Policy for an Aging Society

Abstract

MEDICAL STUDENTS AND RESIDENTS ARE TAUGHT to perform a complete review of systems in a thorough patient workup. Through this process, patients may report less prominent concerns that may be meaningful to the physician’s evaluation. As a complement to the new series, Care of the Aging Patient: From Evidence to Action, in this issue of JAMA, a Commentary will provide a forum for discussion of a policy review of systems for the care of older adults. In the first article, Reuben brings into sharp relief the need for greater expertise and new approaches to caring for older patients as they face physical decline and advanced illness. Using the case of Mr Z, Reuben examines the patientcare encounter and the analytical and interpersonal processes that the physician must undertake. For most US physicians, both specialists and generalists, this story is likely unfamiliar, and physicians may hardly be able to imagine themselves or colleagues conducting the kind of extensive evaluation described. Patients would flock to this comprehensive yet individualized care. Although this approach is at the core of training in geriatric medicine, such specialists are rare, and fewer students are seeking careers in geriatrics or primary care. In each year from 2007 to 2009 fewer than 100 US medical graduates pursued postdoctoral training in geriatrics. The crisis represented by this shortage is made clear by imagining an alternate scenario: usual care rather than best case. In the usual care scenario, Mr Z would have been considered a healthy older man. His falls would not have been explored and his concerns would have been referred to specialists. He ultimately could have sustained a major fracture, requiring surgical intervention. During that hospitalization, he most likely would have become weak and had iatrogenic complications, such that even a very prolonged rehabilitation would not return him to his prior function. During this time, someone most likely would have discovered that his wife at home had Alzheimer disease and was unable to care for herself. Hopefully, a capable social worker would have helped husband and wife to be admitted to the same long-term care facility, but they might have been separated since he would be in rehabilitation and she in custodial care. Their complex health care could lead not only to poor patient care but to costly overuse of technologies and most importantly loss of the function, dignity, and personal values they would have chosen. Reuben’s careful analysis suggests that anticipating and addressing patients’ evolving short-term, midterm, and longterm issues provides better care in all metrics: quality, fewer errors, and reduced overuse of health care services. Everyone is better off. Why don’t patients have more access to this kind of care and what will it take to provide it? The 6 characteristics of optimal quality of care for a patient facing frailty are: (1) extensive knowledge of the aging process, of prognostic indicators, and the multiple geriatrics syndromes; (2) proactive and anticipatory care that is longitudinal; (3) a well-functioning practice structure with a multidisciplinary team or network, in which care is coordinated efficiently and effectively and linked to community resources; (4) personal interaction with the relationship grounded in good communication skills and a clear sense of the patient’s values, goals, and preferences; (5) practices that manage care across diverse settings to ensure safe transitions and continuity; and (6) health care institutions, especially hospitals, that incorporate acute care of the elderly units, early mobilization, careful attention to drug interactions, and other best practices to reduce the grave risk they currently pose to frail, older individuals. Several current US policy initiatives may have the potential to improve the situation. First, workforce support for primary care should always include explicit attention to geriatric medicine. Most geriatric specialists begin postgraduate training in family medicine or general internal medicine, the 2 largest and mostthreatened primary care specialties. Geriatric medicine is at even greater risk—less widely sought than primary care. As initiatives to reallocate residency positions under the graduate medical education (GME) limits are considered, geriatric medicine should be foremost on that list—a core discipline for Medicare and Medicare GME payment priorities. Incentives such as loan forgiveness or repayment may help bridge the gap until effective payment reform occurs.