Elizabeth J. Bragg

The development of academic geriatric medicine: progress toward preparing the nation's physicians to care for an aging population.

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full‐time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy‐one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.

Are Internal Medicine Residency Programs Adequately Preparing Physicians to Care for the Baby Boomers? A National Survey from the Association of Directors of Geriatric Academic Programs Status of Geriatrics Workforce Study

Patients aged 65 and older account for 39% of ambulatory visits to internal medicine physicians. This article describes the progress made in training internal medicine residents to care for older Americans. Program directors in internal medicine residency programs accredited by the Accreditation Council for Graduate Medical Education were surveyed in the spring of 2005. Findings from this survey were compared with those from a similar 2002 survey to determine whether any changes had occurred. A 60% response rate was achieved (n=235). In these 3‐year residency training programs, 20 programs (9%) required less than 2 weeks of clinical instruction that was specifically structured to teach geriatric care principles, 48 (21%) at least 2 weeks but less than 4 weeks, 144 (62%) at least 4 weeks but less than 6 weeks, and 21 (9%) required 6 or more weeks. As in 2002, internal medicine residency programs continue to depend on nursing home facilities, geriatric preceptors in nongeriatric clinical ambulatory settings, and outpatient geriatric assessment centers for their geriatrics training. Training was most often offered in a block format. The mean number of physician faculty per residency program dedicated to teaching geriatric medicine was 3.5 full‐time equivalents (FTEs) (range 0–50), compared with a mean of 2.2 FTE faculty in 2002 (P≤.001). Internal medicine educators are continuing to improve the training of residents so that, as they become practicing physicians, they will have the knowledge and skills in geriatric medicine to care for older adults.

Which Patients Benefit the Most from a Geriatrician's Care? Consensus Among Directors of Geriatrics Academic Programs

Given the anticipated limited availability of geriatricians for the foreseeable future, how should the geriatricians specialized clinical skills be deployed to optimally benefit the health of our aging population? Directors of geriatrics academic programs (DGAPs) at all 145 U.S. allopathic and osteopathic medical schools were asked this question as part of a winter 2007 on‐line survey. The DGAPs were to indicate the types of patients who would most benefit from a geriatricians services in three practice situations: primary care, consultations, and care in the hospital. The survey response rate was 74.5%. There was high consensus among the DGAPs on the benefits of having a geriatrician care for the most complex and vulnerable older adults in primary care and hospital settings. There was slightly less consensus as to when geriatrics consultations are beneficial. The patient subsets that were viewed as benefiting the most from geriatrician care were aged 85 and older, frailty, geriatric syndromes, severe functional impairment, and complexity. The results of this survey suggest that, because of the predicted shortage of geriatricians, the DGAPs would target geriatricians to work with the most vulnerable older adults. These findings offer the beginning of a consensus statement as to the role of geriatricians in the continuum of American medical care.

The effect of early discharge after vaginal delivery on neonatal readmission rates

Objective To determine the effect of a structured program for early neonatal discharge from a tertiary medical center on the risk of neonatal readmission. Methods An early-discharge program was instituted at our tertiary medical center in July 1993, with the objective of discharging mothers and infants within 24 hours after vaginal birth. The readmission rate of vaginally delivered infants during the early-discharge period (July 1, 1993, through March 31, 1995) was compared with the rate during a conventional-discharge period (January 1, 1992, through June 30, 1993). Analyses were performed to examine two groups within the early-discharge group: those discharged within 24 hours of vaginal delivery; and those discharged within 1 hospital day of vaginal delivery. Results During the early-discharge period, 1.24% of neonates were readmitted within 10 days of birth, compared with 1.35% during the conventional-discharge period. In the early-discharge period group, infants born vaginally and discharged within 24 hours of birth had a readmission rate of 1.46% compared with 1.14% for those who stayed longer than 24 hours after delivery. Similarly, the readmission rate was no different for infants who were discharged within 1 hospital day. The primary indications for readmission in both periods were infections and jaundice. Conclusion Implementation of a structured program for early neonatal discharge does not have an association with increased risk of neonatal readmission to the hospital.

Rural–Urban Distribution of the U.S. Geriatrics Physician Workforce

OBJECTIVES: To determine the distribution of geriatricians across the rural–urban continuum from 2000 to 2008 and to compare with primary care physicians in 2008.

National Survey of Geriatric Medicine Fellowship Programs: Comparing Findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs Geriatrics Workforce Policy Studies Center

This article documents the development of geriatric medicine fellowship training in the United States through 2009. Results from a national cross‐sectional survey of all geriatric medicine fellowship training programs conducted in 2007 is compared with results from a similar survey in 2002. Secondary data sources were used to supplement the survey results. The 2007 survey response rate was 71%. Sixty‐seven percent of responding programs directors have completed formal geriatric medicine fellowship training and are board certified in geriatrics, and 29% are board certified through the practice pathway. The number of Accreditation Council for Graduate Medical Education–accredited fellowship programs has slowly increased, from 120 (23 family medicine (FM) and 97 internal medicine (IM)) in 2001/02 to 145 in 2008/09 (40 FM and 105 IM), resulting in a 21% increase in fellowship programs and a 13% increase in the number of first‐year fellows (259 to 293). In 2008/09, the growth in programs and first‐year slots, combined with the weak demand for geriatrics training, resulted in more than one‐third of first‐year fellow positions being unfilled. The number of advanced fellows decreased slightly from 72 in 2001/00 to 65 in 2006/07. In 2006/07, 55% of the advanced fellows were enrolled at four training programs. In 2008/09, 66% of fellows were international medical school graduates. The small numbers of graduating geriatric medicine fellows are insufficient to care for the expanding population of older frail patients, train other disciples in the care of complex older adults, conduct research in aging, and be leaders in the field.

ACGME requirements for geriatrics medicine curricula in medical specialties: progress made and progress needed.

In the recent past, most physician visits by older adults were with a primary care physician, with less than 40% of ambulatory visits to other specialists. Since 1991, that trend has reversed. In 2001, 53% of ambulatory visits by patients aged 65 years or older were to nonprimary care specialists. Demographic trends and an expanding geriatrics medicine knowledge base require that every physician develop skills specific to the care of older adults. There are concerns that physicians-in-training are not learning adequate specific geriatrics medicine content to prepare them for the rapidly expanding numbers of older adults who will be seeking medical care. Training standards to prepare residents and fellows for practicing medicine are established by experts in the various medical specialties serving on individual residency review committees (RRCs) of the Accreditation Council for Graduate Medical Education. In 2002 (with a follow-up in 2003), the Association of Directors of Geriatric Academic Programs’ team at the University of Cincinnati School of Medicines Institute for Health Policy and Health Services Research reviewed all 91 nonpediatric specialties’ RRC program requirements to identify the specific curriculum requirements related to geriatrics medicine training. As of 2003, 27 of the 91 RRC-accredited specialties have specific geriatrics training requirements; the other 70% of these specialties did not specifically mention geriatrics training. Even among the spe-cialties with specific geriatrics training requirements, curriculum expectations are modest. The geriatrics-specific descriptions within the program requirements of the 27 specialties are presented in this article. The authors encourage the RRCs for all nonpediatric specialties to update their program requirements to ensure that future physicians graduating from their graduate medical education programs are adequately prepared to care for older adults.

A National Survey on the Current Status of General Internal Medicine Residency Education in Geriatric Medicine

OBJECTIVES: The dramatic increase in the U.S. elderly population expected over the coming decades will place a heavy strain on the current health care system. General internal medicine (GIM) residents need to be prepared to take care of this population. In this study, we document the current and future trends in geriatric education in GIM residency programs.DESIGN, SETTING, PARTICIPANTS: An original survey was mailed to all the GIM residency directors in the United States (N=390).RESULTS: A 53% response rate was achieved (n=206). Ninety-three percent of GIM residencies had a required geriatrics curriculum. Seventy one percent of the programs required 13 to 36 half days of geriatric medicine clinical training during the 3-year residency, and 29% required 12 half days or less of clinical training. Nursing homes, outpatient geriatric assessment centers, and nongeriatric ambulatory settings were the predominant training sites for geriatrics in GIM. Training was most often offered in a block format. The average number of physician faculty available to teach geriatrics was 6.4 per program (2.8 full-time equivalents). Conflicting time demands with other curricula was ranked as the most significant barrier to geriatric education.CONCLUSIONS: A required geriatric medicine curriculum is now included in most GIM residency programs. Variability in the amount of time devoted to geriatrics exists across GIM residencies. Residents in some programs spend very little time in specific, required geriatric medicine clinical experiences. The results of this survey can guide the development of future curricular content and structure. Emphasizing geriatrics in GIM residencies helps ensure that these residents are equipped to care for the expanding aging population.

The Development of Academic Geriatric Medicine in the United States 2005 to 2010: An Essential Resource for Improving the Medical Care of Older Adults

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full‐time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.

Preparing The Health Care Workforce To Care For Adults With Alzheimer’s Disease And Related Dementias

In the United States, one in nine people ages sixty-five and older and one-third of people ages eighty-five and older have Alzheimers disease. The number of cases of Alzheimers disease is projected to triple by 2050, from 5.0 million in 2013 to 13.8 million. This will challenge the health care workforce, which is already inadequate in both size and training. We assessed what is likely to be an increasing shortage of physicians, nurses, and social workers with specialized training in geriatrics and, more specifically, in the care of people with dementia. We highlight the limited training of health care professionals in best practices of dementia care and chronic disease management. To address these shortfalls, we recommend the dissemination of team-based models of care that integrate health and social services; expansion of education loan forgiveness and faculty development programs to attract students into clinician-educator careers focusing on Alzheimers disease; inclusion of curricula specific to the disease in all health professions training; expansion of federal programs to train existing workers; and increased compensation for the direct care workforce.