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In the Balance |

Treating Our Societal Scotoma: The Case for Investing in Geriatrics, Our Nation's Future, and Our Patients

Rosanne M. Leipzig, MD, PhD; William J. Hall, MD; and Linda P. Fried, MD, MPH
[+] Article and Author Information

From Mount Sinai School of Medicine and the Mailman School of Public Health of Columbia University, New York, and University of Rochester School of Medicine, Center for Healthy Aging, Rochester, New York.

Acknowledgment: The authors thank Karen L. Sauvigné, MA, for her editorial and technical support.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0760.

Requests for Single Reprints: Rosanne M. Leipzig, MD, PhD, Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, 1468 Madison Avenue, Box 1070, New York, NY 10029.

Current Author Addresses: Dr. Leipzig: Brookdale Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, 1468 Madison Avenue, Box 1070, New York, NY 10029.

Dr. Hall: University of Rochester School of Medicine, Center for Healthy Aging, Box 58, 1000 South Avenue, Rochester, NY 14620.

Dr. Fried: Columbia University Medical Center, Mailman School of Public Health, 722 West 168th Street, Room 1408, New York, NY 10032.

Author Contributions: Conception and design: R.M. Leipzig, W.J. Hall.

Analysis and interpretation of the data: R.M. Leipzig, W.J. Hall.

Drafting of the article: R.M. Leipzig, W.J. Hall.

Critical revision of the article for important intellectual content: R.M. Leipzig, W.J. Hall.

Final approval of the article: R.M. Leipzig.

Administrative, technical, or logistic support: R.M. Leipzig.


Ann Intern Med. 2012;156(9):657-659. doi:10.7326/0003-4819-156-9-201205010-00010
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Because the U.S. population is rapidly aging and longevity is increasing, this commentary argues that expanding geriatric medicine training is necessary to optimize outcomes for older adults. The authors note that geriatricians have developed effective strategies for managing complex comorbid conditions in older adults and that the skills of geriatricians are exactly what the United States needs to deal with the Medicare crisis. They propose strategies to promote expansion of the geriatric workforce.

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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 geriatric crisis in Italy: a humble proposal
Posted on May 17, 2012
GiuseppeBellelli, MD
University of Milano-Bicocca, Geriatric Clinic, via Cadore, 48 - 20900 Monza, Italy
Conflict of Interest: None Declared

We read with great concern the editorial by Leipzig et al. (1) on the dramatic inadequacy of a geriatric workforce facing the increasing number of older persons in the US. In Italy, if possible, the state of the crisis is worse than in the US, since we will never be able to reach the required amount of geriatricians (since the Italian population is about one fourth than that of US we hypothesize that we will need about 6500 specialists by the year 2030). In fact, our Academies graduate about 120 geriatricians a year, a rate barely sufficient in balancing the specialists' turnover. In this scenario, also taking into account the economic crisis involving all sectors of our society, it would be unrealistic to plan a swinging increase in the numbers of postgraduate students, since it would require too much relevant effort of our public budget. For this reason we propose -although with some regret- to concentrate our effort in specific areas, aiming at obtaining in the short period some results useful for the health of our increasingly older population. First, we should concentrate on setting a number of high-standard research centers dedicated to improve the quality of care both from medical and structural points of view. Obviously, these centers need to be closely linked with hospitals, post acute and rehabilitative settings, nursing homes and home care services to implement the programs generated by the research. Second, strictly connected with those centers, high-quality teaching programs are needed, to influence the education and the training of all young doctors (and other professionals), independently from their particular sector of medical interest. We are well aware the this is a quite reductive approach, which implicitly might sound like a surrender of the geriatric discipline to the demographic and epidemiological changes. However following this model we will probably save the cultural (and hopefully also practical) presence of geriatrics in our health system.

References

1. Leipzig RM, Hall WJ, Fried LP. Treating Our Societal Scotoma: The Case for Investing in Geriatrics, Our Nation's Future, and Our Patients [Editorial]. Ann Intern Med. 2012;156:657-9.

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

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

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