The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 58:M92-M93 (2003)
© 2003 The Gerontological Society of America
Letters to the Editor: Commentary on Dr. Kane's Article. The Future History of Geriatrics: Geriatrics at the Crossroads
Maria Fiatarone Singh
John Sutton Chair of Exercise and Sport Science, University of Sydney, Australia
To the Editor:
Dr. Kane (1) rightfully points out the discrepancy between the rising need for geriatric care among the U.S. population and the current supply of American board-certified geriatricians, who apparently number less than 10,000 as of the year 2001. In addition to the lack of sufficient numbers of such physicians, there exists confusion over the appropriate role that geriatricians should play in the U.S. health care system. In other areas of aging where demand is high, such as for residential housing for older clients, the building industry has responded to the market demand with a myriad of housing options catering to the special needs of this population. In geriatric medicine, where the demand should be equally high, the supply of geriatric physicians is paradoxically low. Why is this?
As a member of the first class of certified geriatricians who completed a geriatric fellowship in 1988, I would suggest that the lack of adequate numbers of physicians who choose this branch of medicine stems from a multitude of intersecting forces. Despite much lip-service to the contrary, I believe there is still a strong bias against aged individuals in our society, at least those who are not seen as still vibrant, contributing, intellectually intact, physically attractive, or embued with other "youthful" qualities. Thus, for a university or medical student to choose geriatric medicine requires an inherent sense of purpose and level of determination that is rarely praised by academic faculty or even fellow students. At medical school graduation in 1981, I remember my teachers actively trying to dissuade me from "wasting" my potential in a field with such a low level of prestige (and economic rewards). Although geriatric fellowships have since been established nationwide, and a geriatric curriculum has been added to many training programs, attitudinal shifts have lagged far behind the structural changes established. Until this happens, it is likely that geriatric fellowships will continue to be less desirable than other specialties, or filled by those who cannot find places elsewhere. In addition to this basic problem of ageism in society, there are other factors that limit attractiveness of the field, such as fewer technological procedures, stressful or depressing working conditions, patients who do not recover or improve with care, the frustration and complexity of managing multiple systems disorders and social problems at the same time, and income levels perhaps not commensurate with the workload required to provide excellent care.
What, then, is the solution to this situation? Aged care will always include some elements of frailty, decline, degeneration, diminishing potential, and futility. These features cannot be disguised or removed. The key is to be able to attract health care providers who can accept these features of the specialty and integrate them into the many other positive components, such as the intellectual challenge of managing multiple complex medical problems simultaneously, the emotional satisfaction of integrating the family and social context of illness into the medical management of patients, and the spiritual gift of sharing grief, bereavement, small victories in the face of tremendous odds, and even death itself with one's patients. This attraction must begin long before residency programs, when bias and attitudes toward aged care are already firmly established by experiences in medical school. Positive role models of geriatricians in practice and in academic medicine should be present as early as high school career counseling sessions, as well as in college and medical school. It is very likely that the selection process for medical school itself, emphasizing scientific achievement and intellectual superiority above all else, is more appropriate for choosing basic scientists than primary care physicians or geriatricians. Although there will always be a need for a certain number of geriatricians who will contribute to the understanding of the scientific basis of aging and disease, there will always be a need for larger numbers of physicians who can practice primary and specialty geriatric care. The admission process would have to change, prioritizing medical student characteristics that are necessary for the practice of high-quality geriatric medicine (a genuine respect and care for the aged, a spirit of service to the community, commitment to care without regard to the potential for cure, an ability to perceive the differential expression of illness in relation to its social context, and an interest in the whole person rather than a single organ system or process).
In addition to rethinking the kind of student who is admitted to medical school, the other way to address the deficit of geriatricians is to present a wide variety of options for the practice of geriatric medicine. Rather than limiting the field to end-of-life issues or nursing home care, as Dr. Kane suggests might be possible, I would instead promote a broad range of possibilities to the prospective geriatrician. As in all specialties, there should be opportunities, for example, for primary care practice, work within specialized tertiary care referral centers, academic environments, or public health organizations. In addition to what Dr. Kane has outlined, there should be an option for the practice of preventive geriatrics, emphasizing such disciplines as exercise physiology, nutrition, and psychological well-being, integrated directly into mainstream medical practice. Any attempt to define geriatrics by limiting it to any of its subcomponents can only be destructive and ultimately reduce even further the pool of physicians and other health care professionals considering this career choice. No one would suggest, for instance, that pediatrics be defined as either the provision of well-child care only, or limited to pediatric oncology. Neither can geriatrics be limited to single aspect of need for a diverse population of older adults who grow more heterogeneous with the passage of time.
Thus, the deficit of geriatric practitioners requires a redefinition of both who is admitted to medical school and the range of ways in which geriatrics can be legitimately practiced. Those geriatricians who do not stay within geriatric academia after training should not be deemed failures by their mentors, but rewarded for carrying out the very difficult task of applying what is learned from research to the real world. Geriatrics also has to be taught more widely to nonphysician health care professionals, as well as to other branches of medicine and surgery, because older adults will always have contacts with these other health care providers, no matter how many geriatricians are trained. The current crossroads are an opportunity we should take to improve both the quality of physicians trained and the quality of the geriatric care they provide.
 |
Acknowledgments
|
|---|
Address correspondence to Maria Fiatarone Singh, MD, FRACP, Professor of Medicine, John Sutton Chair of Exercise and Sport Science, University of Sydney, Sydney, Australia. E-mail: m.singh{at}fhs.usyd.edu.au
|
Reference
|
|---|
- Kane RL. The future history of geriatrics: geriatrics at the crossroads. J Gerontol Med Sci. 2002;57A:M803-M805.[Free Full Text]
Top
Reference