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Commentary

Section of Geriatric Medicine and Gerontology, Center for Health Services Studies, Warwick Business School, The University of Warwick, Coventry, United Kingdom

I liked Kane's article ⁽¹⁾, despite disagreeing with its primary theme and conclusions. Professor Kane should be acknowledged for his views, which have been shaped by his wide clinical and academic experience, but I feel that he has produced a rather narrow, if not slightly depressing, perspective and vision of future geriatrics.

This article is intended for a U.S.-based readership because its focus is the development and future of American-style geriatric medical practice. From an overseas perspective, I have never quite understood why the lack of emphasis in the United States on acute geriatric care has gone relatively unchallenged by geriatricians. This area has been virtually ignored by Professor Kane and yet, in my view, may be the salvation of geriatrics in his country. The resurrection of the discipline of geriatric medicine in the United Kingdom in the 1970s was largely the result of a greater emphasis on acute hospital-based care of elderly frail people, allowing them access to investigations and procedures common and routine in younger people, and providing the opportunity to begin the process of rehabilitation. Geriatric medicine is now the largest medical subspecialty in the UK, and this power and influence now ensures that all other areas of older people's care is open to geriatric specialist involvement. This includes acute and rehabilitative care, primary and community care (intermediate care model), stroke medicine, various aspects of palliative and dementia care, and long-term care where it exists. General practitioners (GPs) are now being encouraged if not financially rewarded for taking specific professional interests in subspecialty areas such as care of the elderly.

The United States has made significant progress and gained remarkable achievements in geriatrics, including probably the best model of academic geriatric practice (compared with the slower development of academic geriatrics in Europe) ⁽³⁾, comprehensive geriatric assessment ⁽⁴⁾⁽⁵⁾, and having the substantial influence of the American Geriatrics Society both professionally and politically. Professor Kane's views on the future options available may compromise these achievements. More optimism is needed. For example, I believe that geriatrics is an excellent model for guidelines if they are age sensitive, focused on the practical needs of older people, interdisciplinary, and evidence based. The recently published Falls Guidelines of the American Geriatrics Society are an excellent example of this and have been well received in Europe: They have prompted several unique European initiatives in this area ⁽⁶⁾.

Whilst I agree that practicing a Chronic Disease Model for older people should be professionally rewarding for geriatricians, this should not exclude their involvement in other important dimensions of the discipline discussed in the article and my commentary. It is true that geriatrics has been at the crossroads for many years in several countries, but this need not be seen as a major concern—this allows the discipline and its disciples to continue to be innovative and creative. There will always be a political agenda for the health care of older citizens, and this must be used to advantage in identifying need, emphasizing quality of life issues, and promoting good health in retirement, which is a perspective not discussed by Professor Kane.

If geriatricians go down a path of least resistance (Chronic Disease Model) and make no other detours, they will be depriving the U.S. population of the type of specialization that is paramount to achieving a healthier old age.

	References

Top References

 

1. Kane RL, 2002. The future history of geriatrics: geriatrics at the crossroads. J Gerontol Med Sci 57A:M803-M805. [Free Full Text]
2. Morley JE, 2002. Drugs, aging, and the future. J Gerontol Med Sci 57A:M2-M6. [Free Full Text]
3. Michel JP, Gold G, 2001. Coping with population aging in the old continent—the need for European academic geriatrics. J Gerontol Med Sci 56A:M341-M343. [Free Full Text]
4. Cohen HJ, Feussner JR, Weinberger M, et al. 2002. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 346:905-912. [Abstract/Free Full Text]
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