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Section of Geriatrics, The University of Chicago, Illinois
Clinical geriatrics as described by Dr. Kane (1) is in the throes of another midlife crisis, having gone from a youthful promise to rejuvenate the old at no excess cost to fear of extinction as a profession. Kane proposes a solution that sounds to me like another attempt to repackage our product and sell it as new and improved, as the new model for complex chronic disease management. In support of this proposal, he offers the results of outcome studies of geriatric care that demonstrate effectiveness of "geriatric care models." The problem with such a broad generalization is that there are many geriatric care models and it is difficult in any given report to determine what in the black box accounted for the results, or lack of them.
My view of this literature, including the recent excellent Veterans Administration trial of inpatient and outpatient Geriatric Evaluation and Management Units, is that our results are consistent but modest, largely qualitative, and transient (2). However, having said that, I do think our outcomes should be viewed in perspective. Our results are at least as impressive, for example, as influential cardiovascular drug trials and phase II chemotherapy trials in oncology. The way the data are presented can hide this important fact. Statistical significance and relative risk statements obscure small absolute risk improvements in so-called hard end points. Increasingly, disease-model trialists are examining the quality of life achieved by interventions. Expert panels now routinely consider the incremental cost of interventions. Geriatrics should explicitly present our clinical outcomes in the common language of outcomes, for example, number needed to treat, in order to demonstrate our bang for the buck on par with prestigious organ- and disease-based specialties.
One approach is to engage with the other specialties. The Hartford Foundation is sponsoring an exciting experiment to introduce geriatric training into the surgical and medical specialties. Hartford has partnered, for example, with the American Society of Clinical Oncology to support innovative joint training in oncology and geriatrics; this is an experiment, if you will, in hybridization. This has already born fruit in the inclusion of standardized functional measures for elderly subjects recruited to studies conducted by the cooperative trials groups. This trend should be encouraged by requiring all sponsored clinical research to account for age and functional status at recruitment and for outcomes as they are now for race and gender. One might worry that, if every specialty learns a few functional assessment tools, geriatricians may become redundant. I doubt this. Surgeons want to operate; gastroenterologists want to scope. Rather, the Hartford model and the requirement that age and functional status be reported for trials ought to create awareness and a referral base for geriatrics among the specialties.
My second concern is that Dr. Kane raised but did not address the problem of recruitment to the field. In our Darwinian world, the sexy, not the strong, inherit the niche. In the United States, geriatricians are becoming an endangered species; our reproductive rate appears to be falling below population replacement levels (3). The United Kingdom environment offers a comparison case. Recently the National Health Service published a series of hybrid policy and evidence-based National Service Frameworks, including the National Service Framework for Older People. Knowledgeable experts have criticized the document, but two things stand out to a U. S. reader (4). First, the U. K. environment supports population-level policy that trains geriatric consultants in all levels of care, that is, long term, intermediate, acute, and community. It mandates their integration into delivery of care to the elderly population, something unlikely to happen here. Second, the standards adopt explicit "disease" management guidelines for geriatric syndromes for which there are adequate evidence-based data. Unfortunately, only falls met the criteria for inclusion, but the falls standard is adopted on par with stroke-management guidelines. This both rewards past performance and challenges future British geriatricians to establish a research base for clinical practice. In the U. K., geriatricians are not the rare birds we are in the United States. In 1993, geriatricians comprised 17% of the National Health Service medical specialist consultant workforce, the largest single specialty represented. This dropped to 15% by 1999, but the field had increased overall by 22% (5).
Darwinian evolution worked slowly. Our views of evolution have changed as a result of the research of the late Stephen Jay Gould and others who have shown that saltatory evolution works rapidly in response to environmental change. Random chance favors the lucky mutant and the generalist. If we do not wish to trust to luck, I suggest our future favors a generalist strategy, and a wide net for recruiting the next generation.
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This article has been cited by other articles:
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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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J. E. Morley Editorial: Hot Topics in Geriatrics J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2003; 58(1): M30 - 36. [Full Text] [PDF]
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D. R. Thomas Letters to the Editor: The Future History of Geriatrics: Consulting the Experts J. Gerontol. A Biol. Sci. Med. Sci., January 1, 2003; 58(1): M92 - 92. [Full Text] [PDF]
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