COMMENTARY: Defining Geriatrics to Forge Coalitions and Gain Leverage

Today, nearly a century after geriatrics entered the lexicon of American medical professions, leading geriatricians still continue to wrestle with the very definition of our fieldFare we specialists, subspecialists, or, uniquely, ‘‘supraspecialists’’? In this ongoing effort, we have continued to swim valiantly against the tide of medical and scientific progress, which has inexorably added more tiers of specialization, subspecialization, sub-subspecialization . . . ad infinitum. This powerful trend continues to be reinforced by the principles of scientific reductionism, which is especially pronounced in academic medical centers, where science is king and subspecialization is a strategy for faculty to cope with the explosion in knowledge and sophisticated clinical practice that allows them to remain at the cutting edge in their field. For medical practitioners (other than dedicated generalists) this trend has demanded an ever-deepening body of knowledge and clinical skills focused in ever-narrower domains of expertise and practiceFsometimes characterized as ‘‘knowing more and more about less and less.’’ Consistent with this trend, perhaps ironically, the American Board of Internal Medicine and the American Board of Family Practice now classify geriatricians as subspecialists and certify them as such, although the depth and focus implied by this subspecialization inevitably comes at the expense of the breadth of effort and skill in coordinating care between those domains and practiceFprecisely the added value that most geriatricians bring to the care of their elderly, frail, and most-complicated patients. Thus medical disciplines in the early 21st century span a spectrum with generalistsFfamily physicians, general internists, pediatricians, and general internists at one extremeFand medical, surgical, and other specialists and subspecialists at the other. Geriatricians claim a third, yet-more-ambitious but potentially ‘‘schizophrenic’’ position: we proclaim that we are both consummate generalists (for older adults) and, indeed, also expertsFspecialists, if you willFin understanding, managing, and coordinating the health care of patients with the most complex, chronic, progressive, and interacting diseases and syndromesFwhich ultimately uniformly prove fatal. Grappling with our ambitious but perhaps ambiguous identity has consumed enormous time and energy throughout the history of our professional organization (the American Geriatrics Society (AGS)), even as the ‘‘aging [or silver] tsunami’’ of the American population approaches ever closer and the challenge of meeting the healthcare needs of our elderly citizens threatens to inundate and bankrupt our expensive and arguably dysfunctional healthcare system. It is therefore encouraging that leaders of the AGS developed a strategic plan in 2006 that focused upon this challenge and generated support for the fourth Institute of Medicine study of geriatrics, which was recently released. This focused upon the fundamental changes in the U.S. healthcare system that will be required to successfully address the magnitude and complexity of this challenge with a solution that is affordable and in the true best interests of our elderly citizens and those who support them. These recommended changes laudably emphasized the relative and paradoxically growing dearth of professionals and even family and lay citizens that must join forces to meet the needs of the approaching ‘‘silver tsunami.’’ Concurrently, academic leaders within our field of Geriatrics, notably members of the Association of Directors of Geriatric Academic Programs (ADGAP), embarked upon a spirited grassroots exercise to define what we do as clinical practitioners that is most distinctive and, from our perspective, also adds greatest value to the care of generally the oldest, most-complex, frailest, and most-vulnerable Americans. Anchored in the ongoing ADGAP geriatric workforce study funded by the Donald W. Reynolds Foundation and first published in 2002, the present effort is presented in a report by Warshaw et al. in the current issue. This report is coupled with descriptions of geriatric care models from two academic health centers and a self-study by ADGAP Address correspondence to William R. Hazzard, MD, University of Washington School of Medicine, Seattle, WA. E-mail: william.hazzard@med.va.gov