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In the Balance |

Is Geriatric Medicine Terminally Ill?

Adam G. Golden, MD, MBA; Michael A. Silverman, MD, MPH, CMD; and Michael J. Mintzer, MD
[+] Article and Author Information

From the University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando; West Palm Beach Veterans Affairs Medical Center, West Palm Beach; and University of Miami Miller School of Medicine and the Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, Florida.

Acknowledgment: The authors thank S. Barry Issenberg for his editorial feedback of the manuscript and insights on medical education.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-3079.

Requests for Single Reprints: Adam G. Golden, MD, MBA, 5201 Raymond Street, CLC-136, Orlando, FL 32803; e-mail, mailto:adam.golden@ucf.edu.

Current Author Addresses: Dr. Golden: 5201 Raymond Street, CLC-136, Orlando, FL 32803.

Dr. Silverman: 7305 North Military Trail, Code 114; West Palm Beach, FL 33410.

Dr. Mintzer: 1201 Northwest 16 Street, 11GRC, Miami, FL 33125.

Author Contributions: Conception and design: A.G. Golden, M.A. Silverman, M.J. Mintzer.

Analysis and interpretation of the data: A.G. Golden.

Drafting of the article: A.G. Golden, M.A. Silverman, M.J. Mintzer.

Critical revision of the article for important intellectual content: A.G. Golden, M.A. Silverman, M.J. Mintzer.

Final approval of the article: A.G. Golden, M.A. Silverman.

Provision of study materials or patients: A.G. Golden.

Administrative, technical, or logistic support: A.G. Golden.

Collection and assembly of data: A.G. Golden, M.J. Mintzer.


Ann Intern Med. 2012;156(9):654-656. doi:10.7326/0003-4819-156-9-201205010-00009
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Although substantial academic resources are directed to encourage interest in geriatric medicine, fewer internal medicine and family medicine residents are seeking geriatric medicine fellowship training. This commentary argues that the specialty is not viable. Rather than continue these efforts to promote the training of geriatric medicine specialists, the authors suggest that the medical profession devote resources to develop geriatric competencies in nongeriatrician physicians.

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In Response
Posted on May 3, 2012
DavidHamerman, MD
Columbia University Medical Center
Conflict of Interest: None Declared

Two recent articles "In the Balance" cast a very baleful eye on the state of geriatrics in our nation, viewing it either as "moribund" (1), or as a "societal scotoma" (2). As both articles make clear, in light of the "graying" of America, and the important conceptual clinical practice innovations geriatrics has developed for comprehensive care of older persons, especially those with multiple and complex "geriatric syndromes", the possibility that it may not survive in this nation's health care system is truly a cause for alarm, reconsideration, and corrective actions. Indeed, the issues are critical and sufficiently important to call for a multi-disciplinary approach to review the current state of geriatrics, and make recommendations for its future based on viewpoints from many constituencies: legislative, professional providers, researchers on aging processes, health policy planners, industry, and consumers - an interaction perhaps best sponsored and supported by a prominent Foundation concerned with national health.

It is also appropriate, I believe, as one who has been in a leadership position in academic geriatrics for over two decades (3), to indicate a personal point of view here. The establishment of the National Institute on Aging and the appointment of Robert Butler as its founding Director in 1974, signalled the potential for emergence of a new medical discipline in this country, one that would define precepts of diversified health care for the elderly, with the underpinning of a growing content of basic biomedical science on aging. From this union, a greater understanding of aging processes and their transitions to chronic diseases could arise (4), be part of clinical practice (5), and form the educational content presented to medical students, trainees, practitioners, and biogerontologists engaged in research (6). In my view, these prospects that would have created a more unified and profound academic disicpline have not been achieved: geriatric practice has not been integrated with its fundemental aging science base. It is still possible to achieve this, however, with the potential for actual "translation" of research studies on aging to ameliorate inception of chronic diseases, a prospect that would enhance the importance of the practice of geriatrics in the coming decades of the 21st century.

References

1. Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med. 2012; 156: 654-6.

2.Leipzig RM, Hall WJ, Fried LP. Treating our societal scotoma: the case for investing in geriatrics, our nation's future, and our patients. Ann Intern Med. 2012; 156: 657-9.

3. Hamerman D, Maklan CW. Editorial. Geriatric practice. Taking up where primary care leaves off. Am J Med. 1987; 82: 525-8.

4. Hamerman D. Geriatric bioscience. The link between aging and disease. Baltimore: Johns Hopkins University Press. 2007.

5. Hamerman D. Editorial. Integrating aging into geriatric practice: an emerging orientation for health care. J Am Geriatr Soc. 2010; 58: 2024- 5.

6. Hamerman D. Editorial. Can biogerontologists and geriatricians unite to apply aging science to health care in the decade ahead? J Gerontol A Biol Sci Med Sci. 2010; 65A: 1193-7

Conflict of Interest:

None declared

The Need for Geriatrics
Posted on May 6, 2012
Philip DSt John, Head, Section of Geriatric Medicine, Chris MacKnight, Roger Wong, David Hogan, Pam Jarrett, Jose Morais, Ken Madden
University of Manitoba
Conflict of Interest: None Declared

Most older adults are in good health. However, an important minority have multiple interacting medical problems, poor functional status, cognitive loss and social isolation. These people are better served by a care model that recognizes their complexity.

The geriatric model of care is not particularly innovative or new. But it is effective. Decades ago Marjory Warren advocated for interdisciplinary care by "a team whose central theme is optimism and hope" with early ambulation, monitoring of progress, and the use of assistive devices. She stressed the care environment: good lighting, clear hallways, space for congregate activities and kindly staff. Since that time, a large body of evidence has demonstrated the benefit of this model of care. Warren advocated for a specific specialty in geriatrics, but recognized that it could not provide care for all older adults. She therefore argued that geriatrics should form part of the curriculum of all medical students and nurses, and that research into diseases affecting older people should be undertaken. These points remain relevant to this day (1). Indeed, they are remarkably similar to those made in a recent Institute on Medicine report (2).

Now, we are told our specialty is dying in the US (3). Geriatrics has had numerous near-death experiences before and survived (4). The need for special expertise in the care of older adults, particularly frail older adults, has always been apparent. Geriatricians have led the way in research into syndromes that have interested few other specialists. They have pioneered models of care and conducted research to provide strong evidence for these models (2, 5). Geriatricians will be needed to train future generations of physicians, and other professionals. Finally, they will be needed to help administer health care systems for older adults.

Of course, geriatricians will never provide the majority of care for older adults. Defining the role of geriatricians is therefore essential. This role will differ depending on local circumstances, practices, and resources. In some settings, this may be as specialist consultants while in others, as primary care providers or limited to academic and administrative roles. Nothwithstanding this, several key points remain constant - there is a need for both specialized geriatric training programs and greater geriatric training for all health care providers; proper models of care for frail older adults are needed; and, research into syndromes and health conditions affecting older adults should be a priority.

References

(1) Warren MW. Care of the chronic aged sick. Lancet. 1946;(6406):841 -3.

(2) Institute of Medicine Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: The National Academies Press, 2008.

(3) Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med. 2012;156(9):654-6.

(4) Leonard JC. Can geriatrics survive? Br Med J. 1976;(6021):1335-6.

(5) Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.

Conflict of Interest:

All authors are geriatricians.

The Pareto Principle Doesn't Make You an Expert
Posted on May 8, 2012
Kenneth M.Madden, Editor-in-Chief, Kenneth Rockwood
Canadian Geriatrics Journal
Conflict of Interest: None Declared

"Is Geriatric Medicine Terminally Ill?"(1) has resulted in a great deal of discussion throughout geriatric medicine programs in Canada. Since geriatric medicine here is a consultative subspecialty as opposed to a primary care discipline, we believe that the situation in Canada is sufficiently different that there is no need to advocate for the "mercy- killing" of Canadian geriatrics. Canadian trainees read the Annals avidly and need to be aware that this line of reasoning, even if it holds in the US (about which we are dubious), does not hold in Canada.

In our view, Golden et al. have made the error of confusing the Pareto principle with being an expert. The Pareto effect(2) is the well established phenomenon where eighty percent of all problems can be solved with only twenty percent of the knowledge base. This is why a well- trained generalist is an essential part of the health care system, since they can efficiently and easily deal with eighty percent of medical issues. No-one in the Canadian health care system claims that all (or even most) older adults should be treated by a geriatrician, any more than that all arthritis patients should be cared for by a rheumatologist. Geriatric Medicine subspecialists are best employed by treating the minority of patients that have multiple complexities due to frailty, not in internecine squabbles over all patients with graying hair.

Frailty is a highly age-associated state of increasing risk due to an accumulation of deficits that reflect multisystem physiologic changes(3). Firing a shotgun blast of subspecialists to evaluate each organ system independently is both ineffective and expensive, a circumstance remediated by the comprehensive geriatrics assessment (CGA). The most recent meta- analysis demonstrated that the CGA (compared with usual care) lowered patient mortality, increased the chance a patient returned to their own home, and increased post-discharge cognitive function(4). The research on which CGA is built requires disciplinary knowledge if it is to be advanced. In not even mentioning how the complexity of frailty challenges current models of care, their paper misses the entire point of the subspecialty.

There are obviously many questions for Canadian geriatricians to grapple with, such as how much to be involved at the primary care level, the balance between clinical care and research to advance the specialty, and whether more remuneration alone is a fix. We will be addressing these issues in an upcoming issue of the Canadian Journal of Geriatrics (www.cgjonline.ca).

REFERENCES

1. Golden AG, Silverman MA, Mintzer MJ. Is Geriatric Medicine Terminally Ill? Ann Intern Med. 2012;9(156):654-7.

2. Pareto V. Manual of political economy. New York,: A. M. Kelley; 1971.

3. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicne defined by frailty Clin Geriatr Med 2011;27:17-26.

4. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.

Conflict of Interest:

None declared

Geriatrics is Very Much Alive
Posted on May 10, 2012
John R.Burton, MD, S. Chris Durso, MD, MBA, The Johns Hopkins Bayview Medical Center, Baltimore, MD
The Johns Hopkins University School of Medicine
Conflict of Interest: None Declared

TO THE EDITOR: Golden and colleagues (1) ask if geriatric medicine is terminally ill and make a case for restructuring training by reallocation of resources from fellowship training to teaching initiatives to "gerontologize" medical students and non-geriatricians.

We would counter that geriatrics is very much alive and the fellowship-trained geriatricians have accomplished much of what Golden proposes. Academic geriatrics was started in recent decades by non-geriatricians who saw a need for improving the health care of seniors through research, education and program innovation. They developed fellowship programs to train physicians to lead this movement. The care of seniors has been enriched by this growing number of fellowship-trained geriatricians.

Two accomplishments exemplify these accomplishments: 1) the geriatrization of students and non-geriatricians has been ongoing for years with support of foundations, the VA and the NIH/NIA. The impact of geriatricians has been magnified greatly by training many non-geriatrician scholars who have won career development awards in geriatrics such as those named for the late leaders Dennis W. Jahnigen, T. Franklin Williams and Paul B. Beeson. These scholars represent nearly every specialty and subspecialty of medicine and surgery. These emerging non-geriatrician leaders would admit their careers were greatly nurtured by fellowship- trained geriatricians. 2) New knowledge in caring for seniors is vital and has been accomplished mostly by fellowship-trained geriatricians. Consider the advances, for example, in care delivery systems (e.g. Guided Care, Hospital at Home, post hospital care management, acute care of the elderly units, innovations involved in transitions of care), the understanding, impact, evaluation, prevention and treatment of polypharmacy, frailty, incontinence, falls and delirium. Decreasing support of fellowship training and subsequently diminishing the core group of teachers and researchers trained in and focused on geriatrics as suggested by Golden would be unwise in the face of accelerating numbers of seniors with complex medical problems coupled with the need for experts trained to guide clinical program development for these individuals. Non- geriatricians can and should continue to teach geriatric principles and do innovative research improving the care of seniors. But there remains a need for a robust corps of fellowship trained geriatricians who stay tightly focused on the care of seniors and who nurture, challenge and inspire each other and other physicians. The enduring metaphor, "don't through the baby out with the bath water, "seems applicable to the thesis of Golden.

John R. Burton, MD S. Chris Durso, MD, MBA The Johns Hopkins University School of Medicine The Johns Hopkins Bayview Medical Center Baltimore, Maryland 21224

References

1. Golden AG, Silverman MA, Mintzer MJ. Is Geriatric Medicine Terminally Ill? Ann Intern Med. 2012;156:654-6

Conflict of Interest:

None declared

Reports of the death of geriatrics are greatly exaggerated
Posted on May 10, 2012
Timo E.Strandberg, Member of the EUGMS Executive Board, Antonio Cherubini, Jean Petermans, Desmond O'Neill, on behalf of the EUGMS Executive Board
European Union Geriatric Medicine Society (EUGMS), London EC1M 4DN, UK
Conflict of Interest: None Declared

It is untimely that there could be serious discussion about geriatric medicine suffering from terminal illness(1) in 2012, the European Year of Active Ageing. Not only is there a deepening evidence base for clinical geriatrics, elucidation of the molecular basis of the geriatrics approach, fresh insights into the mechanisms of aging and chronic disease, but geriatricians also report high levels of professional satisfaction in America and in Europe. Of even greater importance is the increasing proportion of older patients requiring expert care presenting to all specialties. If geriatrics is dying in the USA, it is not due to terminal illness: rather we need to detect the would-be murderer, as the victim is alive and kicking!

In 2005, a task force of the American Geriatrics Society identified five core goals for geriatrics(2): high-quality health care for every older person, expansion of geriatrics knowledge base, increasing number of healthcare professionals employing geriatric principles, recruiting physicians into careers in geriatrics, and influencing public policy of these principles. These are valid and sustainable principles for an aging world.

The principles embody a useful dualism: while not all older patients need a specialist geriatrician at all times, they need confidence that geriatrics is a core part of their training of all physicians who treat them (3). To this end, a strong focus of geriatrics is needed as a specialty and academic discipline to lead in research, education and training, as well as providing effective services. The problems with reimbursements may be peculiar to North America; when solid evidence demonstrates that geriatrics can reduce suffering and days in hospital(4), and save healthcare dollars, it is puzzling that this does not translate to better reimbursement for geriatricians. Moreover, with more frail and multimorbid patients attending health services, there is increasing need for geriatric advice in almost all medical and surgical specialties.

In Europe, geriatrics is developing rapidly: the congresses of the European Union Geriatric Medicine Society (EUGMS, www.eugms.org) attract increasing numbers of physicians; EUGMS works to harmonize geriatric training; its Silver Paper(5) forms a solid roadmap for the future of the specialty and new evidence-based programs have been launched at national and multinational levels in rehabilitation, acute and palliative care.

Aging is a global phenomenon: a worldwide perspective on geriatrics can provide insights that resist ageism and professional conservatism, and help respond more effectively to the complexities of caring for the most complex group of patients.

References

1. Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med 2012;156:654-656.

2. American Geriatrics Society Core Writing Group on the Future of Geriatric Medicine. Caring for Older Americans: The future of geriatric medicine. J Am Geriatr Soc. 2005;53:S245-S256.

3. The Lancet. Demanding dignity, and competence, in older people's care. Lancet. 2012;379:868.

4. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553.

5. Cruz-Jentoft AJ, Franco A, Sommer P, Baeyens JP, Jankowska E, Maggi A, Ponikowski P, Rys A, Szczerbinska K, Michel JP, Milewicz A. Silver paper: the future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease--a report of the European Summit on Age-Related Disease. Aging Clin Exp Res. 2009;21:376- 85.

Conflict of Interest:

All authors are geriatricians and members of the Executive Board of the EUGMS.

Geriatric Medicine should be redefined taking a fundamentally based concept of ageing into consideration
Posted on May 28, 2012
Andrea B.Maier, internist-geriatrician, Johannes J. Meij
Department of Gerontology and Geriatrics, Leiden University Medical Center
Conflict of Interest: None Declared

As stated by Golden et al., Geriatric Medicine is struggling to identify its clinical niche. In contrast to many specialists who are focused on a their organ of interest, there is a general understanding that Geriatricians' interest is the whole elderly person, focussing on the result of functional changes that accompany many chronic diseases during the ageing process. Patient management is often based on disease-specific pathophysiological factors of age related diseases, and adaptation of the environment on the somatic condition of the elderly patient (e.g. occupational therapy, physiotherapy). In clinical practice, symptoms are frequently 'explained' by the 'ageing process', characterised by a decrease of function of various organ systems, e.g. endocrine, autonomous and musculoskeletal. This decrease is also often summarized as the 'frailty' syndrome, although up till now, this syndrome hasn't been clearly defined (1). Ageing theories vary, ranging from an evolutionary point of view, to telomere shortening, DNA damage and radical-mediated oxidative damage. The pathophysiological background of the multisystem change during the ageing process is just slowly discovered (2) and the contribution of each of the mechanisms to the ageing process in humans is still largely unknown (3). The number of initiatives of fundamental translational biological studies on ageing in humans is slowly increasing. From a Geriatricians point of view, revolutionary evidence for a direct relationship between cellular senescence and ageing associated disorders has very recently been provided in mice (4). A higher number of senescent cells in situ has also been associated with a higher chronological and biological age in humans (5). The recent indications of plasticity of the ageing trajectory in model organisms should strengthen the effort to find targets of age related degeneration and disease in human populations. Therefore, next to the management of age associated diseases, there is a clear need for a biological understanding of the ageing process, its clinical implication and the development of targeted interventions. The extension of the niche of Geriatric Medicine, driven by a fundamentally based concept of the understanding of the ageing process is likely to attract outstanding clinicians and researchers to the field of ageing.

References:

1. Rockwood K. What would make a definition of frailty successful? Age Ageing. 2005;34(5):432-4.

2.Fulop T, Larbi A, Witkowski JM, McElhaney J, Loeb M, Mitnitski A, Pawelec G. Aging, frailty and age-related diseases. Biogerontology. 2010;11(5):547-63.

3. Vijg J, Campisi J. Puzzles, promises and a cure for ageing. Nature. 2008;454(7208):1065-71.

4.Baker DJ, Wijshake T, Tchkonia T, LeBrasseur NK, Childs BG, van de Sluis B, Kirkland JL, van Deursen JM. Clearance of p16Ink4a-positive senescent cells delays ageing-associated disorders. Nature. 2011;479(7372):232-6.

5. Waaijer ME, Parish WE, Strongitharm BH, van Heemst D, Eline Slagboom P, de Craen AJ, Sedivy JM, Westendorp RG, Gunn DA, Maier AB. The number of p16INK4a positive cells in human skin reflects biological age. Aging Cell. 2012 May 22. doi: 10.1111/j.1474-9726.2012.00837.x.

Conflict of Interest:

None declared

Need to Increase the Geriatric Workforce
Posted on May 29, 2012
HajimeIchiseki, M.D., Ph.D.
Joto Ichiseki Clinic, Takaoka, Toyama, Japan
Conflict of Interest: None Declared

The recent articles by Golden and colleagues (1) and Leipzig and colleagues (2) clarified a number of serious issues related to geriatrics. Nobody knows what lies ahead in the future, but there is one thing people can make an accurate forecast in the next few decades: population structure. The declining birth rate and increasing life expectancy push the world, industrialized countries in particular, toward a super-graying society. What is essential in this situation is to create a sustainable system which provides better care with lower costs for the elderly. Along with "How to improve reimbursement for geriatricians," "How to increase the geriatric workforce," and other geriatrics-related issues, attention should be paid to "How to make the maximum use of geriatrics specialists."

Identifying clinical niches in which only geriatricians could fill completely is essential. When an earthquake with a magnitude of 9.0 and the subsequent tsunami struck northeast Japan on March 11, 2011, local hospital infrastructure was devastated and countless numbers of health records were washed away. Health conditions of many victims, elderly people in particular, seriously worsened because of the deterioration of their existing chronic conditions such as heart disease. In such situation, the Japan Geriatrics Society showed a strong presence by distributing about 20,000 technical manuals on how to treat elderly patients in the event of disasters. Moreover, it published handy-to-carry and chart-like notebooks for the elderly so that health care providers clearly understand the chronic conditions and medications of elderly victims. It is worth noting that the notebooks are designed to effectively convey clinical information about age-related risks such as incontinence, falling, muscle weakness, and difficulty in swallowing. Making up for the declining health literacy of the elderly is undoubtedly one of the crucial roles of geriatricians.

Another important thing is to raise the public awareness of when and how they should consult geriatricians. It is necessary to enable the public to understand that geriatricians are, as it were, life-planning partners from the viewpoint of patient-centered care (3). The desirable health goals of individual patients tend to change as they age (4). With regard to longitudinal care, access on demand, coordination among subspecialists, and home-based care, geriatricians can play the leading role in treating the elderly with multiple and complex illnesses.

In order to solve a variety of geriatrics-related issues, the unique characteristic and the importance of geriatrics need to take deep root in society.

References

1. Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med. 2012; 156: 654-56. [PMID: 22547474]

2. Leipzig RM, Hall WJ, Fried LP. Treating our social scotoma: the case for investing in geriatrics, our nation's future, and our patients. Ann Intern Med. 2012; 156: 657-59. [PMID: 22547475]

3. Reuben DB, Tinetti ME. Goal-oriented patient care: an alternative health outcomes paradigm. N Engl J Med 2012; 366: 777-79. [PMID: 22375966]

4. Bardes CL. Defining patient-centered medicine. N Engl J Med 2012; 366: 787-3. [PMID: 22375968]

Conflict of Interest:

None declared

Re: Is Geriatric Medicine Terminally ill?
Posted on May 29, 2012
LeslieLibow, Geriatrician
Mt. Sinai School of Medicine
Conflict of Interest: None Declared

The authors of “Is Geriatric Medicine Terminally Ill,” (Golden, Silverman, Mintzer; (1)) could re-title their article as follows: “Is the older person in America Terminally Ill?”

The essential problem faced by the too small number of geriatricians is not simply, as referred to by the authors, the poor wages paid and/or the inadequate reimbursement for care of many medical problems experienced by the very old. Rather, it is the essence of “oldness” of the patients. This “oldness” contributes to turning medical students and physicians away from rendering care to the very old.

The many physicians and gerontologists who helped establish the new field of geriatric medicine never intended to have geriatricians give care to the entire population of the very old. Rather the main population served by the field of geriatric medicine is the very old (75 years and beyond—13,000,000). In addition, geriatricians were intended to be teachers of all other physicians in training and advisors to health care systems and government.

The very old have multiple organ abnormalities including heart, gastrointestinal tract and bony skeleton. Many also suffer from memory impairment with a more widespread defect of cognition— the “so called” dementia. The skin too wrinkles and the general appearance is different from when the person was 20 or more years younger. These changes are is in a direction of less youthful appearance and this is considered unattractive in our culture and in other cultures too.

The authors suggest the development of non-physicians to teach geriatrics and/or to deliver geriatric care. This is a serious departure from the tradition of U.S. medicine. This radical change would require the creation of an officially recognized two class system of care with the continued centrality of physicians in the care of all age populations other than the very old. Our culture would have to embrace the concept that the very old do not deserve to have physicians as their principal medical providers nor as a key clinician on teams developed to render care to them.

Thus far we have not created a computer or a robot which is an effective alternative to a keen physician who is aware and concerned about the very old person’s complex clinical history and usually multiple medications-often averaging 9 medications per day per each very old person.

It was an innocent error for the field of internal medicine and geriatrics to reduce the fellowship period from two years to one year. I agree with Golden, Silverman and Mintzer (1) that one year is inadequate time for a geriatric specialist to acquire the clinical body of knowledge of geriatrics while also learning to organize and participate and possibly lead the team necessary to provide enlightened and cost effective care to the very old.

It is said that the approach to support and care of the very old population is the measure of the tone and ethics of a society. Let those of us within internal medicine and geriatrics not rush to abandon our responsibilities.

References

1. Golden, A.G., Silverman, M.A. and Mentzer, M.J. Is Geriatric Medicine Terminally Ill? Ann Intern Med. 2012; 156, 654-656

2. Libow, LS. Geriatrics in the United States—baby boomers’ boom? N Engl J Med. 2005; 352:750-2. [PMID: 15728805]

Conflict of Interest:

None declared

The Future of Geriatric Medicine: Needs Healing, Not More Bruising! Musings of a Fellow and Program Director in Geriatric Medicine
Posted on June 4, 2012
T.S.Dharmarajan, MD, FACP, AGSF, Professor of Medicine and Associate Dean, New York Medical College, Valhalla, NY, Vi, Abhishek Kumar MD, Fellow, Geriatric Medicine, Montefiore Medical Center (North division), Bronx, NY
Montefiore Medical Center (North division), Bronx, NY
Conflict of Interest: None Declared

To the editor,

"Is Geriatric Medicine Terminally ill?" in the Annals (1) and "The Case for Investing in Geriatrics" (2) invoke much thought. Is it not premature to term geriatric medicine terminal; rather, than address factors for its perceived decline with solutions for healing?

The Aging of America warrants development of programs that address functional decline and disability in the old (3). The shortage of geriatricians will continue, calling for physician competency in geriatrics (4). Besides internal medicine, several specialties are formulating approaches to include training in geriatric care (4). The American Gastroenterological Association issued a position paper supporting this concept (5); Oncology and other specialties will follow.

The value of geriatric medicine fellowship is questioned (1). As a geriatric medicine fellowship program director for two decades, after training about 120 fellows, the value is clearly evident. The differences in approach to geriatric patients by trained geriatricians is obvious: in terms of knowledge and confidence, constructing a differential diagnosis, leading a multidisciplinary team and addressing management (including polypharmacy). One year of training to gain this expertise is merely a fragment of time in a physician's professional life. Most fellows, properly nurtured, enjoy caring for elders and do not regret the year spent. Undoubtedly, geriatrics requires emphasis during internal medicine residency; but how much more can the overworked resident be taught, knowing the regulations imposed by the ACGME? (6).

Quoting a current fellow (second author): "Did I read the Annals article (1) right? I re-read in disbelief. Dr. Golden played the devil's advocate well; perhaps a bit too well! Like my trainee colleagues, I tried to unsuccessfully dismiss the negativity that followed. One wonders the impact the article will have on future trainees contemplating geriatrics for a career. The subspecialty gets poor peer recognition in the physician community, lacking a well defined market niche, possibly from shortage of trained geriatricians. Today, we do see older patients actually seek geriatricians for care. Additionally, students and residents burdened by huge educational loans, upon reading these comments (1), might turn even more biased against geriatrics, anticipating the poor future returns."

Long ago, "pediatrics" was unrecognized; general practitioners addressed every illness. Today pediatrics stands distinct and subspecialized. Geriatric medicine is ironically young and needs nurturing to adult years. The New York ACP chapter Geriatrics Task Force, for one, is addressing issues. Pessimism is detrimental. Geriatrics is not a failed experiment, but in fact, a beautiful innovation, young in its life span!

References

1. Golden AG, Silverman MA, Mintzer MJ. Is geriatric medicine terminally ill? Ann Intern Med. 2012; 156:654-6

2. Leipzig RM, Hall WJ, Fried LP. Treating our societal scotoma: The case for investing in geriatrics, our nation's future, and our patients. Annals on Intern med. 2012; 156: 657-9

3. Kelley AS, Ettner SL, Morrison RS et al. Disability and decline in physical function associated with hospital use at end of life. J Gen Intern Med. 2012; Mar 2; ahead of print

4. Kuehn BM. Effort under way to prepare physicians to care for growing elderly population. JAMA. 2009;302:727-8

5. Hall KE, Proctor DD, Fisher L et al. American Gastroenterological Association Future Trends Committee Report: Effect of aging of the population on Gastroenterology Practice, Education and Research. Gastroenterology. 2005.129:1305-38

6. Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system - rationale and benefits. New Eng J Med. 2012; 366: 1051-6

Conflict of Interest:

None declared

The issue is ageism
Posted on June 20, 2012
Luis Garcia-Fabela, Miguel Rivero-Navarro, Mario Perez-Zepeda, Luis Perez-Robledo
Centro Medico ISSEMyM Toluca; Instituto Nacional de Geriatria
Conflict of Interest: None Declared

TO THE EDITOR: The issue is ageism!. Ageism is defined as prejudice or discrimination against or in favor any age group, in this case, the aged (1). People would think that if there is a person least likely to sustain stereotypes and prejudice against older persons, it would be a doctor. However, ageism starts early in medical life; since medical school we can find negative perceptions and discriminating ideas toward the elders. Medical learning is also reductionist in nature, focus on a single organ or system is the rule, coexistence of multiple affections on various levels is neglected, so complexity and co-morbidity doesn’t exist or are poorly understood. Maybe there lies the reason why there are few persons interested on the holistic view of geriatrics. Traditional and seemingly short-view and industry-driven endpoints (mortality, survival, etc) taught since medical school, seem to be of little value in elder care where disability, symptoms, falls, delirium, etcetera are of paramount significance. As told by Verbrugge (2) from her socio-medical perspective: “people live with chronic conditions rather than die from them…symptoms and disability are the principal outcomes…”. However, from a primary care point of view, it is difficult to define and to give attention to complex patients (3); disability and complexity theories are not traditionally taught in medical school.

Lack of understanding of this shift of attention and multidimensionality that requires geriatric care might explain dissatisfaction reported by general internists (4) compared versus geriatricians, professional satisfaction correlates with patient’s outcomes and satisfaction (it’s a bidirectional relation). Improving one older person’s function and independence, preventing falls and delirium, identify and treat cognitive impairment and depression, all should be recognized because saves money to the system, and fulfills both the health professional and the human person. That’s why is imperative to change the medical care paradigm towards older persons in a world that’s rapidly ageing and there’s a shortage of geriatric care specialists and non-ageist medical practitioners available; there is a mismatch between what’s happening in our ageing societies and political, educational and health issues. In Mexico we are clear that as in American geriatric care crisis referred by Golden (5) on the Journal, probably, the solution to it is trying to fuse the best of the medical healthcare model (focus on disease) and the social model (focus on the person), and take it all the way since medical school to postgraduate training courses. Elderly persons wait for answers and actions now, because the medical healthcare model as we know it might be terminally ill, already.

References

1. Ory M; Hoffman MK; Hawkins M; et al. Challenging Ageing Stereotypes. Strategies for Creating a More Active Society. Am J Prev Med 2003; 25(3Sii): 164-171.

2. Verbrugge LM; Jette AM. The Disablement Process. Soc Sci Med 1994; 38(1):1-14.

3. Grant RW; Ashburner JM; Hong CC; et al. Defining Patient Complexity from the Primary Care Physician Perspective. Ann Int Med 2011; 155: 797-804.

4. Leigh JP; Kravitz RL; Schembri M; et al. Physician Career Satisfaction Across Specialties. Arch Int Med 2002; 162: 1577-1584.

5. Golden AG; Silverman MA; Mintzer MJ. Is Geriatric Medicine Terminally Ill? Ann Int Med 2012; 156(9): 654-657.

Reply to Libow
Posted on June 29, 2012
Adam M. Golden, MD, MBA
None
Conflict of Interest: None Declared

Dr. Libow discounts the poor reimbursements as the major cause for the declining interest in geriatric medicine. Instead, he believes that it is the negative attitudes of students and physicians toward “oldness” that is primarily responsible. Although attitudes are clearly a factor, Dr. Libow under values the reality that market forces are a key issue in medicine, and human nature    Negative attitudes are often ameliorated by reasonable and equitable incentives. Most people, for example, have attitudinal issues with human feces and feeding tubes, yet the subspecialty of gastroenterology, is thriving.   Gastroenterology fellowship positions are competitive among internal medicine residents (many of whom are saddled with large amounts of student debt).

 Just to clarify for the readers, we did not “suggest the development of non-physicians to teach geriatrics or deliver geriatric care.  Rather, we stated that many non-fellowship trained geriatricians and non-geriatrician physicians are currently teaching medical students and housestaff about the care of the elderly patient (1). With continual poor interest in geriatric fellowship training, resources need to be directed toward the further development of non-geriatrician experts in aging medicine. With regard to his concern about non-physicians delivering geriatric care, physician assistants and nurse practitioners are already providing geriatric care in the outpatient, inpatient, and long-term care settings.

 References

Golden AG, Silverman MA, Mintzer M. Is geriatric medicine terminally ill? Ann Intern Med. 2012;156:654-656. [PMID 22547474]

 

Reply to Hamerman
Posted on June 29, 2012
Adam M. Golden, MD, MBA
None
Conflict of Interest: None Declared

As geriatricians we too are dismayed by the current state of our subspecialty. We agree that a multi-disciplinary approach is needed to assess and address the current state of geriatric medicine (1). There have been previous attempts by geriatricians to define the mission of geriatrics (2).  However, as you suggested, future attempts need broader input from consumers, health care administrators, and health care planners.

 We also agree that despite much progress in the basic science of aging, current efforts to address frailty are limited.  Basic science research efforts have not translated into geriatrician-specific medical interventions. The geriatrician physician-basic scientist is a true rarity.  In fact, many of the new clinical treatments for older adults are coming from non-geriatricians (psychiatrists, neurologists, ophthalmologists, cardiologists, oncologists, etc.).  It remains unclear if future progress in the study of aging will provide sufficient incentive to initiate the policy and training changes needed to revitalize and save the subspecialty of geriatric medicine.

 References

  1. Golden AG, Silverman MA, Mintzer M. Is geriatric medicine terminally ill? Ann Intern Med. 2012;156:654-656. [PMID 22547474]
  2. Besdine R, Boult C, Brangman S, Coleman EA, Fried LP, Gerety M, Johnson JC, Katz PR, Potter JF, Reuben DB, Sloane PD, Studenski S, Warshaw G; American Geriatrics Society Task Force on the Future of Geriatric Medicine.  Caring for Older Americans: The future of geriatric medicine. J Am Geriatric Soc. 2005;53: S245-S256. [PMID: 15963180]

 

Reply to Madden
Posted on June 29, 2012
Adam M. Golden, MD, MBA
None
Conflict of Interest: None Declared

Writing on behalf of the Canadian Geriatrics Society, Dr. Madden contends that our line of reasoning may be "dubious." However, no evidence is provided to dispute the facts that the subspecialty of geriatric medicine in the US remains an unpopular career choice, is poorly reimbursed, and lacks sufficient research demonstrating its effectiveness compared to non-geriatricians (1).

 Instead he employs the Pareto principle to state that geriatricians should focus their clinical efforts on the care of the frail elderly. While we cannot speak for Geriatrics in Canada, it is not clear that this should be the predominant focus for geriatricians in the US. To support his argument, Dr. Madden relies on a meta-analysis of CGAs that analyzed data from 22 trials from 6 countries (only one study was published during the last 10 years) (2). Two of the 22 studies did not include a geriatrician as part of the CGA team.  The meta-analysis showed that inpatient interdisciplinary geriatric assessment wards improved clinical outcomes in older adults. There was no stratification based on frailty and there was no effect on overall mortality (3). Much of the success of these inpatients units was presumed to be based on the specialization of gerontological nursing and the implementation of multidisciplinary geriatric-focused protocols (2).  The relevance of this data to the effectiveness of geriatricians in the current American health care system remains uncertain (3).

Dr. Madden also provides no evidence to explain how limiting geriatric medicine to the care of the frail elderly would revitalize the subspecialty. Focusing on the frail elderly as the clinical niche for geriatricians might further discourage interest in the subspecialty, unless it is accompanied by significant positive changes in physician recognition and physician reimbursement.  Furthermore, alternative pathways are currently available for non-geriatricians in the United States to develop the skills needed to care for frail older adults through organizations, such as AMDA and others. 

There are no simple solutions as Drs Madden and Rockwood's reply would suggest. If geriatric medicine is to survive as a clinical subspecialty in the US, it will require dramatic health care policy reform efforts, some of which are eloquently listed by Leipzig et al.(4), and by Dr. David Hamman's online response to our article(5).

References

  1. Golden AG, Silverman MA, Mintzer M. Is geriatric medicine terminally ill? Ann Intern Med. 2012;156:654-656. [PMID 22547474]
  2. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ. 2011;343:d6553. [PMID 22034146]
  3. Totten A, Carson S, Peterson K, Low A, Christensen V, Tiwari A. Evidence Brief: Effect of geriatricians on outcomes of inpatient and outpatient care. VA-ESP Project #09-199;2012.
  4. Leipzig RM, Hall WJ, Fried LP. Treating our social scotoma:  the case for investing in geriatrics, our nation's future, and our patients. Ann Intern Med. 2012;156:657-659 [PMID:22547475]
  5. Hamerman D. In Response. Annals of Internal Medicine Online. Accessed at: https://annals.org/article.aspx?articleid=1134666#ChallengesinMeasuringtheEffectivenessoftheGeriatrician on June 2, 2012.
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