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The Geriatrics Imperative: Meeting the Need for Physicians Trained in Geriatric Medicine
Lillian Chiang
University of California Los Angeles School of Medicine
JAMA. 1998;279:1036-1037.
The need for training in the care of geriatric patients is reshaping graduate medical education. Primary care residencies are moving toward mandatory training in geriatrics, but it is not clear whether such training has improved either the quality or quantity of physicians caring for the elderly.
The increasing proportion of health care expenditures for people older than 65 years has been widely documented.1 But despite growth in this segment of the population, few new physicians are seeking training in geriatrics. More geriatric fellowships are available, yet the percentage filled decreased from 90% in 1990 to 74% in 1992.2 More than 20% of slots in the 16 top geriatric fellowship programs went unfilled from 1991 to 1994 for lack of qualified applicants.3 Since fellowship training is now a requirement for certification in geriatric medicine, the number of certified geriatricians is likely to decrease as those currently certified retire or defer recertification.4
Fortunately, most elderly patients today can be appropriately cared for by primary care generalist physicians.3 These successfully aging individuals comprise 30% to 40% of patients in primary care practices.5 But health care workforce research predicts that the supply of board-certified geriatricians will fall short of the number needed to care for all elderly patients.2 Generalists will need to fill in the gaps and provide the vast majority of medical care for older people. It is essential that new physicians, especially those planning careers in primary care medicine, have adequate clinical skills to provide the highest quality care for their older patients.
How well prepared are generalist physicians to manage the problems associated with aging? Research on the quality of geriatrics education has found significant shortcomings. While family medicine residents can correctly identify disease, they are not as proficient at identifying nonpathologic changes associated with normal aging.6 For example, impaired proprioception, a normal consequence of aging, was frequently misclassified as pathology, while diminished far vision was often identified incorrectly as normal in the elderly.
A study of 93 internal medicine residents indicated that an intensive 4-week clinical rotation in geriatrics significantly improved residents' knowledge of geriatric medicine as measured by pretest and posttest scores on a 35-item quiz.7
The principal source of geriatric fellows who may subsequently enter academics are internal medicine and family medicine residencies.8 With a projected deficit in full-time geriatric faculty needed for postgraduate educational needs,9 the improvement of geriatric training in internal medicine and family medicine residencies would not only produce more generalist physicians competent in geriatric care, but perhaps also foster new faculty who are the cornerstone of education within these residency programs.
Elective or Mandatory Training?
As recently as 1990, 80% of family practice and 36% of internal medicine residencies included a formal curriculum in geriatrics.10 Among those with geriatrics curricula, only 61% of the internal medicine programs required residents to participate in the geriatrics training, compared with 92% of the family medicine residencies. Not surprisingly, fewer internal medicine residencies had certified geriatricians on the faculty (42% compared with 68% of the family medicine programs). Residency directors cited lack of faculty, low rating of geriatrics in importance by department chairs and program directors, and the perception that residency curriculum was too full as the most common reasons for failing to implement geriatrics curricula.
Most graduate training in geriatrics is elective, and only a small portion of residents pursue it. A study by the Trustees of Boston University in 198911 found that approximately 25% of US residency programs in internal medicine, family medicine, neurology, psychiatry, and physical medicine offered elective geriatric rotations, but fewer than half of all residents in these programs actually take the elective. Some programs had mandatory geriatrics rotations, ranging from 55% in family medicine to 2% in neurology. Overall, 62% of family practice residents, 48% of psychiatry residents, 26% of internal medicine residents, 17% of physical medicine residents, and 3% of neurology residents had taken either a required or an elective rotation in geriatrics.
In 1992, a survey of primary care residencies found that long-term care experience in geriatrics was required in 86% of family practice residency programs vs 25% of internal medicine programs.12 In addition, most geriatric curricula in the programs surveyed were taught in nursing home settings with less emphasis given to rehabilitation, organization, health care financing, and coordination of care between acute and chronic settings. Barriers to implementation of nursing home rotations included the lack of available faculty and scheduling conflicts with other rotations.
Changing Standards
Since 1994, the Accreditation Council for Graduate Medical Education has required that internal medicine residencies offer elective didactic and clinical curriculum in geriatrics.13 In addition, 12% of questions on the American Board of Internal Medicine certifying examination now test specific knowledge of geriatric medicine.13
The Institute of Medicine in 1993 recommended that all residencies in internal medicine and family medicine have a mandatory 6 months of geriatrics training by 1996 and 9 months of training by 1999.14 Follow-up surveys will be required to see whether training has actually increased.
Vanguard Programs in Primary Care Medicine
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Several new projects that address the inadequacies in geriatric education are now under way. The American Academy of Family Physicians (AAFP) Foundation program provides training by a group of family practice geriatrician consultants in 2-day visits focused on direct clinical teaching, modeling, curriculum development, and faculty development. The project is expected to reach 30 to 40 family physicians and geriatric medicine faculty and 100 to 160 family practice residents each year. Another set of workshops is to be held at regional meetings of the Society of Teachers of Family Medicine. Regional meetings will review effective teaching strategies, distribute teaching materials, and develop new geriatric curriculum with faculty from community hospital residency programs.
The Hartford Foundation recently funded geriatrics curricula development at 7 sites through its Geriatrics in Primary Care Training Initiative: University of Rochester School of Medicine, Baylor College of Medicine, Harvard Medical School, University of California Los Angeles (UCLA) School of Medicine, Johns Hopkins University School of Medicine, University of Chicago Pritzker School of Medicine, and University of Connecticut School of Medicine. The programs will emphasize clinical skills and topics in geriatrics not usually covered in traditional internal medicine and family training programs. For example, the internal medicine program at UCLA requires 2 to 4 half days in outpatient geriatrics, comprehensive geriatric assessment, or home visits in the first year; 22 afternoons of nursing home, subacute, and geriatric psychiatry training in year 2; and a 4-week inpatient/outpatient geriatrics rotation in the third year of residency. In addition, changes in knowledge and personal attitudes toward older patients will be evaluated.15
These programs are at the cutting edge of medical training that is committed to addressing imminent workforce issues. As the need for geriatrics-trained generalists increases, more changes in residency programs undoubtedly will follow.
REFERENCES
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1. American Association of Retired Persons. A Profile of Older Americans: 1996. Washington DC: American Association of Retired Persons;1997.
2. Reuben DB, Beck JC. Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions. Washington, DC: National Academy Press; 1994.
3. Besdine WB. Geriatrics content in residency curricula. Am J Med. 1994;97(suppl 4A):10S-12S.
4. Reuben DB, Zwanziger J, Bradley TB, et al. How many physicians will be needed to provide medical care for older persons? physician manpower needs for the twenty-first century. J Am Geriatr Soc. 1993;41:444-453.
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5. Kane RL, Solomon DH, Beck JC, et al. The future need for geriatric manpower in the United States. N Engl J Med. 1980;302:1327-1332.
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6. Beall SC, Baumhover LA, Maxwell AJ, Pieroni RE. Normal versus pathological aging: knowledge of family practice residents. Gerontologist. 1995;42:113-117.
7. Lindberg MC, Sullivan GM. Effects of an inpatient geriatrics rotation on internal medicine residents' knowledge and attitudes. J Gen Int Med. 1996;11:397-400.
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8. Kohrman CH, Lyttle CS, Anderson RM, Levey GS. National study of internal medicine manpower, XIV. Patterns of residency and fellowship over time, 1987 update. Arch Intern Med. 1989;149:2179-2185.
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9. Reuben D, Bradley TB, Zwanziger J, et al. The critical shortage of geriatrics faculty. J Am Geriatr Soc. 1993;41:560-569.
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10. Reuben DB, Fink A, Vivel B, et al. Geriatrics in residency programs. Acad Med. 1990;65:382-387.
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11. Trustees of Boston University. Analysis of Issues Related to Exceptions to Limits to Medicare Reimbursements for Geriatric-Related Graduate Medical Education. Report on Contract No. HRSA 240-88-0030. Rockville, MD: US Dept of Health and Human Services; 1989.
12. Counsell SR, Katz PR, Kuruza J, Sullivan GM. Resident training in nursing home care: survey of successful educational strategies. J Am Geriatr Soc. 1994;42:1193-1199.
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13. Jahnigan D. Geriatric education for internal medicine residents. Am J Med. 1994;97(suppl 4A):43S-45S.
14. Institute of Medicine. Strengthening Training in Geriatrics for Physicians. Washington, DC: National Academy Press; 1993.
15. Reuben DB, Lee M, Davis JW, et al. Development and validation of a geriatrics knowledge test for primary care residents. J Gen Intern Med. 1997;12:450-452.
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