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

The number of fellowship programs and the number of fellows
have slowly increased over the past decade. In 2001, there were 119
allopathic and 7 osteopathic geriatric medicine programs, and 62
geriatric psychiatry programs in the U.S. Approximately 330 geriatric
medicine and 86 geriatric psychiatry fellows were participating in
those programs. Nonetheless only 73% of first-year positions in
geriatric medicine and 63% of those in geriatric psychiatry were filled
for academic year (AY) 2001-2002. Forty percent of the trainees are
graduates of U.S. medical schools.
Results of surveys conducted in 2001, for this report, to gather
information about AY 2001-2002 fellowships, revealed considerable
variation among programs. Most were small, with only 15 medicine
programs reporting having more than four first-year fellows. The
median number of geriatric psychiatry first-year fellows was two per
program. Only 51 medicine and 10 psychiatry programs reported
offering training beyond the one-year required clinical experience.
Only 5 medicine programs had more than two second-year trainees,
and there were only two second-year geriatric psychiatrists in
training. Finally, 58 geriatric medicine (60%) and 29 geriatric
psychiatry (62%) programs had either none or only one U.S. medical
school graduate first-year fellow.
As previously stated, the VHA is the major source of financial
support for first-year geriatric medicine and psychiatry fellows. In
academic year 2000-2001, the VA funded 197 first-year geriatric
medicine and geriatric psychiatry fellow slots. Funding for first-year
geriatric fellows also comes from Medicare’s graduate medical
education reimbursement program. Other sources of support include
the Bureau of Health Professions (BHPr), clinical revenue generated
by faculty, medical school funds, other state or federal revenue,
foundation grants and individual donors. Funding for advanced
training—beyond one year—for clinician-educators is very limited,
although there are numerous NIH, VHA, and private foundationsupported
research training programs. In the University of Rochester’s
2001 survey of graduates of geriatric medicine fellowship programs
during the past decade, respondents were asked to indicate the most
influential factors in their decision to choose a career in
geriatric medicine. The most frequent response (42%) was “societal
need for more physicians to care for the elderly.” Over half of
respondents had made their career choice during residency training,
and 27% had made the decision before beginning medical school.
Almost half (48%) stated that a role model or mentor had influenced
their choice.
Several factors may account for the relatively small number of
applicants to geriatrics fellowship programs and the recruitment of
only small numbers of U.S. medical school graduates. One factor is
that physician interest in primary care is correlated with interest in
geriatrics, and the increased interest in primary care that began in the
late 90s is now weakening. Another significant influence in medical
students’ career choices is debt. More than 80% of U.S. medical
school graduates are indebted upon graduation; the average debt
is just shy of $100,000. A further disincentive is that the income of
both academic and non-academic primary care physicians and
geriatricians remains relatively low compared to that of procedureoriented
disciplines.
The recruitment of high-quality U.S. medical school graduates
into geriatric fellowship programs remains a challenge for the
discipline. The retention of first-year fellows for additional years of
academic training has been low. In the future, incentives will be
needed to attract the best graduates of U.S. family practice, internal
medicine, and psychiatry residency programs to academic careers in
geriatric medicine. Loan forgiveness programs (such as that recently
started by the NIH for research-oriented physicians) and/or integrated
five-year “research fellowship and junior faculty” awards could
alleviate the current financial disincentives facing young physicians
considering careers in academic geriatrics.
Preparing all Physicians to
Care for the Aged: Graduate
Medical Education
In 1999, 9,780 physicians graduated from family practice and internal
medicine residency programs, but only 321 subsequently entered
geriatric medicine fellowships. Also in 1999, 1,056 trainees graduated
from psychiatry residencies, with only 86 enrolling in geriatric
psychiatry fellowships. During the same year an additional 14,176
physicians graduated from other residency and fellowship programs
(excluding pediatrics) whose specialties do not offer subsequent
fellowships in geriatric medicine. Thus, formal geriatric medicine
training for virtually all physicians ends with their residency training.
This emphasizes the urgent need to increase geriatric medicine
training in residency programs.
The future practices of U.S. physicians will necessarily involve
providing care to increasing numbers of older adults. Twenty-one
percent of family physicians’ practices in 1999 consisted of
ambulatory visits from adults age 65 and over. It is projected that by
2020 at least 30% of family physicians’ outpatient practices, 60% of
their hospital practices, and 95% of their nursing home and home
care practices will involve individuals age 65 and older. In 1999
thirty-nine percent of general internists’ practices comprised
ambulatory visits from adults age 65 and over. These percentages are
also expected to increase considerably by 2020.
We conducted separate surveys of General Internal Medicine
(GIM) and Family Practice (FP) Residency Programs as part of our
project. We found that 93% of GIM and 92% of FP responding
programs had geriatrics curricula. These results indicate increases in
training, compared to 36% of GIM and 80% of FP programs that
reported, in a 1998 study, having geriatrics curricula. Our survey data
suggests that although the number of physician faculty available to
teach geriatric medicine in FP residency programs has not changed
significantly over the past 13 years, the number in GIM programs has
increased. The most frequently cited barrier to improving geriatric
medicine training was over-crowded curriculum demands placed on
residency programs.
As with internists and family physicians, the number of
psychiatrists with certification in geriatric medicine is small, and
recruitment into fellowship programs is weak. Thus, general
psychiatrists without advanced training in geriatric mental health will
continue to provide the majority of psychiatric care to older adults.
The psychiatry training requirements developed by the psychiatry
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