Statement on Patients in
Peril: Critical Shortages in Geriatric Care
| Submitted to: |
Special Committee on Aging, United States Senate
|
| Date: |
March 13, 2002 |
The Association of American Medical Colleges (AAMC) welcomes
the opportunity to submit this statement for the record on
how we can encourage the education and training of more geriatric
physicians. The Association represents all of the nation's
125 accredited allopathic medical schools, approximately 400
major teaching hospitals, including 74 Veterans Affairs medical
centers, 88,000 faculty of these institutions represented
by 100 constituent academic and professional societies, and
more then 160,000 men and women in medical education as students
and residents.
As educators of tomorrow's doctors and as providers of health
care services, medical schools and teaching hospitals are
very aware of how society's needs are changing. The nation's
population is aging. Older Americans are now living healthier,
better quality lives as we have become more adept at forestalling
the onset of disease through scientific interventions. With
increased life expectancy, the number of those age 85 and
over is growing rapidly. However, there are identifiable groups
of older persons who are frail and more vulnerable and require
significant resources or even lack access to services.
Medical education is a complex and long process. There are
no "quick-fix" solutions to shifting the medical
education paradigm, but medical educators are taking steps
to ensure that newly trained physicians are well-schooled
in providing high quality health care for our senior Americans.
Medical education takes place along a continuum, starting
with four years of undergraduate medical education. In these
years of medical school, students learn content, that is the
knowledge, skills, values and attitudes needed for the practice
of medicine and are exposed to clinical practice. They graduate
as "undifferentiated" physicians. Medical school
generally is followed by three to seven years of graduate
medical education (GME) in a clinical setting. In their residency
years, new physicians apply the content of undergraduate medical
school to patients in clinical settings and specialize in
their chosen discipline. As practitioners, physicians evolve
their style of practice based on clinical experience and ongoing
formal and informal education. Physicians are keenly aware
of the need for continued learning, and participate in programs
of continuing medical education (CME). The concepts of independent
lifelong learning and continuous adaptation of new knowledge
and techniques to medical practice define what it means to
be a physician.
Opportunities to integrate learning about the care of older
people abound along the entire medical education continuum
and geriatricians play key roles in this teaching. Medical
schools, teaching hospitals and a variety of other organizations
have been devising and implementing new methods and approaches
to change and improve the medical education process at the
undergraduate, graduate, and continuing medical education
levels.
Undergraduate Medical Education
Nearly twenty years ago, the AAMC took the position that
this country's changing demography demanded that all physicians
should be trained to treat the elderly patient. With sponsorship
from the National Institute on Aging and the Pew Memorial
Trust, an advisory committee developed a report on the preparation
for improved geriatric care in the undergraduate medical education
curriculum. Five responsibilities of medical schools to accomplish
the goal of better undergraduate preparation for the treatment
of the elderly patient were outlined and schools were encouraged
to:
- provide a focus for change in the educational and training
programs to increase attention to the aging process and
elderly patients;
- seek support to expand research in aging to improve clinical
care, to stimulate medical student interest in the fields
of gerontology and geriatrics, and to foster interactions
with other specialties and disciplines;
- offer a variety of clinical settings and patient encounters,
including ambulatory, long term institution, and home care
experiences, through which students can learn special arrangements
for the care, diagnosis and treatment of the elderly;
- arrange for students to interact with healthy, independent
elderly persons; and develop geriatric educational material
within all disciplines; and
- urge scientific disciplines and medical specialty societies
to develop and disseminate geriatric education material
in their fields.
At the time of the AAMC's geriatric report in 1982, only
15 U.S. medical schools had identifiable departments, sections,
divisions or units in geriatrics or gerontology. For academic
year 2001-02, preliminary data show that 56 medical schools
have identifiable units, including 3 separate centers or units
at the departmental level. Most schools have sections or divisions
of geriatrics or gerontology in the departments of internal
medicine or family practice.
For 100 years, medical schools in this country have undergone
national oversight and review by the practicing profession,
represented by the American Medical Association, and medical
educators, represented by the AAMC. As the arbiter and standard
setter for medical education, the Liaison Committee on Medical
Education (LCME) conducts an annual review of all accredited
medical schools, including a survey of medical education programs,
to assess medical schools' compliance, in specific terms,
in courses of instruction and their place in the curriculum.
The annual inventory of geriatrics training, like that of
other disciplines needing greater prominence in the curriculum,
examines how schools are complying with standards such as
the following for geriatrics and related areas:
- The faculty must introduce current advances in the basic
and clinical sciences, including therapy and technology,
changes in the understanding of disease, and the effect
of social needs on demands for medical care;
- Clinical instruction...must include the important aspects
of acute, chronic, continuing, preventive, and rehabilitative
care;
- Students must have opportunities to gain knowledge in
those content areas that incorporate several disciplines
in providing medical care, for example, emergency medicine
and the care of the elderly and disabled; and
- All instruction should stress the need for students to
be concerned with the total medical needs of their patients
and the effect on their health of social and cultural circumstances.
The LCME's annual survey asks medical schools how they comply
with the standards from an operational perspective. As medical
schools are organized in many different ways, so is the variation
in medical school curricula. However, nearly every medical
school requires the teaching of geriatrics. The vast majority
(92 percent) teaches students about geriatrics as part of
a required course. 15 percent cover the topic as a separate
required course, the rest teach it as part of a required course.
Most schools also offer separate elective courses.
Medical school graduates have indicated general satisfaction
with the level of instruction being devoted to in geriatrics.
In 2001, 64.9 percent of medical school graduates responding
to the AAMC's annual Graduation Questionnaire (GQ) stated
they felt they were well-prepared to care for older patients
in acute settings and 64.5 percent felt they were well-prepared
to care for older adults in ambulatory settings.
In the last two years, the John A. Hartford Foundation in
New York City, working with the AAMC, has awarded a total
of $4.8 million to 40 medical schools to enhance their gerontology
and geriatrics curricula. A list of these schools is attached
to this statement. Each institution has received up to $50,000
a year, totaling $100,000 over the course of the two-year
grant. Each school offers a fully integrated curriculum spanning
the four years of undergraduate medical school education.
This is critical because it reinforces the relevance and importance
of geriatrics and the care of the elderly throughout the curriculum,
rather than limiting such information to a single course.
The institutions provide medical students with the necessary
skills to deliver high quality, compassionate care to the
nation's burgeoning elderly population, and to handle effectively
the complex issues associated with end of life care.
There are several points during the four years of medical
school when students gain experience with caring for the elderly.
In the preclinical phase of medical school, typically the
first two years, basic scientists discuss issues of aging
and senescence as these concepts apply to physiology and pharmacology
for example. Also in the preclinical years, many schools are
incorporating small group tutorial curricula emphasizing problem
solving and taught around cases, often involving elderly patients.
Students use these cases to learn not only history-taking
and diagnosis skills, but also doctor-patient communications
and case management skills. For example, more than 80 percent
of medical schools provide training in identifying and treating
elder abuse and neglect
Examples of the kinds of experiences the schools are providing
medical students include "senior mentors." Senior
mentors are healthy elderly who meet regularly with a student
or group of students throughout the four years of medical
school giving students the opportunity to experience the issues
the elderly face, but elderly who are not ill. Discussions
range from involvement in community activities, health issues,
nutrition, to discussions about sex and companionship. Additional
experiences include nursing home visits, retirement community
involvement, chronic diseases of the elderly, and mental status
examinations.
Medical schools also introduce students to clinical medicine
early in the preclinical phase of study. These introductions
to patient programs often provide ongoing interactions with
the same patients, providing opportunities for the bio-psycho-social
learning that is so important in understanding issues of aging.
Students are assigned patients, frequently elderly, and are
expected to obtain their histories and in consultation with
their supervisors, devise a treatment plan. These clerkships
or community preceptorships (periods of instruction) are based
primarily on experiential learning. In the teaching hospital,
where roughly one-quarter to one-third of all inpatient cases
are Medicare enrollees, students routinely encounter elderly
patients in their clinical education. Early exposure to clinical
experience in a particular specialty and encounters with faculty
who serve as role models and mentors during these clinical
experiences are often important factors in students' career
choices.
One of the schools has established an apartment where students
visit an elderly couple, or individual. These people are portrayed
by "standardized patients" who present the same
case history and setting to each student who visits. Students
are presented with different scenarios that focus on issues
such as nutrition, alcoholism, abuse, loneliness - issues
faced by the elderly.
All of the programs and materials developed by the 40 schools
funded through the John A. Hartford initiative are required,
as part of the funding, to be made available to other medical
schools for adaptation and implementation. The AAMC has developed
a website to facilitate the exchange of information among
the medical schools, as well as anyone interested in the topic.
As health care shifts from hospital inpatient-centered care
to integrated managed care systems utilizing a variety of
ambulatory care settings, medical educators are shifting much
clinical education to diverse outpatient settings. Nearly
all medical schools offer student clerkships in ambulatory
care settings. The system of care for the elderly must particularly
be viewed as a large system of health and social services
that are likely to be delivered in a variety of settings,
ranging from the tertiary teaching hospital to the home. For
example, nearly all medical schools provide educational opportunities
in home health care as part of a required course or other
educational experiences in home health. The challenges of
providing a sufficient number of sites where students can
learn from appropriate faculty are formidable. It is difficult
to assure uniform quality of teaching from different clinical
faculty in a wide variety of settings and to assess student
learning. Experiences of the 40 schools funded by Hartford,
as well as work underway in at least 20 other medical schools,
will be critical to assuring better health care for the elderly.
Graduate Medical Education
Graduate medical education (GME) is recognized and accepted
as an essential phase of medical education. Its principal
goals are to prepare proficient practitioners of medicine
and to equip them for continued professional development.
Each specialty has a formally organized board that establishes
the minimum length of time to be spent in training and the
other criteria a resident must fulfill to be eligible for
certification. While undergraduate medical education is university-based
and molded by the academic traditions of higher education,
GME has historically been hospital-based and developed from
a tradition of "on-the-job" experiential training.
Many of the same concerns about providing appropriate teachers
and nonhospital teaching sites also are prevalent among educators
of residents.
GME training programs are accredited by the Accreditation
Council for Graduate Medical Education (ACGME). In practice,
programs are required to submit information about their curricula
to the appropriate Residency Review Committee (RRC) which
evaluates the data during the accreditation process. For example,
program requirements for residency education in internal medicine
have a geriatric component:
- Residents must have formal instruction and regular, supervised
clinical experience in geriatric medicine.
- The written curriculum must include experiences in the
care of a broad range of elderly patients.
- Geriatric clinical experiences must be offered. They
may occur at one or more specifically designated geriatric
inpatient units, geriatric consultation services, long-term
care facilities, geriatric ambulatory clinics, and/or in
home-care settings. (ACGME Program Requirements for Residency
Education in Internal Medicine 2001)
Geriatrics as a defined specialty is relatively new. It was
recognized by the American Board of Medical Specialties (ABMS)
in 1985 as a subspecialty of internal medicine and family
practice. The first examination for which a physician could
become a board-certified geriatrician was offered in 1988.
Thus, the specialty has not had a very long time to mature
and is still developing. Residency training opportunities
in internal medicine and family practice geriatrics have increased
dramatically since 1989. In 1989-90, there were 50 training
programs in internal medicine and family practice geriatrics
approved by the Accreditation Council on Graduate Medical
Education (ACGME). In 2001-02, there were 120 approved training
programs.
Obstacles and Constraints to the Development of Academic
Geriatrics
Increasing the visibility of geriatrics in medical schools
is difficult given the current shortage of academic geriatric
faculty. Faculty can serve as important role models for medical
students and they can influence students' career choice. Data
from the AAMC's faculty roster database show that there are
734 faculty reporting geriatrics (either internal medicine
or family practice geriatrics) as a medical specialty among
the 125 allopathic medical schools. This compares with 121
faculty in June 1991 and 468 faculty in June 1995. While the
number of geriatric faculty has increased more than four times
since 1991, most geriatric leaders believe current numbers
are inadequate.
A broad spectrum of clinical training sites where the elderly
are served, from nursing homes and day care centers to physicians'
offices and home care, are needed to expose medical students
to elderly people with varying health status. Simply seeing
elderly patients in the hospital during geriatric assessment
rounds does not provide the full learning experience necessary
for career choice. Patients must be evaluated in social and
various care settings. However, most medical educators lament
the paucity of appropriate clinical training sites at both
the graduate and undergraduate education levels. Finding training
sites of uniform quality and faculty who are willing to teach
in these sites, particularly practitioners who must generate
clinical income in a cost-conscious environment, is challenging.
Establishing and maintaining high-quality educational sites
is costly.
Increasing emphasis on multi-disciplinary and integrative
teaching is well-suited to enhanced geriatrics education and
educators are developing innovative programs, as illustrated
by the AAMC/Hartford geriatrics grants initiative. However,
this demands the time and attention of a limited number of
trained educators who face the demands of many competing responsibilities.
Medicine is an increasingly complex field, and many worthy
courses compete for students' time. Like other integrative
subjects that require multi-disciplinary approaches, geriatrics
needs to be well-integrated into the curriculum.
Recruitment of students into geriatrics is difficult. While
the number of residency training programs in internal medicine
and family practice geriatrics has increased substantially
since 1989, many geriatric training positions are not being
filled. For the 2001-2002 academic year, only 375 of 494 geriatric
training positions offered were filled.
Clearly, geriatrics has not yet enjoyed a high degree of
popularity with students and residents. This patient population
requires particular skills and understanding. For example,
patients with impaired mental capacity may not recognize their
own physician. The key to more geriatricians is making the
specialty more attractive to students as a career choice.
The AAMC has invested significant effort to learn as much
as possible about medical student specialty choice by asking
graduating seniors about factors influencing specialty choice.
The results - and they haven't changed materially from year-to-year
- tell us that medical students are influenced by their educational
experiences. These include positive clerkship experiences
and physician role models. Students also pick specialties
that interest and challenge them intellectually and that are
consistent with their values and personalities. With more
role models and the opportunity to see the elderly in ambulatory
settings, students should develop increased interest in this
career.
A significant constraint in attracting more medical students
to train in geriatrics is the comparatively low level of payment
for primary care and evaluation and management services under
the Medicare Fee Schedule and other third party payment systems.
The vast majority of geriatricians' services provided to Medicare
beneficiaries are visits and consultations.
AAMC Activity Related to Improvements in Medical Education
The AAMC and its members are fully aware and sensitive to
the perception that the graduates of our current medical education
system may be misaligned with what society wants and needs
from the medical education community. Society now recognizes
the need for a broader view of health care and wants doctors
who can and will attend equally well to all aspects of health
care.
As part of a major initiative to address societal concerns
the AAMC embarked on a project to assist medical schools in
their efforts to create a better alignment between the training
of new doctors and society's expectations of physicians. Called
the Medical School Objective Project (MSOP), this effort was
not directed specifically at geriatrics education, but applies
to all medical education. In recognizing new expectations,
the MSOP panel reached consensus on a set of four overarching
attributes that characterize the qualities all physicians
must possess: they must be altruistic, knowledgeable, skillful
and dutiful. The panel also set forth learning objectives
for the medical student curriculum derived from those attributes.
The attributes and objectives apply equally to the education
of geriatricians as they would any other medical career choice.
In January 1998, the AAMC issued the first report which sets
forth the objectives that can guide medical schools in developing
goals that reflect an understanding of the implications for
medical practice and medical education of evolving societal
needs, practice patterns, and scientific developments. Among
them is that medical school graduates must demonstrate an
understanding of, and respect for, the roles of other health
care professionals, and the need to collaborate with others
in caring for individual patients and in promoting the health
of defined populations. Physicians must feel obliged to collaborate
with other health professionals and to use systematic approaches
for promoting, maintaining and improving the health of individuals
and populations.
Emphasis on interdisciplinary learning as the health system
shifts from physician-oriented systems of care to systems
utilizing teams of health care professionals is critical,
particularly in geriatrics. Interdisciplinary teams, in which
health professionals from multiple disciplines apply their
special skills, knowledge and values to achieve common goals,
can enhance innovation, improve the quality of patient care,
and strengthen academic-clinical ties and partnerships among
institutions and settings. While the challenges of changing
behavior and cultures are great, the benefits from interdisciplinary
education have huge potential.
The MSOP Report I also notes that in caring for individual
patients, physicians must apply the principles of evidence-based
medicine and cost effectiveness in making decisions about
the utilization of limited medical resources. They must be
committed to working collaboratively with other physicians;
other health care professionals, and individuals representing
a wide variety of community agencies. As members of a team
addressing individual or population-based health care issues,
they must be willing both to provide leadership when appropriate
and defer to the leadership of others when indicated. They
must acknowledge and respect the roles of other health professionals
in providing needed services to individual patients, populations
or communities.
Strategies for Schools of Medicine
In addition to revising physician education constantly due
to advancements in scientific and medical knowledge and changes
in treatment patterns, medical schools may wish to adopt several
strategies to attract medical students to geriatrics. In 1992,
the AAMC issued a report on the generalist physician that
recommended an action agenda to increase the attractiveness
of primary care medical careers. Many of these strategies,
repeated from the report on the generalist physician in boldface
type below, have been successfully employed to increase the
number of students choosing careers in primary care specialties.
They also can be utilized to increase the number of students
choosing careers in generalist specialties from which geriatricians
tend to obtain their residency training.
Schools of medicine should establish administrative units
for the generalist specialties. Medical schools should
establish administrative units for geriatrics where the responsibility
for leadership and management of its educational effort can
be focused to assure adequate support. Such units need not
be formal departments or even divisions within departments,
but should have sufficient administrative authority to be
effective champions for the care of the elderly. Having a
separate department does not necessarily mean that students
will be exposed to geriatric patients. A variety of educational
experiences in diverse settings such as nursing homes, home
care and other nonhospital settings will expose the student
to the broad spectrum of the elderly population. Every doctor
in primary care and specialty medicine should be fully knowledgeable
about the many diseases and disabilities of old age, and understand
the techniques of maintaining function in older patients.
To recruit and advance faculty, medical schools should
provide appropriate academic recognition for scholarship,
teaching and role modeling among faculty in the generalist
specialties. The contributions and special skills of geriatric
faculty should be recognized and rewarded. Faculty from geriatrics
should serve on key administrative and planning committees
in the institution. The current traditional system of rewards
may limit the prestige of geriatrics as a discipline, impairing
the school's ability to attract and sustain adequate faculty.
Retraining of existing mid-level faculty also should be considered.
Medical schools should foster research opportunities in
the generalist fields among faculty, residents and students.
With the explosion in scientific discovery, there are
many unanswered, urgent questions about aging. Geriatrics
is poised to play an important role in meaningful research
efforts to help better understand aging and disability.
Medical schools should require that all medical students
have meaningful curricular experiences in the generalist specialties.
This includes clinical experiences in nonhospital settings
and the opportunity to encounter role models among the faculty
who teach geriatrics. Most medical students make their specialty
choice before the end of the third year of medical school.
The early introduction of positive experiences in clerkships,
preceptorships or other educational activities related to
the elderly population in nursing home or home care settings,
for example, will ensure that students have an appropriate
base for making career decisions. Effective role models are
likely to raise student interest in geriatrics.
It also is important for medical schools to partner with
a variety of public and private entities. Medical schools
and teaching hospitals should seek relationships that enable
them to develop teaching chronic care systems for senior care.
For example, a rural hospital may want to develop a senior
care system, partnering for referrals of the sickest patients
and sending physicians to the academic center for "in-career"
internships during which the physician works alongside academic
geriatricians for a limited period of time.
Recommendations for Congress
The AAMC also recognizes that the federal government can
support an increase in the number of geriatricians trained
through a variety of mechanisms:
Provide adequate support for existing federally-sponsored
student loan re-payment programs. Students who show interest
in geriatrics may hesitate to choose the specialty due to
high levels of educational debt because they cannot afford
to study geriatrics for two additional years. The AAMC believes
that if monetary incentives are provided, they should be directed
at individuals. A variety of federally-sponsored student loan
programs, such as the National Health Service Corps program,
already exist.
Restore adequate funding support for Title VII geriatrics
programs. Increased funding is needed to support multi-disciplinary
geriatric education centers (GECs), geriatric training programs
(GTPs), and Geriatric Academic Career Awards. These programs
are effective in providing opportunities for health care personnel
to develop skills for providing better, more cost effective
care for older Americans. Unfortunately, the Administration's
FY 2003 budget eliminates funding for these programs.
Affiliated with educational institutions, hospitals, nursing
homes, community-based centers for the aged, and veterans'
hospitals, GECs include short-term faculty training, curriculum,
and other educational resource development, and technical
assistance and outreach. GTPs provide fellowships for medical
and dental faculty and provide for curriculum development,
the hiring of faculty, and the first three months of fellowship
training. Geriatric Academic Career Awards support career
development of geriatricians in junior faculty positions who
are committed to academic careers teaching clinical geriatrics.
Provide adequate support for the Geriatric Research,
Education and Clinical Center (GRECC) program in the Department
of Veterans Affairs. Established in 1975, the GRECC program
increases the basic knowledge of the aging process, shares
the knowledge with other health care providers, and improves
the overall quality of health care received by elderly veterans.
The 20 GRECCs established by the VA are at the forefront of
the fields of gerontology and geriatrics. A 1997 audit by
the Inspector General (IG) of the VA noted that "the
GRECC's integration of research, education, and clinical care
activities at major research facilities was an effective method
for addressing the health needs of the elderly." The
IG recommended the development of a method for implementing
GRECC-developed treatment models and educational programs
at more VA facilities. It should be noted that the VA maintains
many programs for older veterans, including 121 geriatric
evaluation management (GEM) programs across its system. Aimed
at keeping the frail elderly out of nursing homes, these GEMs
provide comprehensive health care assessments and other services
to veterans with multiple medical problems and those with
geriatric problems. The VA has set a goal of establishing
at least one GRECC in each of its 22 networks; currently,
there are 20 GRECCs in 18 networks.
Conclusion
As revolutions continue in biomedical science and health
care services, revolutionary forces also are being exerted
on medical education. Medical educators are transforming our
educational paradigm by adopting a broader focus incorporating
responsibility for the life-long learning that physicians
will need to maintain relevant knowledge and skills in a rapidly
changing profession. The AAMC recognizes that increasing the
number of geriatric physicians calls for action on at least
two fronts: voluntary efforts by private sector organizations
and government action to eliminate barriers that prevent us
from meeting the need. Medical schools, teaching hospitals
and other private organizations should work with governmental
bodies to find and craft solutions for increasing the number
of geriatricians.
AAMC 2001 Hartford Grant Award Recipients
- University of Alabama School of Medicine
- Albert Einstein College of Medicine of Yeshiva University
- University of California, Irvine, College of Medicine
- University of Cincinnati College of Medicine
- Columbia University College of Physicians and Surgeons
- Duke University School of Medicine
- Georgetown University School of Medicine
- Indiana University School of Medicine
- Jefferson Medical College of Thomas Jefferson University
- Louisiana State University School of Medicine in Shreveport
- University of Louisville School of Medicine
- University of Massachusetts Medical School
- Meharry Medical College School of Medicine
- University of Missouri-Columbia School of Medicine
- University of New Mexico School of Medicine
- University of Pittsburgh School of Medicine
- St. Louis University School of Medicine
- State University of New York Upstate Medical University
College of Medicine
- University of Texas Health Sciences Center at San Antonio
- Wayne State University School of Medicine
AAMC 2000 Hartford Grant Award Recipients
- University of Arizona College of Medicine
- University of California, Los Angeles, UCLA School of
Medicine
- University of California, San Francisco, School of Medicine
- University of Connecticut School of Medicine
- Southern Illinois University School of Medicine
- Johns Hopkins University School of Medicine
- University of Kansas School of Medicine
- University of Miami School of Medicine
- University of Minnesota Medical School
- University of Missouri-Kansas City School of Medicine
- Mount Sinai School of Medicine of New York University
- University of Nebraska College of Medicine
- University of North Carolina School of Medicine
- Ohio State University College of Medicine
- University of South Carolina School of Medicine
- East Tennessee State University James H. Quillen College
of Medicine
- Texas Tech University Health Sciences Center
- University of Texas Medical Branch
- Medical College of Wisconsin
- University of Wisconsin Medical School
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