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

6
Geriatric Medicine and Geriatric Psychiatry
Fellowship Programs
Background
Training for geriatric medicine fellows began in the U.S. in the early
1970s. A few pioneers organized training programs in long-term care
facilities and hospitals. A 1972 informal AGS survey identified that
there were 6 programs (Libow, 1972). The Administration on Aging
and the VHA began funding geriatric medicine and psychiatry
fellowship positions in the late 1970s, and geriatric fellowship
program growth was significant in the early 1980s with an increase
from 36 programs in 1980 to 93 in 1986 (IOM, 1987). A 1986-87
survey of geriatric medicine and psychiatry programs found that they
were small, and most of the fellows were in their first year of training
(IOM, 1987).
On April 20, 1988 the American Boards of Family Practice (ABFP)
and Internal Medicine (ABIM) administered the first certification
examination in geriatric medicine (ABFP/ABIM) (Cassel, 1987). The
examinations in 1988, 1990, 1992 and 1994 also were open to
practice pathway candidates. The ABFP and the ABIM initially required
two years of fellowship training in an ACGME-approved program for
non-practice pathway entry to the examination. In 1995, after an
extensive debate within their disciplines, the Boards changed the
entry requirements from two years to one year of fellowship training.
Fellows with one year of training could sit for the certification exam
beginning in 1998 (Hazzard, Currin, & Woolard, 2000).
The American Board of Psychiatry and Neurology (ABPN) began
certifying geriatric psychiatrists in 1991, requiring one year of
fellowship training for entry to the examination. A practice pathway
was also available through 1996. Since 1991 the American Boards
of Osteopathic Family Physicians and Osteopathic Internal Medicine
(ABOFP/AOBIM) have both offered a geriatric medicine certifying
examination for graduates of osteopathic fellowship programs. The
exams were initially offered conjointly, similar to the ABFP/ABIM
approach, but since 1995 each Board has conducted separate
examinations. The AOBIM closed the practice pathway option in
1994, and the ABOFP practice pathway closed in March 2002.
In 1987, geriatric medicine fellows were surveyed to determine
their career choice satisfaction (Siu & Beck, 1990). Fellows involved in
teaching and having a medical school appointment had high levels of
satisfaction. However, reports by the Institute of Medicine (IOM) and
Bureau of Health Professions (BHPr) showed that in the early 1990s
fellowship program growth was slow and there were a limited number
of qualified candidates (IOM, 1993, 1994; BHPr 1995).
This chapter documents the growth and development of geriatric
medicine fellowship training in the United States through 2001.
Longitudinal data on training programs and the trainees taken from
existing databases supplement the results of a national survey of
fellowship directors we conducted in the fall of 2001. Our surveys
were mailed to the fellowship program directors of all geriatric
medicine allopathic programs (n=119), osteopathic programs (n=7)
and geriatric psychiatry (n=62) fellowship programs accredited by
the ACGME or the AOA.
Current Status of
Fellowship Programs
Geriatric medicine has struggled to define itself within the primary
care/specialty care world of clinical medicine. The different
perspectives of academic geriatricians and geriatricians in clinical
practice have fueled this conflict. Furthermore, the ABFP/ABIM’s subtle
distinction between developing a certificate of added qualifications
and adding a new specialty board added to the confusion.
A 1988 survey of fellowship-trained physicians planning to sit
for the 1988 CAQ exam assessed their clinical activity. (Reuben,
Zwanziger, Bradley et al., 1994). Primary care accounted for the
majority of clinical care provided by respondents in family practice
(90%) and internal medicine (78%).
In 1993, the National Study of Internal Medicine Manpower
conducted a survey of geriatric fellowship program directors in
internal medicine (NaSIMM) (Lawlor, Lyttle, & Moldwin, 1997). Their
finding that the increase in the number of fellows in the late 1980s
and early 1990s had occurred in training years two and beyond was
of particular interest. The number of one-year programs had
remained steady. In the 1980s most fellows were U.S. medical school
graduates, but the NaSIMM found that in 1993 more than half of
fellows were international medical school graduates (IMGs). The
formal accreditation of geriatrics training had opened the field to
IMGs, since visa requirements generally limit IMG training to ACGME
approved programs.
An editorial accompanying the NaSIMM survey outlined the
arguments for reducing the training requirement for certification in
geriatrics from two years to one year (Reuben & Solomon, 1997). The
two-year fellowship programs in the mid-1980s required 12 months
of clinical training; the remainder of the time was spent in academic
training. U.S. medical school graduates of FP and IM residency
58