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

fellowships is widely recognized. The 1993 Institute of Medicine
report, Strengthening Training in Geriatrics for Physicians specifically
recommended substantially expanding geriatric medicine training in
primary care residencies and increasing geriatric medicine education
in non-primary care specialties. An ambitious recommendation in
this IOM report was to incorporate six months of geriatric medicine
training into family practice and internal medicine residency programs
by 1996 and to have a minimum of nine months of training by 1999.
The Bureau of Health Professions (BHPr) prepared, A National
Agenda for Geriatric Education,in 1995. It addressed geriatrics
training in all residency programs and made specific recommendations
regarding the inclusion of geriatrics curricula. The BHPr report also
recommended linking the presence of geriatrics curricula to the
distribution of graduate medical education (GME) dollars. Several
initiatives over the past eight years have been directed toward
achieving these national recommendations.
Current Status of Graduate
Medical Education
The Accreditation Council on Graduate Medical Education (ACGME)
administers residency review committees (RRCs) for each allopathic
residency and subspecialty program. Representatives from specialty
boards and the specialty societies make up these committees. The
RRCs are responsible for reviewing and accrediting training programs,
and conducting ongoing reviews (usually once every 5 years) of
existing programs. Training programs are evaluated on how well they
have implemented general and specialty-specific requirements for
the structure and content of their programs. A new emphasis on
measuring educational outcomes of programs is currently included in
the reviews. When specific content is regarded as critical by an RRC,
references to this are written into the special requirements to be
utilized by program directors in developing their curricula. During
periodic reviews, programs not responsive to RRC priorities are cited
Table 7.2 Residents' Self-Assessment of Preparedness in Caring for Specific Types
of Patients (Percent)
Specialty Condition Very Somewhat Somewhat Very
Unprepared Unprepared Prepared Prepared
Internal Critically Ill 0 2 30 68
Medicine Terminally Ill 1 7 37 55
Elderly 0 3 45 52
Chronically Ill 0 6 41 52
Nursing home 5 26 56 13
Family Critically Ill 9 25 49 17
Practice Terminally Ill 2 11 45 42
Elderly 1 5 46 48
Chronically Ill 1 7 49 43
Nursing home 4 16 52 27
Obstetrics & Critically Ill 2 12 54 32
Gynecology Terminally Ill 3 15 45 37
Elderly 1 14 57 29
Chronically Ill 3 23 55 19
Nursing home 29 40 27 5
Source: Blumenthal, Gokhale, & Campbell et al., 2001
for deficiencies. Table 7.1 lists the specialties with specific references
to geriatric medicine training in current RRC guidelines. A summary of
these educational requirements is presented in Appendix H.
Little is known about graduating residents’ readiness for practice.
In geriatric medicine a “residency-practice mismatch” exists; new
physicians are typically not adequately prepared to care for the many
complex older adults who will be in their practices (Reuben, McCue
and Gerbert, 1988).
A 1998 national survey of residents graduating from eight
specialty-training disciplines at U.S. academic health centers
addressed this question (Blumenthal, Gokhale, Campbell et al., 2001).
A stratified, random sample of graduating residents was surveyed,
and 65% (n=2,626) responded. Three of the eight specialty disciplines
questioned were internal medicine, family practice, and
obstetrics/gynecology. The survey asked graduating residents from
these three programs to assess their preparedness in several areas
relevant to geriatric medicine (Table 7.2). Significant numbers of
residents in all three specialties indicated they did not feel well
prepared to manage the terminally ill, the chronically ill, nursing home
patients, or other elderly patients.
This chapter reviews current geriatrics training initiatives in
primary care internal medicine, family practice, psychiatry, and
obstetrics/gynecology; non-primary care specialties; and medical
and surgical subspecialties.
Primary Care Graduate
Medical Education
High-quality primary care for older adults requires well-trained
general internists and family physicians, along with geriatricians.
Today’s internal medicine and family medicine residents require
focused training that imparts the attitudes, knowledge, and skills they
will need to provide sophisticated and comprehensive geriatric care.
Resident training is a time of intense clinical experience, and for many
physicians it is their last formal
training before entering practice.
Trends in the selection of
primary care residents, especially in
general internal medicine and family
medicine, influence the quality and
quantity of future primary care
physicians and geriatricians. (The
source of applicants to geriatric
medicine fellowships is the FP/IM
residency graduate pool). The
perceived demand for specialties
and their respective potential
compensation influences student
career choice. During the mid-1990s
managed care’s demand for
primary care physicians drove up
compensation, and medical student
interest followed. Since the 1998
residency match, this trend has
reversed.
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