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

and GIM programs a mean of 2.8 available physician faculty to teach
geriatrics (Reuben, Fink, Vivell, et al., 1990). It appears that the
number of physician faculty available to teach geriatric medicine in FP
residency programs has not changed significantly over the past 13
years, while the faculty in the GIM programs has increased.
In Reuben’s survey the most frequently cited major obstacle to
implementing a geriatrics curriculum was lack of faculty (Reuben,
Fink, Vivell, et al., 1990). Thirteen years later this was still reported
as a significant obstacle. It remains important that existing faculty
members with an interest but no formal geriatric medicine training be
encouraged to teach residents and help foster enthusiasm for the
field.
When we asked residency directors who had been successful in
adding geriatric medicine into their curricula to explain their success,
one of the most commonly cited reasons was that they had a few
outstanding teachers who loved teaching geriatrics. Comments such
as “charismatic faculty who inspire while teaching”, and “lucky to
have a physician who loves to teach with interest in geriatrics” are
just a few examples that indicate how much geriatric education
depends on faculty role modeling. Although expanding the number
of fellowship-trained FP and GIM geriatric educators remains an
important task, many existing faculty can generate excitement for
the field. Programs should support increased geriatric training for
physicians who wish to increase their clinical skills (Mold, Mehr, Kvale
et al., 1995).
Multidisciplinary teams are central to good geriatric medicine
practice, and 83% of FP and 88% of GIM residencies are currently
using this approach. The unique perspectives of many other health
disciplines can help residents learn about clinical solutions to their
complex patients’ problems and health care needs as well as expand
the base of expert geriatric faculty in each program.
The most significant cited barrier to improving their geriatric
medicine training was over-crowded curriculum demands placed on
their programs. This complaint is not surprising given the breadth of
general internal medicine and family medicine training and the
increase in RRC requirements. When FP residency directors were
asked to rate the respective importance of several curricular areas
for training family physicians, pediatrics, geriatrics, and inpatient
medicine were rated as the top three priorities. GIM residency directors
rated ICU/CCU, geriatrics and palliative care. Program directors remain
critical in determining the path of geriatric medicine training for FP
and GIM residents.
These surveys suggest a large number of similarities in geriatric
education across family medicine and internal medicine residencies.
Most programs still depend on nursing homes as the major site for
teaching geriatrics. The fact that most programs are anticipating
stable or increased geriatrics curricula over the next three years is
encouraging. However, faculty resources remain limited. Primary
care residency training will always be faced with balancing many
educational objectives, although FP and GIM program directors recognize
the importance of geriatric medicine to the future of primary care
practice.
Psychiatry and
Obstetrics/Gynecology
Although both psychiatry and obstetrics/gynecology residency
program requirements include specific language mandating geriatrics
training, little is known about how these requirements are being
addressed. The AGS/Hartford specialty projects are helping shape
interest within these specialties. Medicare’s limited support for mental
health care, however, has created a disincentive for psychiatry
programs to further expand curriculum related to the care of older
adults. In addition, aging and mental illness are both viewed as chronic
problems, without the attractive expectation of “cures.” Education in
geriatric psychiatry will need to overcome these biases (Halpain,
Harris, McClures et al., 1999).
Specialty Residents and
Subspecialty Fellows
Since the 1993 IOM report it has been recognized that the training of
all physicians should include general geriatric medicine principles and
specialty-specific topics related to aging. The AGS and the John A.
Hartford Foundation have identified influential leaders within many
specialties and supported them in their efforts to determine how
the needs of our aging population will affect their practices and
educational programs. Curriculum development and faculty development,
although in early stages, are well underway. Evaluation of the impact
of these new initiatives will help direct future investments in curriculum
development and practice.
In summary, the following key questions need to be answered
in order to further develop graduate medical education in geriatric
medicine for all disciplines (Callahan, Thomas, Dunn et al., 2001).
1. What geriatric competencies are appropriate for all primary
care and specialty residents upon completion of training
2. Are multiple clinical training sites required
3. Can residents develop an understanding for the unique nature
of care in different settings, the subtleties of how living and
receiving care in these settings influence medical care and the
patient’s experience of health and illness, if they don’t
participate in care at some of these sites
4. How can programs increase the trainees’ openness to learning
from other health care professions
5. How can programs influence the trainees’ attitudes toward
providing care to older adults
6. Are geriatricians needed to teach Do generalists and
subspecialists currently have the skills and desire to integrate
geriatrics into their teaching
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