American College of Physicians: Internal Medicine — Doctors for Adults ®

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Geraitrics changes its rules to attract more residents

More ambulatory experiences, intellectual challenges part of pitch to meet skyrocketing demand

From the February 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Christine Wiebe

For Arthur W. Feinberg, MACP, it was another "small triumph" in his work as a geriatrician. An 83-year-old man who had lost both legs due to circulatory problems was learning to use prosthetic limbs, and Dr. Feinberg was confident that the patient would soon walk out of the hospital.

"That will be a day of great excitement for me and my staff," explained Dr. Feinberg, chief of geriatric medicine at North Shore University Hospital/New York University School of Medicine. "There's a lot of satisfaction in having someone with a serious illness survive and have a good quality of life."

Dr. Feinberg is a self-described cheerleader for geriatrics, a field that has long attracted physicians devoted to caring for the elderly. But the number of physicians entering the specialty has traditionally been far less than the demand—and the demand is only going to increase. Consequently, recent studies predict a severe shortage of geriatricians. As a result, some leaders in the field are trying to redefine geriatrics to make it a more competitive and attractive option for internal medicine residents.

A bright future

Geriatrics is still a relatively new career path. Certification—in the form of added qualification certificates—has been offered only since 1988, when the boards of internal medicine and family medicine teamed up to offer a geriatrics exam. Formal training in geriatrics generally consists of a two-year fellowship following a residency in either internal medicine or family practice.

At a time when residents are being discouraged from subspecializing because of the changing job market, geriatrics offers new physicians a chance to develop a practice niche while remaining competitive in the primary care market, say experts in the field.

"It's one of the few medical opportunities left," said Christine K. Cassel, FACP, the College's President and chair of the department of geriatrics and adult development at Mount Sinai Medical Center in New York. She explained that she is besieged by calls from employers looking for fellows in geriatrics. "I think that's going to be true in the foreseeable future," she added.

Recent studies have reached the same conclusion. A report issued earlier this year by the Alliance for Aging Research identified a need for 20,000 geriatricians to treat 30 million Americans aged 65 and over; currently, there are fewer than 9,000 geriatricians. By the year 2030, the report concludes, the United States will need more than 36,000 physicians with geriatric training.

Another study conducted by the Institute of Medicine in 1993 estimated that the 65-plus group, which at that time represented 12% of the population, will swell to 20% by 2030. The study also concluded that existing training programs will not produce enough skilled geriatricians to train the number of geriatricians that will be needed in the future.

Just as the post-war "baby boom" led to an increase in "baby doctors," the need for geriatric care is expected to grow as baby boomers reach senior citizenhood. "Geriatrics will be to the coming decade what pediatrics was to the '50s," predicted Ciro V. Sumaya, MD, administrator of the U.S. Health Resources and Services Administration (HRSA).

"I have no question in my mind that geriatrics is going to be one of the hottest [job] areas," added Mazie Blanks, senior vice president of Jackson & Coker, an Atlanta-based physician recruitment firm. She said that while general internists are in great demand today, extra training in geriatrics is one of the few areas that makes sense. "I think it's an absolute plus."

Internists with a certificate in geriatrics will be more competitive in the job market of the future, agreed Marc Rivo, MD, medical director for the south Florida region of AvMed, a non-profit HMO, and former director of HRSA's medicine division. If their training covers the principles of managed care such as chronic disease management, he said, internists will be even more attractive, particularly for management positions. Geriatricians are often tapped to oversee programs targeted at elderly populations, such as risk assessments to avoid hospitalization, that are especially popular with managed care organizations.

Fellowship rules change

Ironically, though, the number of new geriatricians has recently declined, primarily because of changes in training requirements. Until this year, certification was a fairly open process, available even to practicing physicians who had no formal training in geriatrics. Candidates who could pass the exam were "grandfathered" in and received certification in geriatrics.

Now, however, only physicians who have completed a geriatrics fellowship may sit for the exam. As a result, only 545 physicians were certified in geriatric medicine in 1996, compared with about 2,000 in previous exam periods.

Recognizing the need to produce more, not fewer, geriatricians, the boards this year agreed to reduce the minimum fellowship requirement from two years to one year beginning with the 1998 exam. (Board leaders expressed hope that candidates interested in an academic career in geriatrics would pursue longer training, particularly in research.)

However, only two-year geriatrics fellowship programs currently receive accreditation, a glitch that should be resolved within a few years, according to F. Daniel Duffy, FACP, chair of the Residency Review Committee (RRC) for Internal Medicine. Until programs become accredited under the new rules—probably by July 1999—fellows will continue to train in two-year programs but will be able to sit for the exam after one year, Dr. Duffy said.

In addition to adopting the more lenient requirement for certification, the field hopes to attract residents by exposing medical students and residents to positive experiences in geriatrics.

For instance, accreditation rules now require internal medicine programs to have a structured, written curriculum in geriatrics, explained Dr. Duffy. The RRC plans to strengthen that requirement further in the next few years, he said. "We believe geriatrics is a large part of general internal medicine and the subspecialties of internal medicine."

And as medical students and residents spend more time in ambulatory settings, experts say they will be exposed to a different side of geriatric care than they see in the hospital, where they treat only the sickest patients.

Plus, as senior citizens are increasingly seen as active, diverse people, the image of the elderly is changing, said T. Franklin Williams, FACP, former director of the National Institute on Aging and scientific director of the American Federation for Aging Research.

Finally, research advances in areas such as Alzheimer's disease and the aging process itself are also making geriatrics a more appealing specialty.

'Intellectually challenging'

Eileen Callahan, ACP Associate, for example, decided to pursue a career in geriatrics after discovering during residency that she enjoyed working with older patients. Now a second-year fellow in geriatrics at Mt. Sinai, she especially likes the field's interdisciplinary approach, which allows her to treat "the whole patient" and work with the patients' families and other specialists. "Knowing the job market is wide open for me is just an extra benefit," she said.

Supporters like Dr. Feinberg say that geriatrics is one of the rare fields where a physician can be a consummate clinician and teacher who is constantly learning. Back when he spent most of his time in a tertiary care center, he said he developed an "ICU mentality" that dictated, "Put a tube into every orifice you could find." When he moved into geriatrics, he said he learned to take care of people instead of just an organ system. "It's like being a doctor 30 years ago," he said, "before all the high-tech stuff."

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

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