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COMMENTARY |
Geriatrics and Extended Care, VA Puget Sound Health Care System, and University of Washington School of Medicine, Seattle.
Address correspondence to William R. Hazzard, MD, Director of Geriatrics and Extended Care, VA Puget Sound Health Care System, 1660 S. Columbian Way (S-182-GEC), Seattle, WA 98108. E-mail: william.hazzard{at}med.va.gov
As concisely summarized by Professor Morley (1), as a field, geriatrics has a relatively brief but checkered history characterized by great scope and a dizzying array of relationships with other fields. In the early 21st century, however, we are still struggling with an ambiguous identity that even we in geriatric medicine cannot clearly define: Are we a specialty in our own right, a subspecialty (of internal medicine or perhaps psychiatry), or a "supraspecialty," embracing all of the breadth and complexity germane to optimal health and social care of elderly people and necessitating our multidisciplinary, team-oriented modus operandi?
My dedication to the last of these three has dominated my life both professionally and personally for the past quarter century. I transitioned to this field from a solid base in endocrinology and metabolism, the subspecialty of origin of many future geriatric leaders from my generation. In doing so, with alacrity and no more than a handshake, I accepted a charge by Bob Petersdorf, chairman of the Department of Medicine, Ed Bierman, my mentor and head of the Division of Endocrinology and Metabolism, the training ground of a substantial cohort of those future leaders (Jeff Halter, Andy Goldberg, and Bob Schwartz), and Carl Eisdorfer, chairman of Psychiatry (and reinforced by Paul Beeson) to build a Division of Gerontology and Geriatric Medicine in the Department of Medicine at the University of Washington.
The philosophy of geriatrics, broadly defined as a "supraspecialty," served as a major underpinning of our geriatric program development at three academic health centers: the University of Washington, Johns Hopkins University, and Wake Forest University. However, to succeed in these environments, a corollary principle also guided our efforts at each institution: to develop the aging program on the highest plane of academic currency and respect in order to compete for the resources necessary to build a distinguished, enduring program of excellence, principally by attracting and retaining the best talent. At each institution, this dictated an initial focus on research—the traditional coin of the realm at those institutions—and especially the development of fully research-trained and academically committed fellows and junior faculty as the lifeline of long-term success. It also translated into efforts to recruit the most talented scientists and clinicians from the myriad relevant disciplines to the aging enterprise at each center, an attractive opportunity for them to expand their horizons in a field with enormous growth potential.
This also translated into investing our energies and fate in the mainstream of power and influence at each institution, focusing primarily within the Department of (Internal) Medicine (as a Division or Section of Gerontology and Geriatric Medicine), reaching out in collaboration to all other disciplines within that largest clinical department (with each of the medical subspecialties as well as general internal medicine). However, the supraspecialty definition also dictated that we develop strong, synergistic relationships with multiple other departments in the school of medicine (e.g., psychiatry, neurology, physical medicine and rehabilitation, and surgery and its related specialties and subspecialties) as well as other health sciences schools (critically including nursing, social work, and public health), generally under the umbrella of a center or institute on aging.
The logic of this approach was rooted in the historically based, realistic assumption that geriatricians will remain relatively few in number (indeed, currently less than 1% of United States medical graduates pursue geriatrics at the fellowship level); hence, in the interest of our burgeoning elderly population, the influence of these precious few geriatricians would have to be leveraged maximally through their concentration at academic health centers as researchers, educators, and innovative developers of model programs of both preventive gerontology and geriatric health care. This approach was also designed to foster development of a generation of gerontologists and geriatricians who would mature to become major leaders of academic health centers as center directors, department chairs, and deans in positions affording the opportunity to "gerontologize" the institution in the broadest and most enduring manner.
Perhaps predictably, pursuing this philosophy exerted a profound personal influence upon me and my family. Prepared for a life of academic peregrination and the challenge of geriatric program development by a sabbatical year in the United Kingdom in 1977–1978 to experience the world-renowned British approach to geriatrics, my determination to build geriatrics close to the center of the Department of Medicine led to my progression from Division Head (at the University of Washington), to Vice-Chair (at John Hopkins, 1982–1986), and finally to Chair of Internal Medicine (at Wake Forest 1986–1998) before our return in 1999 to our beloved Seattle and the University of Washington and Veterans Affairs Puget Sound Health Care System.
Has this strategy been validated by our experience at these three centers? On balance, yes, I believe. On the positive side of the ledger, capitalizing on intrinsic distinctive local strengths and opportunities at each academic health center (principally through the efforts of superb scientific and clinical colleagues already on the faculty and training of talented fellows), vigorous, growing, institutionally imbedded geriatric programs were developed at each institution, ones that continue to enjoy "top 20 status" as outstanding, stable new leadership has emerged, academic fellows and junior faculty continue to develop successfully, and geriatrics remains a respected, influential "player" in the mainstream of the academic culture. A number of leaders in American medicine have also traversed this path to positions of major influence as chairs of internal medicine, deans, president of the American Board of Internal Medicine, and even the CEO of Aetna.
However, this model of generating a "geriatric diaspora" as a supraspecialty anchored in internal medicine has by no means evolved as the only approach to successful program development, especially in recent years, which have witnessed an accelerating rise in numbers of departments of geriatrics. Thus, on this issue, the jury clearly remains out.
And I submit that our identity crisis is likely to persist until the whole of medicine and all of the health care professions fully embrace the responsibility of providing optimal care to the oncoming tsunami of aging baby boomers. When that transformation occurs, however, I optimistically predict that geriatrics will clearly emerge at the center of society's successful response to this challenge, and that its premium value as an integrating "supraspecialty" strongly tethered to internal medicine and its subspecialties will prevail and endure.
Reference
This article has been cited by other articles:
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  N. C. Franklin and C. A. Tate Lifestyle and Successful Aging: An Overview American Journal of Lifestyle Medicine, January 1, 2009; 3(1): 6 - 11. [Abstract] [PDF]
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