Integrating geriatrics into the subspecialties of internal medicine: the Hartford Foundation/American Geriatrics Society/Wake Forest University Bowman Gray School of Medicine Initiative.

Abstract

For nearly two decades the John A. Hartford Foundation has supported education and training in geriatric medicine as part of a broad program in health care of older adults to address the American demographic imperative of a progressively aging population. This has included strong emphasis on faculty development in geriatrics, from year-long mid-career retraining fellowships in the 1980s to the present program of prestigious, highly competitive, 3-year early faculty fellowships named for Paul Beeson, a pioneer in geriatric academic leadership, during the past 20 years. Also featured as part of the Hartford program have been special initiatives targeted at attracting medical students to careers in geriatrics and focused efforts to enrich residency programs, board certification examinations, and faculty capacity in geriatrics in internal medicine, anesthesiology, emergency medicine, and obstetrics and gynecology, among others. These efforts have recognized not only the stark, historical underrepresentation of geriatrics in medical education and training in the United States, but they have also addressed the perceived unattractiveness of the field as reinforced by this underrepresentation. Despite a concentration of healthcare effort and resource consumption among older Americans (whose per capita costs are already four times those of citizens less than age 65), curricula in geriatrics at undergraduate and graduate levels of medical education remain grossly deficient in both content and experience in nearly all medical and surgical specialties. This imbalance persists even as the health care needs of older people threaten to overwhelm a system developed principally to serve the requirements of a younger population whose episodic illnesses and injuries may be more given to cure through high technology, often hospital-based care. A vicious cycle of professional disincentives has been established that is particularly inimical to the needs of an older population. Physicians in the specialties and subspecialties focusing on the needs of a younger population have been rewarded with the highest professional and public recognition, highest incomes, and frequently the most controlled, satisfying lifestyles. Those choosing to pursue careers in the primary care specialties have experienced the opposite: the lowest professional and public recognition, lowest incomes, and least controlled lifestyles. In the extreme, these have included geriatrics, which as a field has struggled to attract the quality and quantity of physicians needed to address appropriately the healthcare requirements of older Americans. Skills to meet those requirements are often as much “high touch” as “high tech,” based as much in common sense and emotional intelligence as in the reductionistic, simplistic approach to problem-solving that dominates scientific medicine, and require deep commitment to the humanistic, holistic, and ethical dimensions of patient care, including acceptance of and expertise in care of the very old, frail, and often dying. For editorial comment, see p 641 Somewhat ironically,1 internal medicine has been the fulcrum of this lever between high technology, reductionism, and subspecialization compared with low technology, synthesis, and generalism. Until very recently, however, the large majority of those entering residencies in internal medicine selected a fellowship in one of the 10 medical subspecialties, especially those that are procedure-intensive, notably cardiology, gastroenterology, and pulmonary-critical care medicine. For nearly a generation, internal medicine, the specialty most often selected by US medical graduates, swung progressively toward its subspecialties, attracting “the best and the brightest” to careers focused on the care of patients whose diseases were concentrated within those organ- and disease-based domains. Thus, as scientific medicine of the 20th century produced breakthrough discovery after breakthrough discovery, internists progressively inflected their attention to concentrating upon specific diseases in specific organs at specific timepoints in specific patients. A basic tenet of the present initiative posits that such scientific sophistication has been achieved at the expense of the traditional role of the internist, that of the consummate generalist who compulsively gathers the massive amount of information that proceeds from a reductionistic approach to disaggregating complex problems and synthesizes it all into a comprehensive plan for each patient, weighing and accepting the inevitable trade-offs in diagnosis and treatment. These are attributes that veritably define the expert geriatrician, whose patients virtually never present with a single problem. The compartmentalization that characterizes the subspecialist has also required a narrower approach to patient problem-solving. Hence subspecialists are perhaps most at risk of “missing the forest for the trees” — and this focus has come to include lost opportunities to advance their fields through research and education as the nuances of optimal diagnosis and management became blurred in their very oldest, frailest, and most complex patients. Nevertheless, the reservoir of talent with the requisite scientific and clinical training that might be best applied to improve geriatric health care residing within the large cache of medical subspecialists is enormous. The Hartford initiative is designed to assist leading subspecialists to redirect their attention to the subtleties of the geriatric aspects of their disciplines, to discover opportunities for teaching and research within those aspects, and to internalize the excitement and satisfaction that fuel the professional efforts of those who call themselves geriatricians. To begin to redress this mismatch between talent and the needs of an aging population, as part of its broad aging program, a grant was made in 1994 by the Hartford Foundation to the American Geriatrics Society to develop a program whose title heads this article: An Initiative to Integrate Geriatrics into the Subspecialties of Internal Medicine. Administered by the J. Paul Sticht Center on Aging of the Wake Forest University Bowman Gray School of Medicine, this program is designed to collaborate with each of the medical subspecialties in a multi-year campaign to: . Raise the sensitivity of professional leaders to specific needs, opportunities, and challenges of caring for a progressively aging population through: . Research . Education . Development and evaluation of systems of care . Develop a cadre of informed, committed, and influential academic subspecialty leaders to accomplish this agenda and in turn to attract the best and the brightest of future subspecialists to this opportunity . Incorporate an appropriate geriatric curriculum into fellowship training in each of the subspecialties through enhanced requirements for such training by the Residency Review Committee-Internal Medicine (RRC-IM) . Enrich geriatric content in certifying examinations developed by the subspecialty boards of the American Board of Internal Medicine (ABIM) . Enrich the education and continuing education of subspecialists via: . Articles and editorials in leading subspecialty journals and textbooks . Presentations, seminars, and symposia at regional and national subspecialty meetings . Incorporate more and better gerontological and geriatric research in the portfolios of both governmental (NIH, NSF, AHCPR, DVA) and nongovernmental agencies (professional organizations, foundations, and industry) . Assure strong and appropriate collaboration between the medical subspecialties and general internal medicine (including geriatrics) by — and as a mirror image — incorporation of geriatric subspecialty content in presentations, publications, and professional training and certification in general internal medicine (as well as family medicine and the nonmedical specialties) and the fellowship training of geriatricians. This reciprocal relationship between generalists and sub-specialists regarding geriatric curriculum at all levels — medical student, residency, and fellowship — assumes that, as at present, much of the teaching of students at all levels will be delivered by faculty with in depth expertise in specific content areas, i.e., notably by medical subspecialists who are likely to continue to dominate the ranks of academic clinical faculties in the future. The principal vehicle for addressing this daunting agenda under the aegis of the Hartford grant is the Geriatric Education Retreat (GER), a 5-day total immersion of all attendees (only those faculty committed to stay the entire duration of the GER are invited to attend). This represents a focused strategy to gerontologize exemplary faculty in each subspecialty at leading academic health centers through their active participation in an intensive learning experience in the gerontologic and geriatric aspects of their subspecialty, generally one subspecialty at a time. To date, three GERs have been held. The first, in Endocrinology, Diabetes, and Metabolism, was held at Rosario's Resort, Orcas Island, Washington, August 6–11, 1995, and the second, in Cardiology, took place August 11–16, 1996, at the Rimrock Resort Hotel, Banff, Alberta (see editorial). A third GER, in Medical Oncology, was held at the El Conquistador Resort, Puerto Rico, February 21–26, 1997. A fourth GER, has been scheduled in August 1997 at Whistler, British Columbia. For reasons of efficiency, cross-fertilization, and potential synergism, this GER will combine three subspecialties with substantial overlap in scientific and clinical arenas, especially as they affectolder people: Infectious Disease, Rheumatology, and Allergy and Immunology. The remaining subspecialties of Gastroenterology, Nephrology, and Pulmonary (including Critical Care) Medicine will be held subsequently, subject to availability of additional funds and sustained interest from both geriatric and subspecialty communities. Although at this time it seems unlikely that a separate GER will be held for non-oncologic aspects of Geriatric Hematology, this concept could conceivably also be extended to other specialties such as Dermatology, Neurology, and Psychiatry given guidance of initiative from those disciplines as well as development of financing. The principal features of each GER are as follows: . Planning: Approximately a year before each GER, a planning committee is selected by the project principal investigator (WRH) and coordinator (NW) upon the recommendation of the External Advisory Committee (Walter Ettinger, Michael Rich, Harvey Cohen, Jeffrey Halter). This planning committee is generally co-led by a geriatric subspecialist (i.e., a geriatrician with training and research in the subspecialty whose career has become redirected to gerontology) and a nationally renowned academic subspecialist sympathetic (but not yet committed) to gerontology. A tentative agenda, time, and place are selected, and a potential list of faculty to be invited is composed. For the Endocrinology GER, a national competition involving mini-proposals was solicited, and approximately one-half of attendees were selected on that basis. For Cardiology, all participants were individually invited to attend and played an active faculty role as presenter or session leader. Letters and telephone calls from planning committee co-chairs are employed to secure agreements to attend as well as to solicit synopses and illustrations in advance. . Venue: a resort attractive enough to attract and retain faculty who are sufficiently in demand and receive several similar invitations each year, yet an environment not so plush that some sacrifice is entailed, a strategy designed to yield a greater personal commitment to “gerontologizing” the field . Time and place: generally during a month (notably July or August) when a working family vacation is feasible (or in a sunny clime in the dead of winter) . Attendance: total number 40–50, with equal representation by: ) Subspecialists who are movers and shakers as yet uncommitted to gerontology or geriatrics ) Subspecialists already clearly committed to gerontology or geriatrics ) Geriatricians not originating from that subspecialty . Incentives and agreements: each attendee who makes a presentation or leads a discussion receives a $300 per day honorarium. The expenses of all attendees are paid from the grant, less meals not associated with a session (and excluding expenses for accompanying guests, of course). Each presenting speaker prepares a written summary in advance (with illustrations and tables as appropriate), these being incorporated into a loose-leaf volume distributed on arrival. . Meeting schedule and organization: generally half-day sessions (e.g., 8 am to 12:30 pm), plus several 2 to 3-hour evening sessions to include a mixture of: ) Didactic, socratic, and discussion sessions ) Plenary, small group, and small group feedback reporting sessions ) Informal social functions and exchanges . Topics: ) Gerontology and geriatric medicine: general gerontology for the subspecialist, e.g., geriatric assessment, geriatric syndromes, geriatric pharmacology, team care, system issues, demography, and health care organization and costs ) Gerontologic and geriatric aspects of the subspecialty; e.g, (for cardiologists) aging and cardiovascular physiology, cardiovascular disease in the elderly ) Curriculum in geriatrics for the subspecialty ) How to incorporate that curriculum into fellowship training ) How to assure incorporation of gerontology and geriatrics in fellowship training (via RRC) and certifying examinations (via ABIM) ) Developing subspecialty faculty with interest and expertise in gerontology and geriatrics (including identification of career development funding opportunities) ) Retro-educating certified subspecialists in gerontology and geriatrics (via CME, futuristic educational materials and venues, mini-fellowships) ) Research opportunities (including funding) ) Summary and plans/strategy for follow-up . Follow-up: A closing session is devoted to feedback, evaluation, and concrete plans for follow-up. These plans are specific to each subspecialty but generally include development of journal articles and editorials, presentations to subspecialty society regional and national meetings and groups of fellowship program directors, suggestions for a research agenda to be forwarded to NIH, industry, nonprofit organizations, and foundations, etc., and individual questionnaires 6–12 months later to be forwarded to each attendee regarding progress made to date at their institution in achieving the goals of the GER. Evaluation of the effectiveness of this initiative at this juncture is perforce preliminary, highly subjective, and no doubt biased. Moreover, the project, unprecedented as it is, represents an evolving work-in-progress. Our early assessment of the project is sufficiently encouraging to predict its extension to several subspecialties beyond the original 3-year scope of the project. Perhaps most exciting to those of us in attendance throughout the first three GERs has been the unmistakable spirit of each conclave, most clearly expressed in the enthusiasm of attendees formerly unaffiliated with geriatrics or gerontology as reflected in their statements of commitment to lead a change in attitude and practice within their subspecialties and their institutions in the future. However, we are well aware that the “spirit of the moment,” the “spirit of Banff,” the “spirit of Orcas Island,” or the “Spirit of Puerto Rico,” generally generated after the first 2 or 3 days of the GER, can be evanescent, and, hence, plans for follow-up were more concrete and specific for cardiology and medical oncology than for endocrinology, and these will be monitored with increased attention in future GERs. The direct cost of this project is substantial (to date nearly $1.5 million has been committed from Hartford and lesser amounts from pharmaceutical firms [Merck, Pfizer, and Warner-Lambert] in the form of unrestricted grants). Even greater are the indirect costs, notably undercompensated time and effort of planning and participating faculty. However, the potential gain is enormous, given the multiple benefits that may accrue from a more informed, multi-disciplinary, and cost-sensitive approach to geriatric care by medical subspecialists in the future. Indeed, the likelihood of the outcome of this initiative being favorably judged by history seems enhanced by present secular trends: cost containment of health care is a social imperative even as the population ages and its requirement for health care inevitably grows; more efficient health care of older adults will demand the talents of expert clinicians, both generalists and subspecialists, in those aspects of geriatrics that are most cost-effective, notably astute assessment, a selective application of technology and therapeutics, multi-disciplinary team care, non-hospital-based care (especially home- and community-based long-term care), and appropriate, patient-centered end-of-life care. Thus the prospects seem bright for this project to have substantial lasting impact in improved care of an aging American population in a fashion reflecting well on all sectors of the medical profession, including generalists, subspecialists, and geriatricians.