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The Future History of Geriatrics

Geriatrics at the Crossroads

^a University of Minnesota School of Public Health, Minneapolis

Robert L. Kane, University of Minnesota School of Public Health, Mayo Mail Code 197, 420 Delaware Street SE, Minneapolis, MN 55455 E-mail: kanex001{at}umn.edu.

	Context

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Geriatrics has had a hard time deciding just what it wants to be when it grows up. An early concept of geriatrics equated it primarily with caring for persons in long-term care ⁽¹⁾. A major effort to predict the need for geriatrically trained personnel envisioned geriatrics as primarily consisting of specialists who would handle complex cases on referral and provide oversight and advice otherwise ⁽²⁾. A decade later, as managed care was gaining strength and the demand for primary care seemed insatiable, geriatrics redefined itself as a primary care specialty ⁽³⁾. Today one hears geriatricians describe themselves as those who deal with end-of-life care.

During the era of managed care, geriatrics did not enhance its credibility when it often appeared to be making contradictory promises. To managed care organizations, it promised to decrease the need for other specialists by employing improved primary care methods, while it also promised its parent medical centers, which were anxious to build their patient base for technologically intensive (and expensive) services, increased referrals of older patients who needed just such care.

In many ways, geriatrics might be defined as the synthesis of gerontology and chronic care. The core of geriatric practice consists of addressing geriatric syndromes such as falls, dementia, and incontinence; emphasizing the resultant functional changes that accompany chronic illness; recognizing atypical presentations of common diseases; and managing multiple, simultaneous interaction problems, which require medical attention and coordination of the work of various other disciplines. The basic principles of chronic illness care (i.e., using interdisciplinary team care, recognizing the need for care investments that will bear fruit later, promoting active involvement of patients in their own care, distinguishing care episodes from events, and being sensitive to the context of care as well as the immediate problems presenting) are the hallmarks of geriatric care. Essentially, geriatrics is the epitome of good chronic care.

	Supply

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Geriatricians are in danger of extinction. Extrapolations from current data on production and retention raise questions about the survival of the species. During the so-called grandfather period (1988–1994), 8273 physicians certified in either internal medicine or family practice passed the certificate of added qualifications (CAQ) examination and were certified in geriatrics. Since the fellowship training was required the numbers have declined markedly. From 1996 to 2001, only 1634 physicians passed the CAQ examination (see Fig. 1). The rates of recertifications have vacillated between 308 and 753 at each examination. The failure of many who took the test to take the recertification examination suggests that many of the original group were "closet geriatricians," physicians who knew geriatrics well enough to have passed the examination but who did not want to be identified as geriatricians lest they be expected to exclusively see older patients.

View larger version (17K): [in this window] [in a new window]   Figure 1. Number of physicians who passed the examination for a certificate of added qualifications in geriatrics, 1988–2000.

	Other Strategies

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The early designers of geriatric policy recognized that geriatrics was not likely to entice large numbers of physicians. They envisioned a cadre of geriatricians who could gerontologize the larger numbers of primary care physicians (and even some specialists) by acquainting them with the principles of geriatric care and providing them with tools to facilitate such care. Indeed, this strategy has achieved modest success. Several specialty boards require a geriatric experience. Geriatrics is more visible in medical schools as represented by departments or divisions of geriatric medicine.

However, general interest in primary care has waned. The numbers of physicians entering primary care has fallen to the point where current forecasts predict that the numbers of nurse practitioners will soon exceed the numbers of primary care physicians ⁽⁴⁾. The professional base for geriatrics has already begun to shift. For example, nurse practitioners now hold prominent positions in the American Geriatrics Society.

Gerontologizing has already manifested itself through the issuance of geriatric care guidelines sponsored by a variety of organizations. However, guidelines are difficult to apply in geriatrics because they work best in simple and predictable situations. Geriatrics, which thrives on dealing with multiple, simultaneous interactive problems, is not the best substrate for guidelines.

Meanwhile, a number of geriatric practice models have been shown to be effective in randomized clinical trials. Geriatric evaluation and management programs have been hailed as producing important improvements in the lives of frail older persons ⁽⁵⁾. Special acute care for elderly (ACE) patient units in hospitals have been shown to be effective ⁽⁶⁾. Physician–nurse dyads have proven effective in providing better nursing home care ⁽⁷⁾⁽⁸⁾. At the same time, nurse practitioners have been shown to be as effective as physicians in providing primary care to adults, albeit not older adults ⁽⁹⁾.

Geriatrics thus faces a crossroads. It can continue down its somewhat schizophrenic path as a primary care specialty. It can more clearly emphasize its work in long-term care and attempt to reshape that industry into one in which its contribution to the lives of frail older persons is respected. Or it can offer itself as a model for good chronic disease care.

	Geriatrics as the Model for Chronic Disease Care

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Chronic disease is the major issue in medical care today. The health care system is dramatically out of sync with this epidemiological reality. Despite the predominance of chronic illness, medical care is still based essentially on an acute care model, which is based on incidents and encounters, rather than extended episodes of care. The centrality of chronic disease has been well established ⁽¹⁰⁾.

Geriatrics can be readily viewed as the marriage of chronic disease care with gerontology. The principles of geriatrics are those embodied in good chronic disease care. At present, several potential responses to the challenge of chronic care loom large. First, primary care can continue to be provided by primary care providers who refer to specialists as needed. However, for those persons whose conditions require sophisticated management, primary care from primary care providers may not be the best answer. Second, specialists may offer the best care for this subgroup. They understand the underlying diseases better. They have more knowledge about course and treatment. However, many specialist are narrowly focused on their organ of interest. They may ignore or resent the rest of the person. Third, for these situations, a team consisting of a specialist and a nurse practitioner may offer the best solution. The specialist can attend to the organ system and leave the rest of the person to the nurse practitioner.

	Geriatrics at the Crossroads

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To some extent, geriatrics can control its destiny. It must declare its intentions. Several alternative scenarios loom. They are not all mutually exclusive.

1. Geriatrics can continue as a marginal activity, primarily based in academic medical centers. Its work will be subsidized in the name of teaching and perhaps cross-subsidized to the extent it is credited with attracting a patient base of high users of medical technology.
   
2. Geriatrics can become the dominant model for primary care of complex elderly patients, perhaps combined with a hospital practice that addresses the special needs of such patients in purpose-built geriatric care wards.
   
3. Geriatric primary care can be provided primarily by geriatric nurse practioners, with geriatricians functioning as consultants for particularly complex cases.
   
4. Geriatricians can function primarily in long-term care institutions, frequently working with geriatric nurse practitioners.
   
5. Geriatricians can become end-of-life specialists offering palliative care.
   
6. Geriatricians can become role models for chronic disease care.
   

The argument for pursuing the last option is severalfold. Geriatrics is seen as a marginal activity. Chronic care, although not a high prestige or well-remunerated activity, is at least more ubiquitous and potentially mainstream. Whereas most primary care practitioners have been unwilling to change their practice patterns to accommodate geriatric approaches, because they see only a limited number of very old patients, they should be more motivated to make the requisite changes to accommodate what is now the majority of their clientele. Geriatrics already demonstrates most of the elements needed to create a practicable chronic disease product.

What is needed to create good chronic disease care? First, there must be a new relationship between doctor and patient. Patients must become more actively involved in their care, tracking the course of their problems and communicating more proactively. They must play a more central role in making decisions and be prepared to share the responsibility for outcomes. Second, time should be reconceptualized to allow for a longer pay-off horizon for care investments. Success should be measured over longer periods. Attention should be directed toward preventing clinical catastrophes by detecting early deviations from the expected clinical course. Third, information technology should be harnessed to support the tracking and reporting of salient clinical parameters in ways that focus clinicians' attention. Finally, interprofessional collaboration should be encouraged as long as it is efficient.

To varying degrees, geriatrics has demonstrated all of these skills and approaches. It has the potential to play a central role in shaping the future of medical practice. Some would suggest that moving in this direction means renouncing geriatrics' prime directive: caring for the frail. To the contrary, such a step would create a practice atmosphere that would be more supportive of just such care, not for the few but for the many. It would be a step toward an ageless society, advocated by Neugarten ⁽¹¹⁾, in which care would be apportioned by need, not by age.

Received May 21, 2002

Accepted June 18, 2002

	References

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