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

only documented the reported sources of support, not the amount of
each source utilized by the PDs. Support for accredited graduate
medical education (GME) training is provided by Medicare for all
clinical disciplines. The actual use of the GME dollars is varied and not
well documented. Most program directors negotiate with their hospital
administrators for access to GME dollars to support fellow salaries
and benefits and training program faculty. It was remarkable that 79%
of the medicine and 62% of the psychiatry PDs reported having some
access to GME dollars to support their fellows since these funds go
directly to the hospital. Although Medicare is the major source for all
disciplines’ GME funds, geriatric training programs do not receive
special consideration as compared to other disciplines.
When ACGME-accredited fellowship programs were reduced from
2 years to 1 year of training, the financial impact on fellowship stipend
support beyond the first year of training was significant, particularly
for medicine programs. The loss of VHA funding for second-year
trainees has only been partially replaced, but the VHA remains the
most important source of support for first-year fellowship positions.
The status of second-year Medicare funding remains unclear. Funding
for advanced training for clinician educators is very limited. On the
other hand, numerous NIH, VHA, and private foundation supported
research training programs exist and the supply of these positions
appears to be meeting the demand.
The University of Rochester survey of recent fellowship graduates
documents career decision-making of geriatric fellows trained in the
past decade (Medina-Walpole, Barker, Katz et al., 2002). As a group,
53% of survey respondents made their career decision during
residency and 27% made their decision prior to or during medical
school. “Their career decisions were commonly influenced by mentors
and were motivated by opportunities to address societal needs.”
This survey also emphasizes: “the timing of career decision-making
is important”. Additionally, with half of all respondents influenced
by a role model or mentor, the field must assure the availability of
exemplary faculty role models that embody geriatric career pathways,
as clinician-educators and research-scientists.
The influence of duration of training was also assessed in the
University of Rochester survey. “Irrespective of length of training,
most are doing predominantly clinical work in settings of particular
importance to frail older patients. A majority hold academic
appointments and are participating in teaching. Only 11% devote
greater than half their time to research, the majority of which is
clinical. Further analysis of the 1996-1998 cohort, shows that those
with longer fellowship training are more likely to participate in
academic career development activities.” Also, according to the
Rochester survey, “length of training does not affect the current
clinical practice commitments of respondents but is correlated with
their likelihood of participating in academic career development
activities such as teaching, conducting research, and authoring
publications” (Medina-Walpole, Barker, Katz, et al., 2002).
In summary, geriatric medicine and psychiatry programs have
developed rapidly during the past ten years. The recruitment of
high-quality U.S. medical school graduates into these programs
remains a challenge for the discipline, but its importance has been
demonstrated. Also, the retention of first-year fellows for additional
years of academic training has been difficult. In the future, incentives
will be needed to attract the best graduates of U.S. family practice,
internal medicine, and psychiatry training programs into academic
careers in geriatric medicine. For example, loan forgiveness programs
(such as the one recently started by the NIH for research oriented
physicians) and/or integrated five-year “research fellowship and junior
faculty” awards could alleviate the currently existing financial
disincentives and funding uncertainties facing residency graduates.
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