Geriatric Medicine Training and Practice in the United States at the ...

the fastest acceleration in 12 years. This spending represented 13.2%
of the U.S. gross domestic product. From 1999 to 2000, Medicare
spending alone rose 5.6% to $224.4 billion. Also during this period,
nursing home and home health care total expenditures rose, after
several years of stable rates.
Medicare reimbursement is the single most influential force
shaping medical practice in the U.S., accounting for 26.7% of all
physician income in 2000. Geriatricians limit their clinical practices to
older adults, and thus receive the vast majority of their compensation
from Medicare. Many of the time-intensive services geriatricians
provide to older adults and their families are not adequately
reimbursed. The growing gap between Medicare reimbursement
and the actual costs of delivering medical care seriously affects
the willingness of young physicians to consider careers in geriatric
medicine.
Currently the national average number of geriatricians is 5.5
per 10,000 persons over age 75. Individual state rates range from
2.2-15.9. There are 1.4 geriatric psychiatrists per 10,000 persons
over age 75, with individual state rates ranging from 0.2-4.1. The
number of Certificates of Added Qualifications awarded from 1988
through 2001 includes: 9,907 awarded by the American Board of
Internal Medicine (ABIM) and the American Board of Family Practice
(ABFP), 2,508 by the American Board of Psychiatry and Neurology, and
503 by the American Osteopathic Boards of Internal Medicine and
Family Practice.
Geriatric medicine and psychiatry certificates of added
qualifications are valid for ten years, with re-certification required.
The number of physicians seeking re-certification has been low. It is
estimated that from 1998 through 2004 there will be a 34% reduction
(from 9,256 to 6,137) of ABIM/ABFP-certified geriatricians in the U.S.
Academic Geriatrics Programs
in U. S. Allopathic and
Osteopathic Medical Schools
The growth of geriatric medicine has been and will continue to be
largely dependent on the successful establishment of academic
geriatric medicine programs in U.S. allopathic and osteopathic medical
schools. In the spring of 2001 we conducted a cross-sectional study
that assessed the current status of U.S. academic geriatric medicine
in these schools. Geriatric academic leaders at each of the 144
medical schools were surveyed. Identifiable academic geriatric units
were present in 95 and 10 of the 121 responding allopathic and
osteopathic medical schools, respectively. The most common
academic unit was a division within a department, which existed at
two-thirds of the schools that had identifiable programs. The mean
number of physician faculty was 7.5 FTEs (median 5.0; range 0-42).
Fifty percent of the programs had six or fewer physician faculty, while
8% had more than 18. Fifty-eight percent of the programs had
budgets of one million dollars or less.
There was considerable variability in how each program set
priorities. Allopathic schools tended to devote a higher percentage of
their resources to research, scholarship, and residency and fellowship
training than the osteopathic schools. Osteopathic schools placed
more emphasis on medical student education than allopathic schools.
Both types of programs allocated, on average, 37% of their faculty
and staff effort to geriatric medicine clinical practice. More than 60%
of the program directors cited a lack of sufficient research faculty
and trainees, poor reimbursement for clinical care, and a lack of
institutional financial support as “significant” obstacles to program
development.
It was remarkable that we could identify a leader/contact person
for geriatric medicine at each of the medical schools. Even though
there are currently only six departments of geriatric medicine (Mt.
Sinai School of Medicine, University of Arkansas, University of
Oklahoma, Philadelphia College of Osteopathic Medicine, Western
University of Health Science, and Ohio University College of
Osteopathic Medicine), one-third of the respondents in our survey
stated that they reported directly to their deans. This typically created
access to new financial support and continued interdepartmental
influence.
There is a need to develop medical school geriatrics programs of
the size and scope of other academic disciplines. Although many
medical schools now have credible academic programs with enough
faculty and resources to implement solid clinical, education and
research activities, others lag far behind in the program development
required to ensure the adequate training of future physicians to care
for the elderly. New strategies are needed to nurture these smaller
geriatric medicine programs. In addition to program development
there is a continuing need for new resource investment to train faculty
for roles as teachers and researchers.
Although much has been accomplished in the area of geriatric
medicine program development, there are many challenges ahead.
These challenges are significant and complex, as discussed in
Chapter 5 of this report.
Geriatric Medicine and
Geriatric Psychiatry
Fellowship Programs
The Administration on Aging (AOA) and the VHA began funding
geriatric medicine and psychiatry fellowship positions in the late
1970s. Initially the American Boards of Family Practice (ABFP) and
Internal Medicine (ABIM) required two years of fellowship training in
an ACGME-approved program for candidates to be eligible to sit for
the CAQ examination. In 1995, both Boards changed the entry
requirement from two to one year of training. The first exam for
fellows having one year of training was given in 1998.
The American Board of Psychiatry and Neurology (ABPN) began
certifying geriatric psychiatrists in 1991, requiring one year of
fellowship training for entry to the exam. In addition, since 1991 the
American Osteopathic Boards of Family Practice and Internal Medicine
(ABOFP and AOBIM) have both offered a geriatric medicine certifying
examination for graduates of osteopathic fellowships. Osteopathic
fellowship programs require two years of training. Each certifying
Board initially offered a practice pathway, permitting practicing
physicians without fellowship training to sit for the exam. The
ABFP/ABIM closed this option in 1994, the ABPN in 1996, the AOBIM
in 1994, and the ABOFP in March 2002.
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