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Division of Geriatric Medicine, Saint Louis University School of Medicine, and Geriatric Research, Education, and Clinical Center, VA Medical Center, St. Louis, Missouri
The question is not What will geriatrics be when it grows up? but When will geriatrics grow up? As an adolescent specialty, geriatrics has enjoyed "experimenting" in various areas of the health care playground, some a little more risky (e.g., managed care) than others. But, as adolescents who learn from their experience (remember that the most curious adolescents learn the most, although they are usually the biggest risk takers), geriatricians have learned where to be successful, and where not. The step now is to move into adult roles of leadership, innovation, vision, and yes, influence and power.
Based on Kane's (1) declaration of intentions, which I agree are not mutually exclusive, here are some suggestions for the future of geriatrics.
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Models of Care |
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So, what innovative model of care would allow targeting of diverse services (from high touch to high "tech"), would benefit from control in medical decision making for frail older persons, and would prosper from geriatric leadership? What model of care would also grant geriatrics a bit of influence and power? (Please do not let the word power frighten people. Whenever there are competing forces, as there are in health care, a balance of power is essential to ensure judicious use and delivery of services.) The next model of care that would change the future of geriatrics is The Geriatric Hospital (9). Before the critics claim, "Ridiculous, geriatricians have enough to do in chronic care and our place is in long-term care, not acute care," let me say this. This suggestion in no way puts less importance on areas of long-term care (LTC). Rather, in order for LTC to survive, and thrive, it needs geriatric hospitals. LTC gets a very thin, disproportionate piece of the Medicare pie, compared with the approximately 40% of the Medicare budget that acute care receives. If geriatric principles were to influence acute care more, prehospital and posthospital care could finally be connected, so that a true continuum of care would have a chance.
Another reason for geriatric hospitals is that currently, hospitals are dangerous places for the elderly population (10), who account for approximately 40% of all U.S. hospital admissions (11). Because this statistic includes patients of all ages, rates are higher than this in adult hospitals, and are likely to be even higher in rural areas if elderly populations are disproportionately high. At our hospital, hospitalization rates are higher for those aged 75 and older (usually more frail) compared with those 65–74 years old. Why does the care of chronically ill older persons spin out of control in the hospital? How often do clinicians struggle with the complex acutely ill frail older person for whom the more they do, the more trouble they cause? How often do our older patients come out of the hospital in worse functional shape than when they went in? It is not because of bad medicine or bad care. It is because the system is not set up for the special needs of these patients. Although Acute Care for the Elderly (ACE) Units have improved the situation dramatically (12), a systemwide change has to occur. Again, I hear the critics say, "I can see it happen. St. Elsewhere will become St. Elsewhere Geriatric Hospital, and all we'll have is a hospital full of frail elderly people, more of whom will suffer at the hand of high technology." But a change of name is not enough. Two other transformations have to occur. First, solid geriatric leaders have to become directors of hospitals. Second, these leaders have to become heads of true geriatric departments. By true departments, I mean those that have within them diverse divisions such as cardiology, urology, and orthopedics, to name a few. Now the critics are laughing as I hear them say, "Sure, geriatricians will be telling those specialties what to do?" Of course not. However, geriatricians can change the culture of how things are done, of what is important. It just takes time and perseverance. Geriatricians have done this for nursing home care, for home care, and for subacute or posthospital care. It is time to bring things full circle.
Most of us have resisted utilizing medical technology to the extent that other specialties have, and rightfully so. We realize that overuse of such technology is not the answer to improving functional outcomes among older persons. However, targeting such technology, controlling its utilization, and leading other specialties in directions that make a difference in functional life expectancy, not just mortality figures, will bring us out of the crossroads and into the mainstream of modern medicine. Without this leadership role in hospital care and in technology, geriatricians, as Kane writes, will merely continue to be "cross-subsidized to the extent they are credited with attracting a patient base of high users of medical technology."
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Education |
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As reluctant as we are to admit it, testing drives what students learn (17). Geriatrics requires a stronger presence on the boards. Another route to reach all medical students is to require that all medical schools have a formal geriatrics rotation. Although there may be some debate as to what is the best way to teach the principles of geriatrics (e.g., integrative model within other courses vs block rotation), this would be one tangible method to ensure that all graduates of medical education receive this minimum geriatric educational opportunity. For those readers who are doubtful that "geriatrics" has enough influence to pull this off, I would offer the example of the Family Practice "movement" that resulted in a mandate a few years ago that all medical schools require a rotation in this specialty. Who were the movers and shakers here? Some family medicine academicians would answer "the medical students." As those of you who are on curriculum management committees can attest to, not only do tests drive what students learn, but students are also a driving force or at least a loud voice, in decisions related to curriculum. Could we not "use" our students to help our cause?
After reviewing Kane's article, I conducted an informal survey of third-year students during an ambulatory care class (response rate of 24/30). The students were at the end of their third year. They were asked to "pretend that 10 years from now, you are taking care of a 75-year-old patient with one of the following disorders/diseases/issues. Rank in order the type of physician you think you would have learned the most pertinent and useful information from about this disorder/disease/issue" (Table 1 ). Students were given three choices: geriatricians, general internists, or other specialty. The disorders, diseases, and issues were taken directly from the table of contents of the Geriatrics at Your Fingertips handbook (18). Although two were ranked first choice by 100% of students (falls and end-of-life care), a less than desirable percentage of students ranked geriatricians as first choice for such disorder, disease, or issue as hearing impairment, musculoskeletal disorders, pressure ulcers, and urinary incontinence. Although this was a small survey, it begs the question, How can we expect mastery of geriatric principles by students if they do not see geriatricians as the masters in these areas? The problem (as most other geriatric problems are) is multifactorial: there are changes in health care economics, increases in clinical loads, and competition for research funding. These have all pushed medical education onto the back burner for academic faculty (19).
At least one solution is to form an "Academies Collaborative." One model of an Academies Collaborative (20) has defined four major goals for its work, some of which, we should be proud to say, have been done to some extent among geriatric academic centers but could be solidified through a more formal academic collaborative. These goals are as follows: first, information sharing and infrastructure development; second, educational scholarship and research; third, national resource function, that is, develop and share nationally a strategic approach to medical education; and fourth, advocacy for the educational mission of medical schools (20).
These are only two suggestions to enhance our future as geriatricians based on Kane's declaration of intentions. Whether or not one agrees with his declarations, I would hope that all those in the field of geriatrics realize that the most important statement he makes in his paper is that "geriatrics can control its destiny." Geriatrics is at a crossroads, and it may not matter if some geriatricians go this way, and some go that way. Two things are certain: geriatrics has come a long way, and it must keep going.
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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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