Geriatrics in the United States — Baby Boomers' Boon?
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《新英格兰医药杂志》
The graying of America, a triumph of medical and cultural advances, has caught us unprepared. Our economic system, burdened with Social Security, Medicare, and extended retirement years, is shaking. Our legal system may be overwhelmed by the choosing of surrogates to make health care and end-of-life decisions, evaluations of competence, and the issuing of advance directives. Our health care system is challenged by the sheer number of elderly people and the demands of providing cost-effective care to those who are frail.
For the elderly, health is the foundation of a good quality of life — the obvious reason that the birth of U.S. geriatrics in the 1960s met with public and government support, media attention, and active (though defensive and at times obstructive) interest from medical schools, hospitals, and private practitioners. It was hoped that geriatrics would lead the response to this unprecedented demographic challenge.
(Figure)
And indeed, this specialty has enhanced clinical skills by educating medical and nursing students about the links between aging and disease and by stimulating basic and clinical research. Geriatrics has created new programs of care, ranging from the community-based Program for the All-Inclusive Care of the Elderly to teaching nursing homes and units for acute care of the elderly in hospitals. The nation's first board-approved training program in geriatrics was launched in 1968, based at nursing homes with components in home care, ambulatory care, and hospital consultation. Since then, there has been robust growth in fellowships and residency training within internal medicine, family practice, and psychiatry, with expanded curricula for medical students and the creation of a geriatrics specialty examination and diploma — all of which reflect an increasing acceptance of the need for geriatrics. There are now 120 geriatrics training programs in the United States, with more than 300 fellowship positions. These programs emphasize knowledge and skills related to geriatrics, spanning general medicine and surgery, neurology, psychiatry, rehabilitation medicine, pharmacology, palliative care, and nursing home medicine.
(Figure)
Research emanating from geriatrics has advanced our approaches to falls, gait disturbances, incontinence, nutritional deficiencies, systolic hypertension, diastolic heart failure, frailty, use of restraints, and Alzheimer's disease; it has also placed emphasis on dysfunction in addition to traditional disease categories. Many of these studies have come from long-term care programs, and their findings have been translated into practice in community and acute care hospitals, as well as generalized to younger populations.
But recently, the vigor and progress of geriatrics have reached a plateau. In part, this slowing of growth may be attributable to traditional opposition from within the medical profession — opposition based on the misconception that taking care of older patients is synonymous with geriatrics and on an unwillingness to share available resources. In addition, many physicians, in primary care and academia, see geriatrics as a threat to their professional identity. Some have suggested that the most powerful resistance to geriatrics derives from physicians' subconscious fear of their own aging. Whatever its causes, the opposition continues, and open debate is needed if the development of enlightened care of the elderly is to continue.
There remains a fair amount of confusion about the identity of geriatrics. There is a place for geriatrics both within the hospital and at its interface with the nursing home and the community. For example, geriatricians recently developed a team intervention to reduce the risk of delirium among hospitalized older persons. But the field was developed primarily in response to the needs of the frail elderly — a group, numbering in the millions, that receives most of its health care not in acute care hospitals, but at home, in nursing homes, and in physicians' offices. Geriatrics will lose its way if its resources are disproportionately devoted to acutely ill, hospitalized patients.
Nor is geriatrics synonymous with palliative care. Every clinician must be skilled in rendering end-of-life care, helping patients to achieve a "good death" and not prolonging dying. But although it is true that most who die are elderly, the philosophy and goals of geriatrics differ from those of palliative care. Geriatrics focuses primarily not on easing dying, but on improving the quality of life during a patient's remaining years. Thus, the staffing and program direction of palliative care and geriatrics should remain separate, lest their missions become blurred.
As geriatricians work to distinguish their field from other specialties, they have undertaken studies of several innovations — such as hip protectors, new treatment pathways for Alzheimer's disease, and geriatrics consultation services involving team-based interventions to prevent or reverse declines in function and self-sufficiency.1 Although this last study suggested significant benefits in terms of activities of daily living, physical performance, and mental health, it failed to demonstrate significant differences from traditional care in hospitalization rates or mortality. Such setbacks are part of the growth and maturation of the field of geriatrics.2
Still, geriatrics has had many successes, and the need for skilled geriatricians will only increase as our population ages. In the late 1970s, about a decade after geriatrics had first appeared in the United States, studies of staffing needs showed a gap of thousands of physicians specializing in this field in academia, community and hospital consultation, nursing home care,3 and community-based primary care. A quarter century later, the shortage of geriatricians persists, although it was temporarily ameliorated in the 1990s, when 10,000 geriatricians were certified after taking the geriatrics specialty examination. The applicant pool for available fellowship positions has diminished, and only about 45 percent of positions are filled — a smaller proportion than that in other fields.4
In addition, practicing physicians are shying away from providing care to elderly patients, in part because payment systems do not reflect the time required to render the appropriate care, a problem that can be solved only by proper funding from the government and insurance companies. But insufficient payment is not the only barrier: there are some difficult and fearsome aspects of dealing with the last years of life. Yet to educate all physicians in the basics of geriatrics, we need not seek hundreds of geriatricians but rather competence in the established body of knowledge about older persons among all practitioners. Perhaps once some initial trepidation has been overcome, more students will join the internal-medicine geriatricians who count themselves among the most satisfied of all specialists.5
Given that the baby boomers will soon add 75 million people to the already vast elderly population in the United States, I believe that it would be self-destructive for our society not to nurture the growth of geriatrics. We need new, financially sound delivery systems, new approaches to preventive care, and improved use of existing institutions. In many cases, medicine will have to change its focus from disease to dysfunction and the need for secondary prevention. Nursing homes will undergo further change as they are asked to provide more enlightened long-term care, more rehabilitation, and selective cost-saving acute care. If we are to create and sustain a health care system for the elderly that is both cost-effective and "human-effective," I believe we must first attend to the health of geriatrics.
Source Information
Dr. Libow is a professor at the Jewish Home and Hospital Lifecare System of New York and a professor of geriatrics and adult development at the Mount Sinai School of Medicine — both in New York.
References
Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002;346:905-912.
Campion EW. Specialized care for elderly patients. N Engl J Med 2002;346:874-874.
Libow LS. Testimony at a joint hearing before the Subcommittee on Health and Long-term Care and the Subcommittee on Human Services, of the Select Committee on Aging, House of Representatives, May 17, 1978. Washington, D.C.: Government Printing Office, 1978. (Committee publication no. 95-151.)
Warshaw GA, Bragg EJ. The training of geriatricians in the United States: three decades of progress. J Am Geriatr Soc 2003;51:Suppl:S338-S345.
Leigh JP, Kravitz RL, Schembri M, et al. Physician career satisfaction across specialties. Arch Intern Med 2002;162:1577-1584.(Leslie S. Libow, M.D.)
For the elderly, health is the foundation of a good quality of life — the obvious reason that the birth of U.S. geriatrics in the 1960s met with public and government support, media attention, and active (though defensive and at times obstructive) interest from medical schools, hospitals, and private practitioners. It was hoped that geriatrics would lead the response to this unprecedented demographic challenge.
(Figure)
And indeed, this specialty has enhanced clinical skills by educating medical and nursing students about the links between aging and disease and by stimulating basic and clinical research. Geriatrics has created new programs of care, ranging from the community-based Program for the All-Inclusive Care of the Elderly to teaching nursing homes and units for acute care of the elderly in hospitals. The nation's first board-approved training program in geriatrics was launched in 1968, based at nursing homes with components in home care, ambulatory care, and hospital consultation. Since then, there has been robust growth in fellowships and residency training within internal medicine, family practice, and psychiatry, with expanded curricula for medical students and the creation of a geriatrics specialty examination and diploma — all of which reflect an increasing acceptance of the need for geriatrics. There are now 120 geriatrics training programs in the United States, with more than 300 fellowship positions. These programs emphasize knowledge and skills related to geriatrics, spanning general medicine and surgery, neurology, psychiatry, rehabilitation medicine, pharmacology, palliative care, and nursing home medicine.
(Figure)
Research emanating from geriatrics has advanced our approaches to falls, gait disturbances, incontinence, nutritional deficiencies, systolic hypertension, diastolic heart failure, frailty, use of restraints, and Alzheimer's disease; it has also placed emphasis on dysfunction in addition to traditional disease categories. Many of these studies have come from long-term care programs, and their findings have been translated into practice in community and acute care hospitals, as well as generalized to younger populations.
But recently, the vigor and progress of geriatrics have reached a plateau. In part, this slowing of growth may be attributable to traditional opposition from within the medical profession — opposition based on the misconception that taking care of older patients is synonymous with geriatrics and on an unwillingness to share available resources. In addition, many physicians, in primary care and academia, see geriatrics as a threat to their professional identity. Some have suggested that the most powerful resistance to geriatrics derives from physicians' subconscious fear of their own aging. Whatever its causes, the opposition continues, and open debate is needed if the development of enlightened care of the elderly is to continue.
There remains a fair amount of confusion about the identity of geriatrics. There is a place for geriatrics both within the hospital and at its interface with the nursing home and the community. For example, geriatricians recently developed a team intervention to reduce the risk of delirium among hospitalized older persons. But the field was developed primarily in response to the needs of the frail elderly — a group, numbering in the millions, that receives most of its health care not in acute care hospitals, but at home, in nursing homes, and in physicians' offices. Geriatrics will lose its way if its resources are disproportionately devoted to acutely ill, hospitalized patients.
Nor is geriatrics synonymous with palliative care. Every clinician must be skilled in rendering end-of-life care, helping patients to achieve a "good death" and not prolonging dying. But although it is true that most who die are elderly, the philosophy and goals of geriatrics differ from those of palliative care. Geriatrics focuses primarily not on easing dying, but on improving the quality of life during a patient's remaining years. Thus, the staffing and program direction of palliative care and geriatrics should remain separate, lest their missions become blurred.
As geriatricians work to distinguish their field from other specialties, they have undertaken studies of several innovations — such as hip protectors, new treatment pathways for Alzheimer's disease, and geriatrics consultation services involving team-based interventions to prevent or reverse declines in function and self-sufficiency.1 Although this last study suggested significant benefits in terms of activities of daily living, physical performance, and mental health, it failed to demonstrate significant differences from traditional care in hospitalization rates or mortality. Such setbacks are part of the growth and maturation of the field of geriatrics.2
Still, geriatrics has had many successes, and the need for skilled geriatricians will only increase as our population ages. In the late 1970s, about a decade after geriatrics had first appeared in the United States, studies of staffing needs showed a gap of thousands of physicians specializing in this field in academia, community and hospital consultation, nursing home care,3 and community-based primary care. A quarter century later, the shortage of geriatricians persists, although it was temporarily ameliorated in the 1990s, when 10,000 geriatricians were certified after taking the geriatrics specialty examination. The applicant pool for available fellowship positions has diminished, and only about 45 percent of positions are filled — a smaller proportion than that in other fields.4
In addition, practicing physicians are shying away from providing care to elderly patients, in part because payment systems do not reflect the time required to render the appropriate care, a problem that can be solved only by proper funding from the government and insurance companies. But insufficient payment is not the only barrier: there are some difficult and fearsome aspects of dealing with the last years of life. Yet to educate all physicians in the basics of geriatrics, we need not seek hundreds of geriatricians but rather competence in the established body of knowledge about older persons among all practitioners. Perhaps once some initial trepidation has been overcome, more students will join the internal-medicine geriatricians who count themselves among the most satisfied of all specialists.5
Given that the baby boomers will soon add 75 million people to the already vast elderly population in the United States, I believe that it would be self-destructive for our society not to nurture the growth of geriatrics. We need new, financially sound delivery systems, new approaches to preventive care, and improved use of existing institutions. In many cases, medicine will have to change its focus from disease to dysfunction and the need for secondary prevention. Nursing homes will undergo further change as they are asked to provide more enlightened long-term care, more rehabilitation, and selective cost-saving acute care. If we are to create and sustain a health care system for the elderly that is both cost-effective and "human-effective," I believe we must first attend to the health of geriatrics.
Source Information
Dr. Libow is a professor at the Jewish Home and Hospital Lifecare System of New York and a professor of geriatrics and adult development at the Mount Sinai School of Medicine — both in New York.
References
Cohen HJ, Feussner JR, Weinberger M, et al. A controlled trial of inpatient and outpatient geriatric evaluation and management. N Engl J Med 2002;346:905-912.
Campion EW. Specialized care for elderly patients. N Engl J Med 2002;346:874-874.
Libow LS. Testimony at a joint hearing before the Subcommittee on Health and Long-term Care and the Subcommittee on Human Services, of the Select Committee on Aging, House of Representatives, May 17, 1978. Washington, D.C.: Government Printing Office, 1978. (Committee publication no. 95-151.)
Warshaw GA, Bragg EJ. The training of geriatricians in the United States: three decades of progress. J Am Geriatr Soc 2003;51:Suppl:S338-S345.
Leigh JP, Kravitz RL, Schembri M, et al. Physician career satisfaction across specialties. Arch Intern Med 2002;162:1577-1584.(Leslie S. Libow, M.D.)