phelan et al., 2008). Second, we should institute a program of loan forgiveness for physicians who choose geriatrics, a policy that has been successful in encouraging physicians to choose rural practice areas. A loan forgiveness program has the potential to increase the number of graduates entering geriatrics. Additionally, changes in reimbursement incentives that place value on complex office-based care of older adults would greatly aid in feeding the pipeline of geriatricians. Third, we need to fully recognize that all physicians, regardless of specialty, will be providing care for markedly increasing numbers of older patients. Medical training should prepare all physicians for this future, starting with the first day of medical school. Some philanthropic foundations have already begun to make a difference, funding programs that provide geriatric training for all physicians (Kuehn, 2009). For example, in the US the Donald W. Reynolds Foundation has provided significant funding to over 40 medical schools to develop and implement geriatrics curricula. Similarly, the John A. Hartford Foundation supports the American Geriatrics Society’s Geriatrics for Specialists Initiative to enhance geriatric training, with a focus on surgeons and related specialty physicians. As part of this effort, in 2007 the
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Association of American Medical Colleges (AAMC), supported by the Hartford Foundation, established a minimum set of 26 geriatric competencies for all medical students. Other specialties continue to develop and implement similar geriatric competencies for residents and practicing physicians. These efforts are essential steps towards assuring broad-based physician competency in the care of older adults, and they require expanded national support. Fourth, medical schools, the pipeline for future geriatricians, need to do a better job of recruiting students with a potential interest in primary care, which, in most cases, is the conduit into geriatric medicine. Just as entry into primary care residencies can be increased by recruiting medical students with a predisposition to primary care practice and humanistic medicine (Phillips et al., 2009), such recruitment can also facilitate entry of students and residents into future geriatric careers. Fifth, although traditional block rotations in geriatrics provide trainees with exposure to key facets of geriatric practice, medical schools and residency programs should also integrate geriatric principles of care throughout training. Students and residents should be exposed to faculty with expertise in geriatrics in most, if not all, rotations, including medical and surgical subspecialties, and in continuity practices, to reinforce geriatric principles of care. Creating the cadre of faculty with the necessary expertise can be accomplished through faculty development programs. Such longitudinal exposure to geriatric training will complement traditional block rotations that don’t give residents and students the opportunity to follow patients long enough to see them improve from the setbacks experienced during hospitalization, nor the opportunity to experience the satisfaction and reward of helping patients and families though the difficult times and declines that occur when serious or fatal illnesses develop. Finally, we need to refocus geriatric training so that the emphasis is not solely on chronically ill and debilitated patients needing geriatric assessment, patients who are dying, demented, institutionalized, or needing support from poorly funded social service agencies. While care of such patients needs to be a part of geriatrics training, sole focus on such debilitated patients cannot always sustain a satisfying career, any more than an oncologist’s career would be satisfying if the oncologist’s patients never experienced a cure or remission from cancer. Rather, trainees need to know and see that most older adults are healthy and live in the community, not in nursing homes. They need to know, in contrast to what they see in the patient mix of current training programs, that only a minority of older adults, even at age 80 or 90, have dementia (Plassman et al. 2007). They need to know that older adults, including those in their 70s, 80s, and 90s, maintain active lifestyles and even run in marathons (Browne, 2000; Potter, 2009). Students and residents should be exposed to these healthy older individuals, as such exposure would likely change the trainee’s perception of geriatrics. We should teach them the knowledge and skills to keep such individuals healthy and active. These skills are not learned in nursing homes and hospices, which are the site of many current geriatric training experiences. Such training is of critical importance in our aging society, in which our goal as physicians should be to help seniors live healthier, longer, and more independent lives.
Conflict of interest statement Both Dr Weiss and Dr Fain receive grant funding from the Donald W. Reynolds Foundation and from the US Health Resources and Services Administration to support development and operation of geriatrics education programs. These organizations had no role whatsoever in preparation of the manuscript.
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