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

important political decision by the American Boards of Internal
Medicine and Family Practice (ABIM and ABFP). In 1987, with
considerable opposition from many of their sister organizations, the
ABIM and ABFP requested permission from the American Board of
Medical Specialties (ABMS) to jointly develop a Certificate of Added
Qualifications (CAQ) in Geriatric Medicine.
The CAQ would certify and recognize academic and practicing
geriatricians, but stopped short of developing a new specialty board.
Under this arrangement board certified internists and family
physicians would need to maintain their primary board certification
to be eligible for the geriatrics CAQ. This innovative agreement
by the ABIM and ABFP resulted in formal certification of geriatric
medicine training programs by the ACGME. In 1988, the first jointly
sponsored (ABIM/ABFP) geriatric medicine certifying examination
was administered. The ABIM and the ABFP report that since 1988
more than 9,900 family physicians and internists have obtained CAQs
in geriatric medicine. The 1988, 1990, 1992, and 1994 examinations
were open to practicing physicians without fellowship training.
Subsequently, entry to the examination required completion of an
accredited geriatric medicine fellowship.
The American Board of Psychiatry and Neurology (ABPN) offered
the first certifying examination for a CAQ in geriatric psychiatry in
1991. There have been over 2,500 certificates in geriatric psychiatry
awarded. The American Board of Osteopathic Family Practice (ABOFP)
and the American Board of Osteopathic Internal Medicine (ABOIM)
began certification in geriatrics in 1991. Currently, 503 certificates in
osteopathic geriatric medicine have been earned.
Centers of Excellence
As the training and certification of geriatricians were gaining
credibility, the IOM sponsored a second study as a follow-up to the
Beeson report. This 1987 paper by the IOM Committee on Leadership
for Academic Geriatric Medicine (IOM 1987) documented slow
progress toward implementing the educational objectives outlined in
the earlier report. Medical student and resident geriatrics education
was still voluntary in most medical schools.
In the mid-1980s fewer than 100 physicians
completed geriatric medicine fellowships each
year. The 1987 IOM report promoted a Center of
Excellence (CoE) strategy, designed to create
critical levels of faculty and other resources at
selected medical schools. These academic
training centers were to produce the needed
number of geriatric medicine faculty for all
medical schools. The CoE program had three
central goals: 1) to develop training programs that
would attract learners and produce future faculty,
2) to implement research programs that would
add to the discipline’s knowledge base and
provide research training, and 3) to provide
clinical training in a variety of settings. The model
was partially based on the VHA’s GRECCs.
However, as the IOM report pointed out, the
GRECCs’ mission did not include training and
placing academic faculty. The CoE strategy was to
expand on the GRECCs’ mission in this regard.
70,000
60,000
50,000
40,000
30,000
20,000
10,000
Source: NIA Budget Office, 2002
0
With funding from the John A. Hartford Foundation of New York
City, the CoE strategy was implemented. In 1988, the Foundation
initiated its first CoE program, the Academic Geriatrics Recruitment
Initiative, to address the critical shortage of geriatric faculty members
in American medical schools. The program’s purpose was to enhance
and increase academic geriatric programs and training, with the goal
of increasing the nation’s capacity to provide effective and affordable
care to its rapidly growing elderly population. This project yielded
positive results, including producing many scientists, teachers, and
clinicians knowledgeable in geriatrics and a higher level of recognition
and appreciation for the discipline throughout medical centers,
universities, and affiliated clinical service settings. In 1997, the
Foundation’s trustees renewed and expanded the previous CoE
concept by increasing the geographic range of funded CoE and
expanding training capacity, particularly in dealing with the country’s
increasingly diverse elders. By identifying and funding CoE nationwide,
more institutional attention will be brought to the field, and faculty will
be able to become the leaders the field needs (See Appendix B for list
of CoE). The American Federation for Aging Research (AFAR) serves as
the CoE coordinating center, and its activities include systematization
within seven previously funded and 11 new CoE, as well as the seven
CoE Designation Award sites.
Pepper Centers
The CoE program was enhanced in 1991 when Congress gave the NIA
additional dollars to establish aging research and education centers
across the country (www.nia.nih.gov). These centers are named for
Claude Denison Pepper (1900-1989), a Florida congressman known
nationwide for advocacy for older adults’ rights. The centers’ primary
goal reflects his interest in helping older Americans maintain their
independence as long as possible. The research conducted by the
Pepper Older Americans Independence Centers supports this goal
by developing ways to delay or even prevent chronic diseases that
disable so many older people and cause them to become dependent
on others.
Figure 3.2 National Institute on Aging Funding History of Older Americans Independence
Centers (Pepper Centers) and Alzheimer's Disease Centers (ADC) (thousands of dollars)
Number of
ADCs
Number of
Pepper Centers
ADC
Pepper
10,831
8,571
13,860
3,627
9,361
20,111
21,991
46,247
44,373
38,969
44,873
33,941 34,650 35,664
41,199
37,102
34,580 35,005
12,732 13,074
11,395 11,114
7,480
3,860
9,404 10,668 11,436
12,868
6,234
1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
5 10 10 12 12 15 20 28 28 28 28 27 27 27 27 28 30 29
-- -- -- -- -- -- -- 3 5 6 8 10 11 10 10 10 10 9
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