General Internal Medicine and Geriatrics: Building a Foundation To Improve the Training of General Internists in the Care of Older Adults

Over the next 30 years, the health care needs of older Americans will challenge physicians and other health professionals as the number of older persons explodes, their lifespans lengthen, and they are treated for more and more conditions. The number of Americans 65 years of age or older has doubled every 30 years since 1900 and will double again in the next 30 years, from 35 million (12.4% of the population) to 70 million (20.6% of the population) (1). Persons 65 years of age or older account for 25% of visits to physician offices, 36% of acute hospitalizations, and 50% of hospital expenditures (2). Medicare reimbursement accounts for 27% of physician income. Persons 85 years of age or older are the most rapidly growing part of the population, and they often have challenging combinations of conditions. Yet in an era that aspires to evidence-based medicine, we have little knowledge about how best to care for the very old, and most physicians are not taught the principles and perspectives that come into play in caring for the aged. This supplement is intended to serve as a foundation for incremental and sustained improvement in the training of internists in the care of older adults. This foundation is based on 3 premises. First, internistsdoctors for adultsprovide most of the general medical care given to older Americans (3). In fact, the proportion of office visits made to generalist physicians by persons 65 years of age or older has nearly doubled in recent years, increasing from 32% of all visits in 1975 to 57% of all visits in 2000 (4). Second, internal medicine faces formidable challenges posed by the rapidly increasing number of older Americans, many of whom have serious chronic disease with its attendant psychological, social, and financial effects. Despite early recognition of these challenges (5, 6), they are surprisingly far from being met: The United States does not yet have an adequate physician workforce with mastery in caring for older persons and with expertise in building the knowledge base of geriatric medicine. Third, meeting these challenges will require a multifaceted approach that engages general internal medicine and subspecialty internal medicine as well as geriatric medicine (3). The papers in this supplement address 3 topics: geriatrics training for residents in internal medicine (7), geriatrics training for general medicine fellows (8), and the development of geriatrics-oriented generalist faculty (9). These topics were selected because the training cycle of internal medicine (Figure) is the production pipeline for many physicians who will care for older Americans in the next 30 years. Moreover, internal medicine training produces many physicians who will build knowledge about how best to care for older persons. Each year, more than 7000 medical students become residents in general internal medicine, more than 3000 graduating residents pursue further training as fellows, and more than 4000 graduating residents enter practice. Among the more than 3000 first-year fellows in 2000, only 290 entered geriatric medicine in 2000 (10) and approximately 200 entered research or teaching fellowships to seek the additional training needed to provide leadership as faculty members in general internal medicine. Most graduating geriatrics fellows become practicing physicians, with a modest amount of time for teaching and neither the training nor the time for research (2, 11). In contrast, a large proportion of fellows in general internal medicine pursue academic careers as faculty members with substantial commitments to teaching or research. Faculty members in general internal medicine play large roles in the clinical teaching of medical students and residents and in generating new knowledge about the care of older persons. The training cycle highlights the fact that improved training in the care of older persons during internal medicine residencies will have downstream effects, increasing the number of practicing physicians with knowledge and skill in geriatric medicine. In addition, geriatrics-oriented faculty in general internal medicine can, through their research, produce new knowledge in the care of older persons. Figure. The internal medicine training cycle. This supplement informs but does not address many key issues in enabling the physician workforce to better care for older persons. For example, enhancing the skills of practicing physicians in caring for older adults and improving the residency training of physicians in family medicine and other disciplines are beyond this supplement's scope. These issues have been addressed elsewhere and require additional work (12). In this paper, we briefly review the history of geriatrics in internal medicine and the role of internal medicine in meeting the medical needs of older Americans. We then review the major findings of the other papers in this supplement and highlight what we believe will prove to be high-yield strategies to improve the training of general internists in the care of older Americans. In each paper, the authors describe current practices, best practices, goals for optimal training, and barriers to achieving those goalsthe gap that must be crossed to develop the physician workforce and the knowledge base for the aging population. The authors conclude by proposing solutions to the barriers identified and outlining the implications of those solutions from the perspectives of various stakeholders. Each paper is based on a systematic overview of the medical literature and on qualitative research done to explore issues not resolved in the literature. Stakeholders and experts reviewed and modified these papers on the basis of discussion at 2 national conferences. Table 1 lists key stakeholder organizations represented at the conferences. Table 1. Stakeholder Organizations Represented at 2 National Conferences on Planning for Sustained Improvement in the Training of General Internists in Geriatrics History of Geriatrics in Internal Medicine Geriatrics developed synchronously and synergistically with internal medicine during the 20th century (13). The term geriatrics was coined in 1914 by Ignatz L. Natscher of Mt. Sinai Hospital, New York, 1 year before the American College of Physicians was founded in the same city. The American College of Physicians and internal medicine grew rapidly in the United States. Annals of Internal Medicine was founded in 1927, and the American Board of Internal Medicine was founded in 1936. The number of physicians interested in geriatrics increased after the American Geriatrics Society was founded in 1942, but geriatrics floundered as an academic discipline in the United States. In 1975, 3 events initiated the modern era in geriatrics (14). Robert Butler published the Pulitzer prizewinning book, Why Survive? Being Old in America (15); the Veterans Administration funded the first Geriatrics Research, Education and Clinical Centers; and the National Institute on Aging opened under Butler's leadership. These events focused national attention on the plight of older Americans and their unique medical challenges, paved the way for postdoctoral training in geriatric medicine, and led to sustained funding for research in the diseases and care of older persons. In 1978 and 1987, reports from the Institute of Medicine (5, 6) called for the development of geriatrics as an academic discipline and a clinical specialty. These reports led to the development of a test for the Certificate of Added Qualification in Geriatric Medicine, administered jointly by the American Board of Internal Medicine and the American Board of Family Practice, and the initial certification of nearly 10 000 physicians as geriatricians. Academic geriatrics programs were developed at most U.S. medical schools, with 290 trainees in 97 fellowship programs in 2001 (10, 16). Even with the development of successful academic programs in geriatrics and the expansion of geriatrics fellowships, it will be impossible to supply the projected number of geriatricians that will be needed to care for older persons in the United States in the near future (17, 18). Most physicians with added qualification in geriatrics do not practice geriatrics predominantly, and the number of certified geriatricians began to decrease in 1998, when the geriatricians who did not renew their certifications outnumbered the recent trainees certified (19). It is now clear that internists rather than geriatricians will provide most medical care for older Americans, and a major function of academic geriatrics programs is to train internal medicine trainees in the care of older persons (20). Role of Internal Medicine for Older Adults The skills of the internist may be especially relevant to 2 aspects of the care of older persons in the 21st century: complexity and treatability. The complexity of illness often increases with age, and internists are well schooled in caring for patients with complex illness. With increasing age, atypical presentations of common diseases and complicating comorbid diseases become more common. The subtentorial diseases that are the bailiwick of the internistthe acute and chronic diseases affecting the internal organsbecome increasingly complicated and confounded by supratentorial diseases, primarily neurodegenerative conditions and affective disorders, all of which can have difficult behavioral and social effects. The combination of subtentorial and supratentorial diseases magnifies the effects of illness on patients, family, and society, frequently complicating medical management, increasing risk for iatrogenic events, and increasing the time required from the caring physician. The treatability of age-associated conditions has increased as well: Previously refractory diseases are now amenable to drugs and procedures prescribed by internists. For example, in the past decade, efficacious pharmacotherapy has become available for benign prostatic hypertrophy, erectile