Ageing and polymorbidity: is there a mismatch between the training of internists and the need?

The Dutch population is ageing, like the populations of the majority of countries throughout the world. At present about 15% of the Dutch population is older than 65 years. This will be 21% in 2025. As chronic diseases often develop in elderly people, the Dutch National Institute for Public Health and the Environment (RIVM) recently calculated the consequences of ageing for the Dutch population. Calculations were carried out with a ‘Chronic Disease Model, simulating the course of diseases in the general population, including trends in the past, unhealthy lifestyles and demographic changes due to ageing. The outcome of these calculations is dramatic. About 6% of the Dutch population and about 25% of the people older than 65 years will suffer from diabetes in 2025, if the present trend in the increase of obesity continues. Relative to 2005, this means an increase of 70% in 20 years. Expected prevalences for other chronic diseases are summarised in table 1. In addition, the prevalence of a variety of other chronic diseases related to ageing, such as dementia, depression, anxiety, Parkinson’s disease and hearing and vision impairment, are expected to increase as well. This is not a national trend. At present, chronic diseases contribute 60% to the global burden of disease and this will increase to 80% by the year 2020. So, chronic diseases are becoming a major problem in the provision of medical care. As single occurrence of chronic diseases in elderly people is rare, an increasing number of individuals with a chronic disease will suffer from more than one chronic condition. This requires an integrated patient-centred rather than disease-centred approach, preferably by a generalist. The majority of chronic diseases of these polymorbid elderly patients fall within one or more of the subspecialities of internal medicine and hence internists will become more and more involved in the care of patients with complex multiple conditions. For this reason, the Dutch Society for Internal Medicine recognised internal medicine for elderly patients as a subspeciality in 2004. One may wonder, however, whether or not this is a pleonasm in view of the ageing of the population and passes over what the core competence of a future internist should be: a generalist with knowledge of ageing and the pathophysiology of age-related diseases, an open mind for psychosocial aspects in the care of the elderly and its consequences for a functional and multidisciplinary approach in the provision of care. In view of this, one may also wonder whether there is a need for a specialisation in geriatric medicine separate from internal medicine rather than integration of this speciality within the core competence of general internists to limit fragmentation of care for the elderly patient. The consequence of this line of reasoning is that the need for internists trained in general rather than subspeciality internal medicine should increase during the next 20 years in parallel with the increase in elderly patients with multiple chronic conditions. The trend in the training of Dutch internists is, however, exactly the opposite. A recent survey revealed that over 90% of the trainees in internal medicine prefer training in one of the subspecialities of internal medicine. Of these, trainees’ interest in a training in the subspeciality elderly or geriatric medicine is about 3%, which in combination with the slight interest to become a generalist is not nearly enough to cover the future needs in the medical care of complex polymorbid patients. This Table 1. Increase of prevalence (%) of chronic diseases in period 2005-2025

Topic: Global Health Care Issues
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences