THE STATUS OF GERIATRIC MEDICINE

Abstract

To the Editor: The current controversies1-4 surrounding the status of geriatric medicine are rooted in the rigid acceptance of the existing specialty-subspecialty paradigm for certification and classification of our medical disciplines. Since geriatric medicine and geriatricians are, in reality, square-pegs which do not fit in the round holes of the latter system, a modification of our conceptual framework is required if we are to resolve these debates. With the help of analogies taken from evolutionary biology and quantum mechanics, I modestly propose a different way of analyzing the nature of geriatric medicine, geriatricians, and the certification process. In his essay, “What If Anything Is a Zebra?”,5 Stephen J. Gould discusses the question of whether zebras are a single evolutionary unit or horses with stripes. Are geriatricians an entity unto themselves or are they a variation of the family medicine (FM)/internal medicine (IM) generalists? FM/IM generalists should be able to deliver quality geriatric medical care; however, that fact does not make them geriatricians any more than FM generalists who deliver quality pediatric care are pediatricians. Maintaining the necessary expertise to practice quality generalist internal or family medicine is a demanding and rigorous endeavor. The latter statement equally applies to those physicians who exclusively practice geriatric medicine. I agree with Beck6 that geriatric medicine is a unique discipline. The global skills and knowledge requirements of the FM/IM generalists and the geriatrician are different, and each have reached a magnitude which virtually precludes the possibility of maintaining simultaneous expertise in both fields. A geriatrician is a geriatrician, not a FM/IM generalist with stripes. Burton and Solomon3 have argued that geriatric medicine is a primary care specialty, while Morley4 has argued that it is a subspecialty. Both arguments are very convincing. Ettinger and Hazzard1 state that geriatricians clinically do mostly primary care, but they also list a number of unique functions for the geriatrician that are clearly features of the subspecialist. When Niels Bohr was confronted with conflicting experimental evidence that light demonstrated both wave-like and particle-like behavior, he was able to correctly resolve the problem only after first rejecting the “either-or” approach of his debating colleagues. Bohr's principle of complementarity7 holds that both the wave and particle theories are necessary to provide a complete description of light. Both primary care and subspecialty criteria are necessary to provide a complete description of geriatric medicine. Geriatric medicine is both a primary care specialty and a subspecialty. Geriatricians are both generalists and subspecialists. The philosophical rationale for the certification process for geriatricians is an enigma. Consider the following two facts. First, after successful completion of a 2-year fellowship in geriatric medicine and passing the certifying examination, a new geriatrician receives only a “certificate of Added Qualifications in Geriatric Medicine”! How are we to attract the “best and the brightest” physicians if we certify ourselves as essentially second-class citizens? Second, all physicians who have received the certificate of Added Qualifications in Geriatric Medicine (CAQG) from the American Board of Family Practice are required to keep their recertification in Family Practice, even if they practice only geriatric medicine. Failure to comply with the latter requirement may result in the loss of the CAQG. Because I practice full-time geriatric medicine, I have not practiced family medicine in a recognizable form for 12 years. Yet, I am required to be recertified in Family Practice every 7 years, while my recertification in Geriatric Medicine is only every 10 years! The latter recertification process violates the adage (attributed to William Osier) that to see patients without study is to sail a stormy sea, but to study without seeing patients is not to sail at all. More significantly, however, it reinforces the perception that geriatric medicine is not a legitimate discipline. The certifying process for geriatricians should result in a Board certification. What is a geriatrician? A geriatrician is a physician who exclusively practices the art and science of geriatric medicine, which is a unique and special discipline. A geriatrician is a physician who has completed a core training in internal medicine or family medicine and a fellowship in geriatric medicine (or the experiential equivalent for the grandfather clause physicians). A geriatrician is both a generalist and a subspecialist. A certified geriatrician should be Board certified. I agree with Ettinger and Hazzard1 that we are what we do; however, in order to successfully convey this idea to others, we will need to modify some of our concepts and procedures.