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

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“While our residents recognize that many of their patients will be over age 65, they also have learned (due to Medicare reimbursement levels and patient complexity) that they cannot afford to care for a high percentage of older adults and maintain a financially viable practice.” Residency directors were also asked to rate on a 7-point Likert scale seven curriculum topics as to their importance for training of family physicians. Pediatrics, geriatrics, and inpatient medicine were rated as the highest priorities (Figure 7.8). Best Educational Practices in FP Residency Programs Directors were asked to describe the best aspects of their geriatrics curriculum. We grouped these open-ended responses into 11 categories. The program directors were most enthusiastic about outpatient and community-based experiences and the overall design of their curricula. Other Initiatives in Internal Medicine and Family Practice Residency Education—The Stanford University Geriatric Education Resource Center The Stanford University Geriatric Education Resource Center (with funding from the John A. Hartford Foundation) developed and disseminates geriatric medicine educational materials for internal medicine and family practice residents. These materials were created with input from the AAFP and eight academic medical centers (Baylor, Harvard, Johns Hopkins, Stanford, UCLA, Chicago, Connecticut, and Rochester). The materials include packaged methods and stand-alone aids for teaching geriatric knowledge and skills. (See http://Sugerc.Stanford.edu/index0.html.) In addition, each year up to six medical school faculty are selected to attend the Stanford Faculty Development Center for training to become Geriatrics in Primary Care (GiPC) seminar facilitators. The one-month facilitator-training course gives participants the knowledge and seminar leadership skills they need to deliver a series of eight 2-hour seminars to faculty and residents in their communities. The seminars are designed to help primary care faculty enhance their ability to care for older patients as well as teach this information to medical trainees and others who teach. Participants are encouraged to explore their attitudes, knowledge, and skills related to geriatrics during a variety of instructional activities including: case studies, didactic presentations, role play exercises, brainstorming sessions, and personal and institutional goal setting. During the eighth seminar, participants develop a set of recommendations for improving their institutions’ educational environments for geriatrics. Psychiatry As with internists and family physicians, the number of psychiatrists with certification in geriatric medicine is small, and recruitment into fellowship programs is weak. General psychiatrists without advanced training in geriatric mental health will continue to provide the majority of psychiatric care to older adults (see Chapter 4). The psychiatry RRC requirements provide a basis for developing residency curriculum in geriatrics (see Appendix H). However, little is known about how these requirements are being implemented. A combined neurology and psychiatry Geriatric Education Retreat (see below) was held in March 2001. The most tangible outcome was interest in developing a combined Geriatric Neurology/Psychiatry geriatrics fellowship program. While psychiatry already has a fellowship program in place, neurology does not. Obstetrics/Gynecology The Council on Resident Education in Obstetrics and Gynecology (CREOG) estimates that by the year 2030, 20% of women cared for by obstetrician-gynecologists (OB-GYN) will be older than age 65. (CREOG Geriatric Education Task Force, 1999). In 1999, CREOG published educational objectives for training residents in OB-GYN. Since 1996, the RRC for OB-GYN has required specific training in geriatrics and geriatric gynecology (see Appendix H). To date no studies have been done to determine the methods currently being used by OB-GYN program directors to implement this new curriculum. Internal Medicine Subspecialties Physicians practicing in internal medicine subspecialty have completed two to three years of general medicine training and additional years of training in their chosen subspecialty. The practice activity of these physicians includes primary care as well as clinical activities specific to the chosen specialty. Most of these physicians will care for large numbers of older adults (see Chapter 4). Integrating Geriatrics Into the Subspecialties of Internal Medicine is a comprehensive project of the American Geriatrics Society aimed at defining the basic knowledge, attitudes and skills every subspecialist must possess to care for the older patient appropriately and efficiently. This project was launched in 1994 with a $1.5 million grant from the John A. Hartford Foundation and a smaller amount of support from Merck, Pfizer, and Warner-Lambert pharmaceutical firms. In 1997, the project received a two-year $1.9 million grant extension from the Hartford Foundation. In 1999, the AGS received another extension grant ($2 million) from the Foundation to carry out more Geriatric Education Retreats (GERs), including an expanded focus outside of internal medicine with a GER for neurologists and psychiatrists. This third phase of the project includes collaboration with the Association of Subspecialty Physicians (ASP) and will have an emphasis on junior faculty development. The project is being administered by The Wake Forest University School of Medicine, with Nancy Woolard as the project coordinator. William R. Hazzard, M.D. (University of Washington) is the project director. The specific aims of this project are to: • Assist leading subspecialists as they redirect their attention to the geriatric aspects of their disciplines. • Identify opportunities for geriatrics-related teaching and research within the subspecialties of internal medicine. • Foster leadership roles for, and professional satisfaction among, the subspecialists who pursue geriatrics-related teaching and research. 80
Geriatric Education Retreats (GERs), 5-day total immersion experiences to help “gerontologize” exemplary subspecialty faculty from leading academic health centers, have been organized to further the project’s objectives. Topics covered during the GERs include educational and research opportunities in geriatric medicine for the relevant subspecialties. GERs have been provided for the following subspecialties: • Endocrinology, Diabetes and Metabolism • Cardiology • Oncology • Infectious Disease • Rheumatology • Immunology • Pulmonary and Critical Care Medicine • Nephrology • Gastroenterology • Psychiatry and Neurology Faculty from general internal medicine also participated in a GER, as described earlier in this chapter. A September 2000 project summary reported that the GER process led to more than 100 publications in subspecialty journals and 60 submitted grant applications for research with an emphasis on geriatrics. More than half of these proposals were funded. A project directed by the American Society of Clinical Oncology (ASCO) is an example of successful expansion of the GERs. Funded by the John A. Hartford Foundation, this project is testing a model for combined training in geriatrics and oncology at the fellowship and junior faculty levels. The ASCO Geriatrics/Oncology Training Program Development Grant is designed to help institutions develop three-year fellowships in geriatric medicine/medical oncology. Trainees will become eligible to sit for the American Board of Internal Medicine (ABIM) certification in medical oncology. In addition, they will be eligible for ABIM certification in geriatric medicine. The John A. Hartford Foundation awarded eight three-year grants under this program in 2002, totaling $225,000 per site, with a required institutional match of $75,000 to $150,000. The Society of Geriatric Cardiology (SGC) founded in 1986, was well established before the GER program started. It is an early example of a medical subspecialty actively addressing geriatrics in its curriculum. SGC provides education, promotes research, and addresses public policy related to cardiovascular disease and aging. The SGC conducts educational geriatric medicine programs for physicians and other health care professionals at national meetings of the American Heart Association, the American College of Cardiology, the American College of Chest Physicians, and the American Geriatrics Society. In addition, it organizes and sponsors (or co-sponsors) standalone symposia and conferences nationwide, often in collaboration with local medical centers. The American Journal of Geriatric Cardiology, the official journal of the Society of Geriatric Cardiology, is circulated every two months to approximately 20,000 cardiologists and geriatric specialists. With funding from Merck, the SGC awards two $20,000 research grants annually. Surgical and other Medical Specialties The Hartford Foundation and the AGS are also active in a parallel project, Increasing Geriatrics Expertise in Surgical and Related Medical Specialties, targeting physicians in specialties not addressed by the internal medicine project. Planning for this project began in 1992 and it was launched in 1994 led by Dennis W. Jahnigen, MD. This ambitious program entered its third phase of funding on May 1, 2001 with a $5.9 million four-year grant. David H. Solomon, MD, (UCLA) and John R. Burton, MD, (Johns Hopkins) are the project co-directors, and Janis Eisner in the AGS New York City office is the project manager. The project’s objectives are: • To improve the amount and quality of geriatric education received by medical and surgical residents. • To identify and support specialty faculty in promoting geriatric training and research within their own professional disciplines. • To assist professional certifying bodies and professional societies in improving the ability of their constituencies to care for elderly patients. In 1998, this initiative established an Interdisciplinary Leadership Group (ILG), a working unit of national specialty leaders committed to improving the care of geriatric patients (see Appendix I). This project sought to stimulate geriatrics-related training among both established leaders and younger faculty in anesthesiology, emergency medicine, general surgery, gynecology, ophthalmology, orthopedic surgery, otolaryngology, physical medicine and rehabilitation, thoracic surgery, and urology by implementing the following activities: • Identification/development of leadership • Development and/or dissemination of curriculum/training materials • Support of educational symposia and special interest groups • Support of resident research seed grants and/or senior investigator awards • Encouragement of change of Residency Review Committee (RRC) special requirements and Board certifying examinations. Plans for the third phase of this initiative include awarding two-year grants to 30 institutions to enrich their residency curricula, help faculty focus on research on geriatric aspects of their specialties, expand the Interdisciplinary Leadership Group (which initiated in May 2002 a new Section of Surgical and Related Medical Specialties in the American Geriatrics Society), provide discretionary grants to each specialty to support leadership development and education activities, develop the Geriatrics Syllabus for Specialists (GSS), establish the Jahnigen Career Development Scholars program, and serve as a clearinghouse for geriatric information for surgeons and medical specialists. The Jahnigen Career Development Scholars program offers, on a competitive basis two-year career development awards to young faculty in anesthesiology, emergency medicine, general surgery, gynecology, ophthalmology, orthopedic surgery, otolaryngology, physical medicine and rehabilitation, thoracic surgery, and urology. This program will help awardees initiate and sustain careers in 81
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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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List of Tables and Figures Chapter
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Figure 7.4 Figure 7.5 Figure 7.6 Fi
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the fastest acceleration in 12 year
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esidency review committee provide a
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Project Methodology National Oversi
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Table 2.2 Secondary Data and their
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3 Historical Development of Geriatr
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$195.9 million NIA extramural suppo
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important political decision by the
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4 The Practice Of Geriatric Medicin
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participants. Geriatricians have be
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Page 91 and 92: Conclusion This report summarizes r
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