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

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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
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