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Office of Geriatric Medicine, University of Cincinnati Medical Center, Ohio
Dr. Kane (1) has succinctly described roles for current and future geriatricians. In addition to defining clinical settings, he defines clinical tasks for which health professionals, including geriatricians, other physician specialists, and nurse clinicians, would benefit from the application of the expanding knowledge base of geriatric medicine to patient care. Dr. Kane labels geriatric medicine's current approach to these multiple roles as "schizophrenic," and he suggests that geriatrics should "declare its intentions" with regard to its future. Although acknowledging that the proposed roles for geriatrics are "not all mutually exclusive," Kane concludes that geriatricians should define themselves more explicitly as experts in the management of chronic disease.
Kane's premises that geriatric medicine is not currently a popular career choice for young physicians and that the principles of geriatric practice incorporate many of the elements of quality chronic care are accurate. His projection on the expected short-term decline in certified geriatricians is supported by a recent analysis of American Board of Internal Medicine (ABIM) and American Board of Family Practice certification and recertification data (2).
The specific reasons that geriatricians are not returning for recertification are not known, but they are probably more complex than those Kane proposes. For instance, it is of interest that an ABIM analysis shows recertification rates for fellowship-trained candidates that are below 60%. For geriatricians originally certified by the ABIM in 1998 and 1990, 59% who were fellowship trained returned for recertification versus 43% of those certified through the practice pathway (A. Wiley and L. Gross, unpublished data, 2001).
A pluralistic approach to geriatric medicine's future role in the United States is more likely to attract young physicians and influence the quality of medical care provided to older adults, than, as Kane believes, a premature narrowing of geriatric medicine's objectives. In my community, Cincinnati and southwestern Ohio, dozens of geriatric medicine and geriatric psychiatry fellows have been trained since the early 1980s, and many remain in the area. Among these geriatricians, some teach and lead research activity at the College of Medicine, some are in full-time nursing home and home care practices, some lead hospice programs, some staff the local Program of All-Inclusive Care for the Elderly (PACE) site, some have developed hospital-based consultation or special care programs, some serve as Medical Directors in Medicare managed-care divisions of insurance companies, some support and staff community mental health programs, and some are in primary care practice. Although small in number, these geriatricians provide leadership and education that widely influences the quality of care received by older adults in their communities. As Kane suggests, a common theme among these varied roles may be the application of the principles of chronic disease management, but the approach is pluralistic—not a narrowing of focus.
Geriatric medicine in the United States remains a young discipline. The aging of the U.S. population will have a major impact on both the practice of medicine and the future health care costs of the elderly population. The demand for the clinical, educational, and management skills of geriatricians from patients, their families, and the leaders of delivery systems will continue to grow. Public and private resources will be applied to attract young physicians into geriatric medicine careers and to ensure that every physician develops skills specific to the care of the older adult. The principles of geriatric medicine practice that developed over the past 50 years, if widely applied to the care of older Americans, will provide for the delivery of quality, cost-effective care for well and frail elderly and older adults with chronic illness.
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  J. E. Morley, J. H. Flaherty, and D. R. Thomas Editorial: Geriatricians, Continuous Quality Improvement, and Improved Care for Older Persons J. Gerontol. A Biol. Sci. Med. Sci., September 1, 2003; 58(9): M809 - 812. [Full Text] [PDF]
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