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

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professional organizations of the groups surveyed. Following each survey listed below, the name of the organization with which we consulted is given: • Survey of Program Directors of Family Practice Residency Programs - Society of Teachers of Family Medicine (STFM) and Association of Family Practice Residency Directors (AFPRD) • Survey of Directors of Geriatric Academic Programs - Association of Directors of Geriatric Academic Programs (ADGAP) • Survey of Allopathic and Osteopathic Geriatric Medicine Fellowship Programs - Association of Directors of Geriatric Academic Programs (ADGAP) • Survey of Accredited Geriatric Psychiatry Fellowship Programs - American Association for Geriatric Psychiatry (AAGP) • Survey of General Internal Medicine Residency Programs - Society of General Internal Medicine (SGIM) 18
3 Historical Development of Geriatric Medicine Training and Practice in the United States Background The United States is facing a crisis in physician expertise to care for its aging population. With the number of elderly increasing from 3.1 million in the 1900s to 70 million by 2030, training health professionals in geriatric care is vital to ensure that older persons receive high quality medical care. Over the last 25 years progress has been made in developing medical education, research, and clinical programs in geriatric medicine (Figure 3.1). The history of geriatric medicine prior to 1975 in Great Britain and the U.S. has been described (Libow, 1990). Early work by Ignatz Leo Nascher in the U.S. and several pioneering British geriatricians, led by Marjorie Warren, established the foundations for modern geriatric medicine. Dr. Nascher chose the term “geriatrics” as a name parallel to “pediatrics.” Dr. Warren established a Department for the Aged in London’s West Middlesex Hospital in 1935. These pioneers recognized that illness can present and evolve differently in the very old and that new approaches to care and treatment were required. E.V. Cowdry edited the proceedings of an early U.S. conference on the problems of aging. This book, Problems of Ageing; biological and medical aspects, was published with funding from the Josiah Macy, Jr. Foundation in 1939. It significantly increased academic interest in gerontology and geriatrics (Cowdry, 1939). After the Second World War, the British established geriatric medicine as a component of its new National Health Service (NHS). The NHS founders established several geriatric specialist positions at major teaching hospitals, and these leaders wrote the early textbooks for geriatric medicine (Cassel, 1995). In 1941, Nathan Wetherell Shock, PhD, became the first chief of the newly formed Unit on Gerontology of the Division of Physiology of the five-year-old National Institute of Health. He later built the Gerontology Research Center of the National Institute on Aging and was the catalyst for the emergence of aging research in the United States. Dr. Shock insisted that aging was not a disease and focused research on two questions: “What are the underlying biological factors that produce what we perceive as aging” and “What are the mechanisms that produce impaired performance with age” In the late 1950s, he and his colleagues began the Baltimore Longitudinal Study of Aging (www.nih.nia.gov). The American Geriatrics Society was founded in New York City in 1942 when a group of physicians interested in advancing medical care for older adults met with the intention of forming a specialty society dedicated to geriatric medicine. Among those physicians were Leo Nascher, Dr. Malford W. Thewlis who was named the first executive secretary, and Dr. Lucien Stark, who became the first AGS president (www.americangeriatrics.org). Some universities established gerontology programs beginning in the 1950s, but medical school interest in geriatric medicine was quite limited well into the 1980s. This slow development occurred despite the landmark passage of the Medicare and Medicaid Acts in 1965. By the mid-1970s British geriatricians had identified and begun to address the challenging clinical syndromes unique to old age, e.g., multiple interrelated diagnoses, adverse events associated with medications, injuries from falls, delirium and dementia, and urinary incontinence. A commitment of resources to develop the new discipline’s scientific basis was now needed. In the U.S., Robert Butler published Why survive Being old in America (Butler, 1975) and this led a successful effort during 1974 - 1976 to establish the National Institutes of Health’s (NIH) National Institute on Aging (NIA). This critical event gained the attention of the American academic medical community. NIA’s small earlier annual budgets rapidly grew as an intramural program in Baltimore and extensive extramural programs were developed elsewhere. By the early 1990s NIA’s annual budget exceeded $300 million and it has more than doubled over the past decade (Table 3.1). Veterans Health Administration The number of veterans over age 65 was projected to increase from 3 million in 1980 to 9 million in 2000. The Veterans Health Administration (VHA) began funding the training of geriatric medicine fellows in 1980, and over the next decade trained 275 geriatricians. The VHA remains the most important source of training funds for geriatricians in the U.S. The Geriatric Research, Education and Clinical Centers (GRECC) program was another of the VHA’s responses to the growing challenge of caring for the elderly. The goals of the GRECC program are to advance scientific knowledge regarding medical, psychological and social needs of older veterans, to develop improved and innovative models to provide clinical services for them, and to advance the quality of education in geriatrics and gerontology throughout the VHA health care system. The GRECCs are affiliated with accredited medical schools that provide education in geriatrics for medical residents, nurses, and allied health care students. The first GRECC was organized in 1975. Between 1975 and 1980, GRECCs were established at 8 VHA medical 19
Page 1 and 2: The Association of Directors of Ger
Page 3 and 4: The Association of Directors of Ger
Page 5 and 6: National Oversight Panel M. Brownel
Page 7 and 8: The American Geriatrics Society . .
Page 9 and 10: List of Tables and Figures Chapter
Page 11 and 12: Figure 7.4 Figure 7.5 Figure 7.6 Fi
Page 13 and 14: the fastest acceleration in 12 year
Page 15 and 16: esidency review committee provide a
Page 17 and 18: Project Methodology National Oversi
Page 19: Table 2.2 Secondary Data and their
Page 23 and 24: $195.9 million NIA extramural suppo
Page 25 and 26: important political decision by the
Page 27 and 28: 4 The Practice Of Geriatric Medicin
Page 29 and 30: participants. Geriatricians have be
Page 31 and 32: Table 4.8 Medicaid Recipients and P
Page 33 and 34: Figure 4.1 Distribution of Certifie
Page 35 and 36: Figure 4.3 Geriatric Caseload for P
Page 37 and 38: Table 4.19 Total Annual Compensatio
Page 39 and 40: panel felt were most important for
Page 41 and 42: 5 Academic Geriatrics Programs in U
Page 43 and 44: Table 5.1 Academic Geriatric Progra
Page 45 and 46: Table 5.1 Academic Geriatric Progra
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Page 49 and 50: Table 5.4 Women and Minority Facult
Page 51 and 52: Figure 5.6 Physician Faculty Vacanc
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Page 55 and 56: Table 5.9 Allopathic Medical School
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Page 59 and 60: Table 5.12 Allocation of Faculty an
Page 61 and 62: Table 6.1 Geriatric Medicine and Ge
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Page 65 and 66: investigators receive $60,000 of su
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Fellowship Training Activities for
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Table 6.16 Fellowship-Trained Geria
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7 Preparing All Physicians To Care
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General Internal Medicine The 1999
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Trends in GIM Residency Programs Re
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Nursing homes and home care experie
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Geriatric Education Retreats (GERs)
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and GIM programs a mean of 2.8 avai
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chapter. The goals of these student
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This program awarded 20 two-year, $
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Conclusion This report summarizes r
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Bureau of Health Professions, HRSA,
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U.S. Centers for Medicare & Medicai
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APPENDIX A. Research Focus of Curre
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APPENDIX C. RESEARCH FOCUS OF NATIO
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APPENDIX E. SELECTED GERIATRIC MEDI
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Appendix F. Geriatric Medicine and
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Helen Hoenig, M.D., M.P.H., Duke Un
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APPENDIX H. RESIDENCY REVIEW COMMIT
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Appendix H. Residency Review Commit
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Association of Directors of Geriatr
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