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COMMENTARY |
The Jewish Home & Hospital Lifecare System, New York.The Mount Sinai School of Medicine, New York.
Address correspondence to Leslie S. Libow, MD, The Jewish Home & Hospital Lifecare System, 120 West 106th St., New York, NY 10025. E-mail: llibow{at}jhha.org
At the time of the 1964 to 1970 period of the creation of the first Board-approved residency–fellowship training program in geriatrics within the United States (1–5), there was almost no use of the term "geriatrics" within U.S. medicine or academia. There appeared to be a fear that the academic establishment would be offended, or worse, that the designation as "geriatrician" would be seen as a denigration of the individual so referred to.
Thus, the approval in 1968 by the American Board of Internal Medicine (ABIM), of a year of geriatrics as equivalent to any other subspecialty year or any general medical year, and credited toward the 3 years necessary to become eligible for the Board exam, was a surprise to many and a focus of celebration for those trying to develop an identified field of clinical and academic geriatrics (2).
During the early years of the fellowship and residency training in geriatrics, the majority of trainees experienced 2 years of geriatric medical training usually as PGY4 and PGY5, occasionally as PGY3 and 4, and even more rarely as a single year of PGY3 or PGY4.
Large numbers of internal medicine residents received 4 to 8 weeks of geriatric training as part of their general internal medicine curriculum and without any goal of becoming geriatricians (2,6).
The method I utilized (2) to obtain approval of the ABIM derived directly from their written guidelines for all fields of internal medicine. The key steps involved the following: 1) developing an approved inpatient and outpatient program of clinical care, teaching, and research focused entirely on elderly people and on aging. This program was in operation from 1964 onward and was in place at the time of the Board approval; 2) obtaining the written support, approval, and commitment to the geriatric program from a) the Chairman of Medicine of the Mount Sinai School of Medicine (the late Solomon Berson, MD, the creator, with Rosalyn Yallow, PhD, of the "Radio-immune Assay," the Nobel Prize-winning insight into the world of micromolecular measurements), and b) the Director of the Department of Medicine (the late Stanley G. Seckler, MD), at the 1000-bed "Mt. Sinai City Hospital Center at Elmhurst," the major public teaching hospital for the medical school. Both of these leaders were ahead of their time in being willing to go against the resistance of colleagues, especially within the field of internal medicine.
In 1976, I started a second geriatric fellowship and residency program linked to another academic nursing home (many years later termed "the teaching nursing home") at the Jewish Institute for Geriatric Care–Long Island Jewish Medical Center of New York (now the Parker Geriatric Institute), a major component of the State University of New York School of Medicine at Stony Brook. Here, too, the Chairman of Medicine at Long Island Jewish (Edward Meilman, MD) utilized his foresight to apply the appropriate support requested by the ABIM (2,3,6) for approval of the training program.
There was turmoil and distress within internal medicine over the recently established field of family medicine, which was considered a threat to the funding and growth of internal medicine and seen as an error in tactics by many in medicine. Thus, the sudden development of the residency–fellowship in geriatrics and the accompanying likely further development of an entire field of geriatrics as a specialty was another understandable worry to those leading internal medicine.
At an ABIM retreat in 1968, at which T. Franklin Williams, John Beck, and I were sharing with the Board our experience and views about geriatrics, one of the leaders of the Board stated publicly: "we should rename the Board as the American Board of Internal Medicine and Geriatrics" with a goal of incorporating rather than dividing.
The establishment of America's first full department of geriatrics in 1982 at the Mount Sinai School of Medicine (4,5,7,8) allowed for further growth of the medical school aspect of geriatrics, since between 1968 and 1982 there were already 10 to 15 newly established fellowships in geriatrics throughout the U.S., with about 50 trainees per year.
The opportunity to develop a medical school curriculum for an obligatory clinical clerkship of 4 weeks in geriatrics for every medical student in their senior year was unusual and stimulating.
Though granted the 4 weeks by the Dean, T. Chalmers, we (Robert N. Butler and myself) still met great resistance from the curriculum committee, whose chairman was actively resistant to the presence of geriatrics and its taking from the pie the time and money from various training programs.
Of special note was our choice of having each student spend 2 of the 4 weeks at the Jewish Home and Hospital, the teaching nursing home partner for the new department of geriatrics. During the initial years, more than 100 students per year experienced this geriatric medicine curriculum. The students surveyed rated this experience very highly in a study initiated by the President of the Medical Center. In all, more than 2300 students have had obligatory training in geriatrics at the medical school, with the majority experiencing a significant portion of this training at the nursing home (2,5,7,8).
References
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