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

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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
Table 6.1 Geriatric Medicine and Geriatric Psychiatry Fellows in ACGME-Accredited Graduate Medical Education Programs (All Years of Training) Family Practice, Internal Medicine, Academic Year Geriatric Medicine Geriatric Medicine Geriatric Psychiatry Total # of Total # Total # of Total # Total # of Total # Programs Fellows Programs Fellows Programs Fellows 1991-1992 17 17 75 181 -- -- 1992-1993 17 16 80 199 -- -- 1993-1994 16 17 82 208 -- -- 1994-1995 15 16 84 204 -- -- 1995-1996 14 22 85 201 38 38 1996-1997 14 22 89 220 44 82 1997-1998 17 29 90 276 47 84 1998-1999 20 37 92 298 49 91 1999-2000 21 42 93 326 55 98 2000-2001 23 28 96 293 61 86 2001-2002 22 -- 97 -- 62 -- Source: AMA and AAMC data from National Surveys of GME programs, JAMA, 1991-2001 Table 6.2 First Year Geriatric Medicine and Geriatric Psychiatry Fellow Positions Available and Filled Family Practice and Internal Medicine, Academic Year Geriatric Medicine Geriatric Psychiatry Total # of Total # of % Total # of Total # of % First Year Fellows in Positions First Year Fellows in Positions Positions Year 1 Filled Positions Year 1 Filled Available Positions Available Positions 1995-1996 206 117 56.7 --* 35 1996-1997 222 144 64.9 82 77 93.9 1997-1998 226 205 90.7 98 81 82.6 1998-1999 262 239 91.2 107 89 83.2 1999-2000 307 269 87.6 113 95 84.1 2000-2001 337 247 73.3 125 79 63.2 2001-2002 373 -- -- 132 -- -- *Data not available Source: AMA and AAMC data from National Surveys of GME programs, JAMA, 1995-2001 programs were not eager to commit to two additional years of training, and many potential applicants were not interested in the academic component of the two-year fellowship. Many program directors felt that the one-year certifying requirement would provide more flexibility, allowing for different tracks for the training of clinicians, clinician-educators, and clinician-researchers. In the spring of 1999, Hazzard et al. conducted a brief survey of geriatric medicine fellowship directors to gather initial feedback on the reduction of the required training duration from two years to one year (Hazzard, Currin, & Woolard, 2000). The responses were mixed. The number of applicants had notably increased, but the quality of applicants was still a concern. Not surprisingly, program directors noted that the fellows’ research productivity had declined. Overall, 61% of respondents stated that the decision to reduce the required length of training was, on balance, positive. The ACGME’s residency review committees (RRCs) for family practice and internal medicine develop the requirements for training in geriatric medicine. They also survey and accredit programs. The ACGME geriatric medicine fellowship requirements were revised in 1997 to account for the reduction in training duration (www.acgme.org). The IM and FP guidelines are nearly identical. In both cases fellowship programs must maintain a close affiliation with an ACGME-accredited IM or FP residency program. The RRCs are currently circulating for comment new draft revisions of the training requirements. The Psychiatry RRC develops training requirements for geriatric psychiatry fellowships. It implemented the most recent requirements in July 1995 (www.acgme.org). The American Osteopathic Association develops training guidelines and accredits osteopathic geriatric medicine fellowship programs (www.aoa.org). Fellowship Program Growth The number of fellowship programs and the number of fellows has slowly increased over the past decade. Table 6.1 displays program growth and total number of fellows in all years of training in ACGME-approved geriatric medicine (FP and IM) programs and 59
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The Association of Directors of Ger
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The Association of Directors of Ger
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National Oversight Panel M. Brownel
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The American Geriatrics Society . .
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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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