The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 57:M813-M814 (2002)
© 2002 The Gerontological Society of America
Author's Response to Commentaries
Robert L. Kane
The quality and imagination of the responses to my thought-piece more than justify the original effort (1). It is hardly surprising that a group of geriatricians should rise to the challenge of explicating why there is a future for geriatrics. The issue is not how we see ourselves but how others see us. If medical students don't see the need, what can we expect from society as a whole? Patients and families love the time and attention they get from an interdisciplinary assessment, but no one seems ready to foot the bill for it. The United Kingdom has opted to try to introduce some basic principles of geriatric care into general practice, but it has not tackled head-on the issues of providing real geriatric care. Geriatricians there do not serve the truly frail in institutions. They remain hospital based, where their skills in acute medicine may be plied, and commingled with those of internists; but the name of the game is chronic care.
It does seem a shame to declare defeat just when the population is about to age in record numbers. The question has never been whether the world needs geriatrics, but rather how can we get the world to embrace it, and, perhaps even more, to pay for it. Indeed, my eulogy was a bit tongue in cheek, as befits an assignment to write future history. Perhaps we can rephrase Santayana to claim that they who explore the future now may inherit one more to their liking.
Nonetheless, a few troublesome facts have to be grappled with. First, despite the zeal of adherents, the cult of geriatrics is still small and its influence is not growing. Geriatrics is hard to sell to physicians and to the general public. It is even harder to support. Second, ageism is still rampant, despite medicine's efforts to deliver every conceivable Medicare reimbursable service. Third, chronic care is the current hot button, which seems to have a greater potential to attract adherents. Even the World Health Organization is getting behind it (2). It is also easier to market. People can accept having a chronic condition much easier than being geriatric. Just think of how hard it is to get adolescents to see a pediatrician. Fourth, despite the enthusiasm for tracing all eventual changes back to improved medical education, medical educators are even more conservative than their colleagues in practice; moreover, waiting for changes based on new cohorts of better-educated medical students would delay a meaningful effect until well into the baby boom crisis. What we need now is a major infra-re-structure. The present health care delivery system is inappropriate to manage the growing burden of chronic disease.
No one seems to challenge the basic premise that geriatrics overlaps heavily with chronic disease care. The issue is whether geriatricians should give up their hard-fought toehold in the hope of getting a better purchase on a larger ledge. Perhaps they need not abandon geriatrics to embrace chronic disease care, but rather engage in broader dialogues that are compatible with the former. A small cadre of geriatricians will undoubtedly find gainful work exclusively serving the needs of frail older persons. Some may be able to design or operate more efficient means to provide acute care to older persons. Still others can make a good income peddling various nostrums and social devices designed to ward off the undesirable aspects of aging. However, the major opportunities to move medical practice seem to lie elsewhere, in the realm of chronic disease care.
I must plead guilty to an accusation of inconsistency. Having criticized geriatrics for its repeated reposturing, it hardly seems consistent to suggest a new opportunistic change in course. Nonetheless, the future beckons. It would be foolhardy to ignore it.
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References
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- Kane RL, 2002. The future history of geriatrics: geriatrics at the crossroads. J Gerontol Med Sci 57A:M803-M805. [Free Full Text]
- World Health Organization. Innovative Care for Chronic Conditions: Building Blocks for Action. Geneva: WHO; 2002.
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