Response to the Report of the Institute of Medicine: Academic Geriatrics for the Year 2000.

Abstract

To the Editor: — “The Report of the Institute of Medicine: Academic Geriatrics for the Year 2000 by the Committee on Leadership for Academic Geriatric Medicine”1 focuses on the recommendation that a limited number of “centers of excellence” be created to provide “highest quality training for the next generation of academic leaders” in the field. The long-term goal for establishing geriatric training sites in many medical schools, and the production of adequate numbers of appropriately trained physicians to meet the needs of the elderly population are deferred, pending establishment of the centers. This stands in distinct contrast to the 1977 Institute of Medicine report entitled “Aging and Medical Education”2 which strongly urged substantial increases in teaching about aging at all levels of medical education as a primary effort. To support their view, the present Committee cites the inadequate numbers of applicants to geriatric fellowship programs and the projected shortfall in geriatric faculty by the year 2000 as evidence that this broad-based effort has failed. Other data suggest a slow but significant growth of geriatric curriculum time in American medical schools. A 1970 survey by Freeman3 documented that less than half of 99 schools had any geriatric content at all; by 1978, an Institute of Medicine survey4 showed that 66% of 81 responding schools had a least some required curriculum in geriatrics, and Barry and Ham's survey in 19835 documented that 72% of 100 responding schools had at least some required curriculum time in geriatrics. The extent and quality of these required curricula are not known, and the “interested” but nongeriatrician faculty described in the report may not be the “career exemplars” needed to inspire careers in academic geriatrics, but one cannot conclude that they are not providing appropriate training for the care of the elderly within the context of primary care. In these considerations, the tension continues between the need to enhance the subspecialty status of geriatrics within academic medicine, and the need to promulgate the “geriatrics for all” philosophy espoused by the Beeson Institute of Medicine report in 19782 and the American Board of Internal Medicine. Whereas the Committee's goal of producing academic geriatricians is laudable, we feel that additional intensive and concurrent efforts must be made to disseminate the knowledge of geriatric practice to the large community of general internists and family practitioners.6 Several new approaches are needed that provide a “continuum” of experience and programs in aging to a broad constituency: a) the introduction of humanistic and biological aspects of aging to those students at the college level destined for a career in the health professions; b) a curriculum over the four years of medical school which includes supervised clinical experience with older patients in the ambulatory setting and the home; c) implementation of geriatric teams that disseminate the educational principles and practice of interdisciplinary care for the elderly to house staff on all services within the hospital setting; d) enhancement of the role of geriatric nurse practitioners through close professional collaboration with physicians and other health professionals; and e) postgraduate exposure for internists and family medicine practitioners in the community, using a nursing home with strong links to an academic geriatric center as a “classroom” for such teaching. The need for parallel developments in these areas of medical education highlights to an even greater extent the inadequacies of federal and other sources of funding for geriatric education. The passage of the Omnibus Health Bill in 1986, with its provision of 4$ million for geriatric fellowship training, stands in sharp contrast to the Senate Committee on Aging's proposed Geriatric Research, Education, and Training Act of 1985 (S. 1100), which represented a much more comprehensive geriatric education package, but which suffered an early demise due to its unpopular cost of 200$ million. There is no question that adequate funding of model training centers for academic geriatricians is needed and would help meet the complex needs of the elderly population. However, to reserve the designation of “centers of excellence” for this effort would diminish and demoralize many meritorious efforts to provide a more broad-based approach to geriatric education. Unless geriatric precepts are adequately represented in the training of all physicians and other health care professionals, the goal of exemplary care for the aged beyond the year 2000 will not be adequately met.