| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
| ||||||||||||||||||||||
COMMENTARY |
University of Medicine and Dentistry of New Jersey, the New Jersey Medical School, and Division of Geriatrics, Hackensack University Medical Center.
Address correspondence to Knight Steel, MD, Division of Geriatrics, Hackensack University Medical Center, 30 Prospect Ave., Hackensack, NJ 07601. E-mail: csheldon{at}humed.com
In response to Dr. Morley's "A Brief History of Geriatrics" (1), I have written my own personal viewpoint of the development of geriatrics in the United States.
Shortly after arriving in Boston in the fall of 1977, I was a guest at a reception peopled by large numbers of faculty from the medical schools in town. One individual came over to me and asked what I did in Boston. When I responded, "I am interested in geriatrics," he looked puzzled and then said, "Jerry who?" Clearly, the field of geriatric medicine needed more vitality and more visibility.
At that time, geriatricians-to-be faced daunting hurdles. Where did geriatrics belong within the profession of medicine? A rapidly enlarging science base and advances in technology were causing internal medicine to splinter into ever more powerful subspecialties. In striking contrast, geriatrics was concerned with all organ systems. But, these were already the property of the organ-specific subspecialties of internal medicine such as cardiology and nephrology or alien specialties such as neurology and psychiatry. The medical establishment did not believe geriatrics was a specialty or a subspecialty.
On the other hand, generalists not infrequently espoused the view that they had been caring for elders for years and, therefore, did not endorse the development of a splinter group, geriatricians. Furthermore, at this time, many general internists saw themselves as being in competition with family practitioners, who were gaining prominence as primary care providers.
Yet, it was apparent that, without formal recognition by the American Board of Medical Specialties, geriatrics would forever be a poor relative within the medical establishment. The opportunity to change the world came in 1988 when the first geriatric examination was administered jointly by the American Board of Internal Medicine (ABIM) and the American Board of Family Practice (ABFP) to 4282 individuals. This was an extraordinary event in so many ways.
The field of geriatrics was determined to be neither a subspecialty nor fully within the domain of general medicine. It was judged to be "an area of added competence," a phrase newly coined for the occasion. Also of note, this was the first time the ABIM and the ABFP collaborated on the design of an examination. A meeting at what was then National Airport outside Washington, D.C., attended by Dr. John Benson (President, ABIM) and Dr. Nicholas Pisacano (President, ABFP) and a few others of us, formalized this truly dramatic understanding. The examination proved to be a success with studies of the answers of the candidates demonstrating that it appeared "to measure something different from that which was measured by both general certifying examinations." Analyses of the scores also failed to support the prevailing belief that simply by taking care of large numbers of elders, physicians became knowledgeable about geriatric medicine (2).
It was apparent to most any observer in the 1970s and early 1980s that geriatrics had little to say even if someone would listen! The Annual Meetings of the American Geriatrics Society attracted only a few hundred people. The presentations generally were unexciting by comparison with those that could be found at comparable meetings. To remedy this, for a number of years, a 1-day meeting with invited speakers was arranged to take place at the same location on the day just prior to the annual meeting with the intent of attracting scholarly presentations and simulating interest in the membership.
Change was mandatory. During the late 1970s and 1980s, the Journal of the American Geriatrics Society tapped some of the giants in the medical profession, including Paul Beeson, Gene Stollerman, and David Soloman, to edit its pages. I must confess that some of us interested in developing geriatric medicine could be heard to brag about our "new" journal and its editor-in-chief when questioned by "outsiders" about the field!
In 1983, the Board of the American Geriatrics Society recruited Linda Hiddemen Barondess to be the Executive Vice President. Her tenure has been characterized by a transformation of the society. This professional society now has about 6000 members and attracts about 2000 participants to its annual meeting. It offers a Geriatric Review Syllabus for those who wish to sit the certifying examination, and a pocket manual, Geriatrics at your Fingertips, for students at all levels. Her efforts led to the establishment of the Foundation for Health in Aging, directed to the questions and the needs of all of us who hope to grow old with the highest quality of life (www.healthinaging.org).
No history of geriatric medicine would be complete without reflecting on the contribution made by T. Franklin Williams to its very being. It was my incredibly good fortune to meet him during my residency in Chapel Hill. He served as my attending there before moving to Rochester, New York, to become the Medical Director of the Monroe County Hospital, a 1000-bed multilevel facility situated on a huge piece of land on the Erie Canal. This hospital, constructed in the 1930s, was deemed so lacking in noteworthiness that it was not even noted on some of the real estate maps of the city when I moved up to join him in 1972. Within a few years after his arrival, the "MoCH," as it came to be known, became central to the teaching program of the University of Rochester School of Medicine. Perhaps more importantly, it became a model for care in sites other than the traditional ones—the acute care hospital and the ambulatory setting. Today, geriatricians have become spokespersons for the principle that care must be person specific and not site specific (3).
Geriatric medicine as practiced in the United States was birthed about a quarter of a century ago. It is just a toddler today. But, like all toddlers, geriatrics is beginning to influence its "parents." A whole series of issues have come to be recognized as essential to medical care. Falls, delirium, incontinence, and, of course, polypharmacy are recognized for their importance even by physicians outside our area of interest. "Function" no longer refers only to organ-specific function, but has come to mean activities of daily living and instrumental activities of daily living to increasing numbers of physicians.
In the future, standardized assessments of elders, such as those developed by InterRAI (www.interrai.org), will be merged with data that flows from ever-more-sophisticated laboratory and radiologic studies. Individual care plans will be based on such a comprehensive assessment, and grouped data will permit an assessment of outcomes as well as policy development. As geriatrics addresses the needs of an aging world, it will lead the profession in the provision of elegant care—care that allows all of us to maximize function and quality of life for the longest period of time.
References
| ||||||||||||||||||||||
| HOME | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|---|
