December 1998 Bulletin

Geriatricians, in short supply, seek help

AGS, Hartford Foundation fund special residency programs in 10 specialties

Elton Strauss, MD, examines patient, at Mount Sinai Medical Center, New York. He urges a "political push" for geriatrics support.

By Sandra Lee Breisch

Will the medical profession be prepared for the flood tide of elderly patients who will show up in waiting rooms in the coming decades?

In 2030, more than 20 percent of the United States population will be age 65 and older and 23 percent of the elderly will be 85 and up. Orthopaedic surgeons will be confronted not only by more elderly patients to treat for arthritis, fractures, osteoporosis and more, but also patients who will challenge the diagnostic and interpersonal skills of the physician.

Orthopaedic surgeons, as well as physicians in all specialties, will find many elderly patients presenting with coexisting disorders that complicate their treatment; the patients' hazy memories and short attention spans may hinder their ability to articulate their problems.

Geriatricians are trained to deal with the elderly, but they're already in short supply. Today, there are 9,000 certified geriatricians and an estimated need for 2,500 to 3,000 more. In year 2000, experts predict a need for 10,000 geriatricians and about 20,000 in 2025. However, only 300 physicians a year graduate in geriatrics.

"Specialists in all fields can help a great deal by relieving the primary care physicians of at least some of the need to consult about geriatric issues," says David A. Solomon, MD, RAND corporation, who is co-director of the American Geriatrics Society (AGS) and the John A. Hartford Foundation Project (Hartford Foundation). The organizations are attempting to fill the present and future gap in geriatric care by introducing geriatric training in specialty residency programs.

The AGS and Hartford Foundation held a two-day conference, "Faculty Development and Residency Training Outreach Program" in Chicago in September to introduced Phase II of "Increasing Geriatrics Expertise in Non-Primary Care Specialties." This is an extension of a project that began with Phase I in 1994, funded with $750,000 for geriatrics residency training programs in five specialties: emergency medicine, general surgery, ob/gyn, orthopaedic surgery and urology.

Phase II, which was approved in March 1997 with funding of $1.5 million over four years, involves a collaborative relationship with five other specialties: anesthesiology, ophthalmology, otolaryngology, physical medicine and rehabilitation, and thoracic surgery. Phase I will continue to receive support and encouragement.

The overall program's goal is to provide an outreach opportunity to residency programs that have a serious commitment to increasing the amount and quality of geriatric education received by trainees, and to provide information and guidance on how geriatrics may be effectively incorporated into existing training programs.

Consulting geriatricians and selected faculty from 20 residency programs and 10 non-primary care specialties met in September to explore curriculum possibilities, obstacles and to identify key allies in their goal to increase geriatrics education, training and curriculum.

"This meeting provides an opportunity to develop linkages between selected programs and begin a sustained discussion of how best to incorporate instruction on the special health care needs of the elderly into non-primary care specialties," said Dr. Solomon.

"Clearly, the first five specialties of Phase I are underway," said Dr. Solomon, who pointed out that "emergency medicine and orthopaedics have been leaders" in this initiative. "Orthopaedics is doing their own thing, such as forming a Special Interest Group (SIG) on aging and holding a symposium at their annual meeting. You might want to look at that as a beginning for you," said Dr. Solomon. He encouraged participants to refer to the Academy's publication, Archives of the AAOS: Caring for the Elderly Patient.

Laura A. Robbins, MS, senior program officer at the Hartford Foundation, said, "All new funds are being directed in our mission to help the elderly." According to Dr. Solomon, institutions with well-developed geriatrics resource materials can use the funding to support additional training in geriatrics for key faculty members involved in the residency programs. "Other institutions may choose to devote the funds to purchasing curricular materials that meet the needs of their residencies [e.g., supporting development of case-based instructional materials]," he said. AGS will support the annual site visits by its expert consultants to each program.

"From 2010 on when the baby boom hits, it's going to be a very large number…. So training in geriatrics in every residency whatever specialty it is-in particular, internal and family medicine-is needed. It's important that the specialist understand what is different about diagnosis and treatment in the elderly person."

Gerald Felsenthal, MD, medical director, Sinai Rehabilitation Center, Sinai Hospital of Baltimore, whose site was selected for a geriatrics residency program, pointed out some potential obstacles preventing various specialties from incorporating multidisciplinary geriatric training programs.

One obstacle is the need for instruction faculty to spend more time on residency geriatrics teaching rounds. "With increasing productivity demanded by all faculty physicians, especially when you're talking about Medicare fees, there's only a limited amount of time you can spend on teaching," explains Dr. Felsenthal. "Teaching is not income generating. So, if you have to devote more of your time to seeing patients in order to earn income, it [time to teach] has to come from somewhere. This is a problem that's been noted in medical schools, it's affecting education in both in medical schools and residency programs."

In order to provide optimum elderly care, Dr. Felsenthal says there needs to be "a joining together" of dedicated support staff or key allies in various specialties within the institution who can cooperate in a multidisciplinary geriatrics assessment program.

Elton Strauss, MD, chief of orthopaedic trauma and reconstructive surgery, department of orthopaedic surgery, Mount Sinai Medical Center in New York, who trained Phase I participants, said he was concerned administrators have "a decreased awareness of what's going on in geriatrics and how complex these patients really are." He stressed the need for a symposium for hospital administrators and third party payers to explain the cost-effectiveness of multidisciplinary geriatric care.

"Multidisciplinary medicine is cost-effective and is the method of the future," Dr. Strauss said. "It's been shown to work in pediatrics and in multiple trauma."

E. Dennis Lyne, MD, a pediatric orthopaedic surgeon and program director, department of orthopaedic surgery, Michigan State University, Kalamazoo Center for Medical Studies, said his residents were "very enthusiastic" about the program. However, he expressed concern that "it was hard to integrate teaching time of our two residency programs, general surgery and orthopaedics. Now, we have a third one to integrate-emergency medicine."

Dr. Lyne noted that pediatrics and geriatrics have similar interdisciplinary approaches to the care of their patient populations. The question is, "How can the two share experiences and work together in the beginning of life to the last cycle of life to support each other and learn from each other's experiences?" he said.

Dr. Strauss noted the need for a "big political push" for geriatrics support and training and "public awareness. "In a mobile society where children are not able to take care of parents or grandparents, taking care of these patients becomes a significant social issue," he said.

In Phase I, the participating programs included:

Emergency medicine: Rhode Island Hospital/Brown University, SUNY at Buffalo and University of Arkansas.

General surgery: Michigan State University, Kalamazoo Center for Medical Studies; Northwestern University; St. Vincent's, New York City; and Yale University.

Gynecology: Bowman Gray, University of Pittsburgh; University of Rochester and University of Utah.

Orthopaedic surgery: Michigan State University, Kalamazoo Center for Medical Studies; University of Colorado and University of Pittsburgh. (In the third year of Phase I, University of Pittsburgh's program moved to Allegheny University.)

Urology: Maimonides, New York City and SUNY at Stony Brook.

The target specialties for Phase II include:

Anesthesiology: University of Pennsylvania; University of California, San Francisco; Duke University; and University of Washington.

Emergency medicine, general surgery and orthopaedic surgery: Michigan State University, Kalamazoo Center for Medical Studies.

General surgery: University of Arkansas for Medical Sciences and University of Colorado, Health Sciences Center.

Obstetrics and gynecology: University of Rochester School of Medicine; University of Alabama, Birmingham; and University of Utah.

Ophthalmology: University of Wisconsin School of Medicine and Baylor College of Medicine.

Orthopaedic surgery: Mount Sinai School of Medicine.

Otolaryngology: Albany Medical College and Indiana University

Physical medicine and rehabilitation: Sinai Hospital of Baltimore and University of Texas Southwestern Medical Center.

Thoracic surgery: Award still pending.

Urology: Case Western Reserve University and University of Iowa School of Medicine.


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