Laura J. Niedernhofer
Submitter: George A. Kuchel | Kuchel@uchc.edu
UConn Center on Aging, University of Connecticut Health Center, Farmington, Connecticut, USA
Published October 22, 2008
I would like to congratulate Dr. Niedernhofer on a most insightful review of Dr. David Hamerman’s timely book Geriatric Bioscience: The link between aging and disease (1). Nevertheless, I believe that Dr. Niedernhofer’s description of Geriatric Medicine does not correctly reflect the current state of this discipline, in some cases contradicting major professional organizations, the Institute of Medicine, and the NIH. Dr. Niedernhofer feels that Geriatric Medicine is miscategorized as a specialty of Internal Medicine and that the field has thus been compromised by presuming that an elderly patient and a younger adult with the same disease should receive the same treatment. I believe that several corrections are needed.
Both family physicians and internists are eligible for training and certification in Geriatric Medicine. Among US medical schools, eight have well-established Departments of Geriatric Medicine. In the remainder, a mixed-governance model is most common with both a Division of Geriatric Medicine within a Department of Medicine and a much broader institutional structure such as a Center with direct reporting to a Dean, Provost or President. While each model has its proponents (2,3), all Geriatricians share a common approach to relevant clinical and research issues irrespective of the governance structure at their institution. In distinct contrast to the organ-based focus taken by most other specialties, a systems-based approach that emphasizes functional outcomes lies at the very core of Geriatric Medicine (4). Moreover, much of what Geriatricians do as clinicians and as investigators involves multidisciplinary efforts designed to overcome traditional organ- and discipline-based barriers (4).
With the exception of Pediatricians, nearly all health professionals will be involved in the care of older adults in future years (5). Geriatricians must continue to play leadership roles in helping to define a society’s capacity to address the specific health needs of older adults. Moreover, aging of our population represents one of the main reasons why biomedical research must move beyond a disease-based focus if we are to meet the needs of our patients in the 21st century (6). From the perspective of aging research, we must not only seek to “add years to life”, but to also “add life to years”. Thus, common geriatric syndromes such as frailty, sarcopenia, delirium, incontinence, falls, and loss of functional independence must also be addressed (4). Given the multifactorial nature of these conditions, innovative approaches for dealing with such complexity will be required in order to define their pathophysiology and to discover novel innovative intervention strategies (4,7).
NIH has played an important role in supporting a move in this direction
with the creation of the Aging Systems and Geriatrics (ASG) Study Section
(8). Other notable efforts include the report on the Future Health
Care Workforce for Older Adults recently issued by the Institute of
Medicine (5). As noted in the report, the geriatric competency of our
entire workforce must be enhanced (5). This is certainly true
for divisions of Internal Medicine and Surgery, where innovative funding
initiatives are beginning to make an impact. For example, the
T. Franklin Williams Scholars Program and the Dennis W. Jahnigen Career
Development Awards Program provide salary support for internists and
surgeons, respectively, who wish to develop academic careers addressing
the geriatric aspects of their own discipline. The Paul B. Beeson Career
Development Award in Aging provides a much more substantial K08/K23
National Institute on Aging/NIH training award for physicians from any
discipline who wish to undertake intense mentored research training
in aging. Finally, the American Geriatrics Society has developed a number
of educational partnerships with sister professional organizations in
both Medicine and Surgery with the goal of developing a state-of-the-art
geriatrics curriculum and research agenda for all of their Divisions.
Submitter: Laura Niedernhofer | firstname.lastname@example.org
Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.
Published October 22, 2008
Thank you kindly for your letter expressing your expert opinion on the current state of Geriatric Medicine. You were able to provide detailed information about training in, and NIH support of, Geriatric Medicine. I am delighted to learn that eight medical schools have Departments of Geriatric Medicine. In my review of Dr. Hamerman’s book, Geriatric bioscience: The link between aging and disease (1), I in no way meant to imply that the quality of Geriatric Medicine has been compromised. In fact, aged Americans have never been healthier (2). My intention was to echo Dr. Hamerman’s concern that the current number of trainees in geriatrics and the level of funding for aging research are insufficient in light of the rapidly changing demographics in the United States.
The number of individuals aged 65 or older will double between 2000 and 2030 (2), at which point, 20% of the American population will be greater or equal to 65 years of age (2). Eighty percent of those individuals will have at least one chronic health condition, while 50% will have two or more (2). At the turn of the 21st century, there were 5.5 geriatricians per 10,000 persons greater or equal to 75 yrs of age (3). The ratio of pediatricians to patients was twice that (4). Furthermore, only 3% of medical trainees eligible for specialization in Geriatric Medicine entered a fellowship program and the number of geriatricians seeking re-certification has declined by greater than 30% (3). Therefore the timeliness of Dr. Hamerman’s text, which should spark interest in clinical geriatric medicine and research, could not be better.
The Association of Directors of Geriatric Academic Programs attributes the dearth of Board-certified geriatricians to a preference of trainees to enter procedure-oriented specializations, which offer a higher income at a time when the cost of a medical education is sky-rocketing. If Geriatrics were developed as in independent department, like Pediatrics and Internal Medicine, with its own sub-specializations, the field might attract a larger fraction of medical trainees and funding for research. This could also be justified based on the fact that the elderly are an increasingly large segment of our population and that recent research, elegantly summarized by Dr. Hamerman’s in Geriatric bioscience has revealed that the elderly have a distinct and complex physiology that contributes to their increased incidence of chronic disease.