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COMMENTARY |
Department of Medicine, Division of Geriatrics, University of California, Los Angeles.
Address correspondence to John C. Beck, MD, Professor of Medicine, Emeritus, UCLA Department of Medicine, Division of Geriatrics, 1562 Casale Rd., Pacific Palisades, CA 90272-2714. E-mail: egebjcb{at}ucla.edu
One of the few benefits of emeritus status is that it removes an individual from the mainstream permitting a retrospective analysis of where geriatrics has been over the last two to three decades and what direction it should be pursuing. Morley's "A Brief History of Geriatrics" (1) permitted me to identify two negative decision nodes that I believe were critical to what exists in the field today, with both of them remediable if the field is to flourish. I refer to the decision to reduce geriatric fellowship training from a minimum of 2 years to 1 year, and the promotion by most of us of divisional rather than departmental status for the field.
With respect to the former, I was reminded of a submission I was asked to make to the Journal of the American Geriatrics Society in which I drew parallels between pediatrics and geriatrics (2). It was implicit in this paper that geriatrics should consider separating (but not divorcing itself) from internal medicine and family practice, psychiatry, neurology, and rehabilitation. A further implication was that geriatrics would emerge as a separate specialty. The specialty would be expected to manage the more complex patients and provide additional opinions to primary care physicians on the appropriate management of cases when there was doubt, as well as provide leadership in the academic community. The health professional political realities of the last two decades made this choice infeasible, and geriatrics emerged as an "added qualification" track in the parent disciplines. The movement within geriatric medicine in the primary care specialties (IM/FP) to reduce the fellowship training period from 2 years to 1 year, largely led by William Hazzard, consolidated those political forces to what I believe has been a detriment to the field. As I see it, this decision was largely driven by difficulties in recruitment into geriatrics, and there has been little if no evidence that it has had a salutary effect on the field. The recent ADGAP report contains ample evidence of a disastrous effect on the field (3,4). In 2001–2002, the first year fill rate was 69%, with 36% of programs having no U.S. medical graduates. Furthermore, there were 61 post-first year fellows in the 51 programs offering second-year training. Thus, the 1-year fellowship has become the standard as well as the norm. This same strategy was used by rheumatology many years ago without solving its recruitment problem, but delaying its emergence as an important clinical and research specialty.
I have no quarrel with the concept that all generalist physicians who foresee careers in clinical care involving large numbers of older patients be required to take an additional year of training in geriatrics, as has been suggested recently by the Society of General Internal Medicine (5). However, in my view, this does not produce a full-fledged geriatrician and only additional years of training will prepare those individuals for their leadership roles in the field, be they primarily clinical, educational, or research, or some combination of these activities. A specialty status could be an outcome in the near future, and Morley has argued clearly for this as long ago as 1993 (6).
Turning to the issue of departmental status, I confess that my ambivalence concerning the place of geriatrics within the institutional hierarchy of the academic medical center was ill informed. The further and more intensive development of academic centers of geriatrics is linked to the decision to confer upon the field departmental or departmental equivalent (e.g., a clearly defined center) status within the present organization of medicine. The contrast, arguably largely qualitative at this time, between institutions where geriatrics is either a department or a center with most nondepartmental units is rather convincing. The existing departments and centers have large amounts of institutional resources committed to the development of the field. This includes institutional recognition of the downstream financial benefits, both professional and hospital, and institutional willingness to return some of these benefits to supporting faculty in the field. The existing departments and centers with substantial institutional financial commitments to them have permitted them to attract increasingly large amounts of resources from the public and private sectors and has facilitated their growth and visibility, size, and quality of educational, basic, clinical, and health services research programs. It would bring the efforts of geriatric medicine, geropsychiatry, geroneurology, and gerorehabilitation under "one roof" and would address many of the disincentives plaguing the field, such as, for example, size and attractiveness of training opportunities, role model development, undergraduate and meaningful graduate experiences in geriatrics. The envisioned academic units should be supported generously by governmental and private funding.
In summary, I believe that America's older population could be best served by the continued growth and strengthening of geriatrics as a specialty in clearly defined academic units.
References
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