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

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Figure 5.4 Geriatric Programs' Annual Budget for AY 2000-2001 (n=109) % Schools 35 30 25 20 15 10 5 0 25.7 32.1 Source: IHPHSR ADGAP Database Project, 2001 1-2 >2-5 >5 Millions of Dollars faculty and fellows. In fact, 71% of the respondents reported that the lack of senior research faculty was a significant obstacle to achieving their program goals. Although research career development funding is available through the NIH and the VHA, attracting and retaining future research faculty remains a significant challenge for the discipline. DGAPs reported concern about the impact of poor reimbursement for clinical activity. Medicare is the primary payer for most clinical services provided by geriatricians (see Chapter 4). In addition to relatively low clinical reimbursement levels, teaching physicians are further burdened by Medicare’s Teaching and Supervision guidelines. The Center for Medicare and Medicaid Services (CMS) rules for compensating physicians who teach and supervise medical students 12.8 18.3 Figure 5.5 Geriatric Programs' Reserve Dollars (n=112) % Schools 100 80 60 40 20 0 82.1 0.5-2.5 >2.5 Millions of Dollars 11.0 and residents require the physicians to be present during a “key portion” of a procedure and require detailed documentation in the medical record. These documentation rules are particularly challenging in the non-hospital care settings such as home and nursing home settings. Another obstacle noted frequently by the DGAPs was the lack of institutional financial support for growth of their program. It is widely recognized that geriatric medicine and other primary care disciplines are seldom the priority at academic medical centers, particularly in comparison to the clinical and research programs of cancer and cardiovascular medicine (Hazzard, 1991). Nonetheless, at several successful geriatric medicine CoE, the programs had grown to the size and strength necessary to compete effectively for institutional resources. Also, the recent Reynolds Education Center grants required a 50% institutional match on the $2,000,000 award. A number of medical schools that had previously demonstrated limited financial commitment to geriatrics achieved the required matching commitments. These events suggest that leaders of academic medical centers are aware of the importance of geriatric medicine, but they have numerous competing priorities. When a DGAP can bring new funds to the medical center for research or education, some deans will respond with significant matching support. Analysis of the DGAPs’ allocation of faculty and staff time suggests that patterns of emphasis vary among academic geriatric medicine programs. For the most part the programs are choosing one or two priority areas for their academic missions. It appears that in many medical schools the resources simply do not exist to put together a comprehensive approach. Among allopathic schools, medical student education was a low priority as compared to osteopathic schools. This may be due to the difficulty in gaining access to curriculum time combined with the high cost and limited institutional support for medical student teaching. A strong emphasis on residency training is also not common in allopathic or osteopathic schools. The new Hartford/AAMC and Reynolds Foundation grant programs will encourage many academic geriatric programs to direct more effort to medical student and resident education (see Chapters 7 and 8). The evolution of academic geriatric medicine in the United States has been pluralistic. The intellectual and clinical content of geriatric medicine overlap with that of other primary care and subspecialty practice. Geriatric medicine has been described as the first “supraspecialty” that can most successfully develop in collaboration with most other medical disciplines (Hazzard, 2000). This unique position of geriatric medicine results in serious challenges for the successful development of geriatric medicine academic programs at U.S. allopathic and osteopathic medical schools. Medical schools are, for the most part, highly traditional and slow to incorporate change. They are organized around discipline-specific departments, with department leaders holding most of the power, control, and the responsibility for negotiating resources from the dean. More narrowly defined departmental divisions have gained some influence, depending on their ability to generate research and/or clinical income. During the past 15 years, some medical schools have recognized the limitations of this “silo” organizational structure and 48
Figure 5.6 Physician Faculty Vacancy Rates (n=115) % Schools 50 40 30 20 10 0 47.8 0 27.0 14.8 have developed successful examples of interdisciplinary clinical, research, and, occasionally, education programs. Many DGAPs were new to their positions. To address the administrative training of the younger DGAPS, a new leadership development program has been established. This 3-year initiative is administered by ADGAP and funded by the John A. Hartford Foundation. The program supports leadership training for competitively-selected DGAPs with 6 years or less of experience in their current positions. Up to six DGAPs will be selected each year and will be funded to participate in formal 4.3 leadership training courses and work with senior mentors on their campuses, as well as with national leaders in geriatric medicine. Six Leadership Scholars were chosen in 2001 and another 5 in 2002. Our survey suggests that new strategies are needed to nurture smaller geriatric medicine programs that do not have the resources to recruit new faculty from CoE. The John A. Hartford Foundation recently announced a small grant award program to provide a “leg-up” to these emerging programs. This new program, “Developing a New Generation of Academic Programs in Geriatrics” is administered by ADGAP. These two-year, $100,000/year awards will enable academic health centers that have already made substantial commitments to geriatrics to further 2.6 2.6 0.9 0.1-1 1.1-2 2.1-3 3.1-4 4.1-5 >5 Physician Vacancies Median 0.5 positions, Range 0-7 positions Source: IHPHSR ADGAP Database Project, 2001 strengthen their programs. It is expected that these grants will help position more medical schools to be competitive for Centers of Excellence or Reynolds Education Center grants. The first awards from this program were made in the winter of 2002. A number of mechanisms exist through the NIA (see Chapter 6), VHA, and the private sector to support the career development of clinician-researchers from instructors to the independent investigator level. Similar career support mechanisms are rare for clinician-educators. The new Reynolds Foundation Geriatric Education Program is expected to provide $60,000,000 for geriatric medicine education centers to 30 medical schools over the next 10 years (the first ten centers were established in July 2001). This program and efforts by the Bureau of Health Professions and the John A. Hartford Foundation through the AAMC medical student curriculum initiative will support the demand for new clinician-educator faculty (AAMC & John A. Hartford Foundation, 2000). Although it has been stated that academic geriatric medicine programs will develop most effectively in environments that encourage cooperation among medical disciplines, other health disciplines, and social scientists (Hazzard, 2000), the optimal organizational structure for geriatric programs remains unclear. Our study revealed the variety of approaches medical schools are utilizing, and it is too early to declare a “best” approach. In this context, it has been a struggle for academic geriatric medicine programs to take root in many U.S. medical schools. Efforts have been assisted by generous support from the federal government, some state governments, and the private sector (Reuben, 1994). In summary, public and private investment in the development of academic geriatric medicine has been substantial over the past 25 years. Our survey of the DGAPs, when combined with other data on academic geriatrics, provides a comprehensive picture of the remarkable progress academic geriatrics has made in the past 25 years and sets a benchmark for measuring further development during the next decade. Many medical schools now have credible Table 5.6 Sources of Geriatric Programs Revenues for AY 2000-2001 (Percent) Category Allopathic Osteopathic All Schools Schools Schools (n=99) (n=16) (n=115) College of Medicinerequired geriatrics support 10.5 23.8 12.3 College of Medicinediscretionary geriatrics support 8.1 34.0 11.7 Direct Hospital Support 9.6 3.6 8.8 Income from Endowments 5.1 0.0 4.4 Clinical Practice 25.7 33.1 26.8 Veterans Health Administration 13.1 0.0 11.3 Research Grants and Contracts, direct and indirect 17.4 2.2 15.2 Educational Grants and Contracts, direct and indirect 9.1 3.4 8.4 Other 0.4 0.0 0.4 Source: IHPHSR ADGAP Database Project, 2001 49
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
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Page 15 and 16: esidency review committee provide a
Page 17 and 18: Project Methodology National Oversi
Page 19 and 20: Table 2.2 Secondary Data and their
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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
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Page 41 and 42: 5 Academic Geriatrics Programs in U
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Page 57 and 58: Table 5.11 Allocation of Faculty an
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
Page 67 and 68: Table 6.7 Program Directors Reporte
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Page 73 and 74: Table 6.16 Fellowship-Trained Geria
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Page 77 and 78: General Internal Medicine The 1999
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Page 87 and 88: chapter. The goals of these student
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Page 91 and 92: Conclusion This report summarizes r
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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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