Clinical Geriatrics

Although everyone recognizes that there are a growing number of older individuals and a need for physicians to be skilled in the special needs and problems of the elderly, little has been done to ensure that medical trainees receive comprehensive training in this regard. As a program director of an Internal Medicine residency program, I make sure on a regular basis that my program meets all of the ever-changing rules and regulations. The American Board of Internal Medicine (ABIM) requires that

“Residents must have formal instruction and assigned clinical experience in geriatric medicine. The curriculum and clinical experience should be directed by an American Board of Medical Specialties (ABMS) certified geriatrician. These experiences 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.”

Each program is left to its own to determine how best to meet this requirement, recognizing that it may emphasize a particular area of strength while offering no experience in others. Is a nursing home experience in itself sufficient to train residents in the care of the elderly? How about a rotation through an inpatient geriatric consultation service or home care program at the exclusion of other experiences?

Clearly, there is a spectrum of care that is involved when considering the older person’s medical needs, and we would do well to train future primary care providers in all areas that may be encountered. I have always tried to include this comprehensive training experience in programs I have been involved in; however, in the absence of a regulatory mandate, geriatrics must compete with other rotations that frankly have little problem attracting residents. Few program directors want to force the issue beyond what they consider to be feasible or minimally necessary in order to satisfy accreditors. Geriatric rotations should not only be educational, but also provide an opportunity for residents to experience a field that they may not have previously considered as a career option. While economic realities are hard to overcome, and specialties such as cardiology and gastroenterology will be hard to compete with, for many, the challenge and rewards in caring for the older patient in a variety of settings will be sufficient to alter their minds. (Perhaps I am too optimistic or naïve.) At a minimum, a well-structured geriatric experience will prepare residents to better understand just why their older patient may not have the same sign or symptom or respond in a similar manner as the younger person in the next hospital bed, and to be better able to prescribe a proper course of treatment.

I was particularly pleased to learn of a new initiative of the ABIM, “Improving Quality of Care for Elderly Patients in the Educational Setting.” While being introduced and tested as a multicenter study, the ABIM will attempt to educate residents about the special needs and problems of the elderly encountered in the ambulatory setting by the use of training modules. It is hoped that specific teaching modules will improve not only one’s fund of knowledge, but also have an impact on attitudes, and provide the impetus for performance improvement projects; the goal is to improve the care provided to the older individual. I applaud the ABIM on this long overdue initiative that will raise the level of awareness in the ambulatory setting that the older person has special needs and problems to consider, and that require skills that need to be mastered if we are to ensure proper care for the elderly. While this program is not mandated and is still in the study phase, it is another step toward the goal of achieving more comprehensive training in the care of the elderly.