Clinical Geriatrics

As a family physician and geriatrician, I, like many in the field, have resisted giving up the very ambitious position of being both a generalist and specialist. But a series of articles examining how to make the most effective use of the nation’s scarce supply of geriatricians in the October 2008 issue of the Journal of the American Geriatrics Society has convinced me that it’s time to refine the scope of geriatrics.

In a commentary that he contributes to the JAGS series, William Hazzard notes that, from the beginning, we geriatricians have staked out a potentially “schizophrenic position.” “[We] proclaim that we are both consummate generalists (for older adults) and, indeed, also experts—specialists, if you will—in understanding, managing and coordinating the health care of patients with the most complex, chronic, progressive, and interacting diseases and syndromes,” he writes.

True. But now, with the eldest of the nation’s 77 million baby boomers reaching retirement age in less than three years, it’s time to make some choices. As the AGS noted in “The Future of Geriatric Medicine” in 2005 and the Institute of Medicine confirmed in “Retooling for an Aging America” this spring, there simply aren’t enough of us to care for everyone.

Roughly 12% of Americans are now age 65 or older, and that figure will reach 20% by 2030. So how do we best deploy available geriatricians to optimally meet the healthcare needs of this rapidly growing group? Gregg Warshaw and colleagues begin the JAGS series with an article reporting the results of a 2007 Association of Directors of Geriatric Academic Programs (ADGAP) survey that put this very question to the directors of U.S. geriatric academic programs (DGAPs). The online survey went out to the DGAPs at all 145 American allopathic and osteopathic medical schools and garnered a near 75% response rate. The strong consensus among respondents: Given the shortage, geriatricians should focus on the most complex and most vulnerable older adults. “The findings offer the beginning of a consensus statement as to the role of geriatricians in the continuum of American medical care,” Warshaw et al conclude.

In a subsequent paper, Christopher Callahan and coauthors offer an example and potential model of an academic urban public health system where geriatricians do just this, and complement the care that primary care practitioners provide to healthier older patients. The Indiana University (IU) health system serves a large and diverse population of older adults, offering a wide range of outpatient, inpatient, and related services. In the IU system, geriatricians play key roles in healthcare administration—thereby affecting the care of all older patients via system design and redesign. They also assist generalists in the care of a large number and broad range of older patients. In addition, geriatricians and their interdisciplinary teams focus on a relatively small number of older adults who are frail or have geriatric syndromes. Primary care physicians at IU, Callahan notes, “tend to cede” these patients to geriatrician colleagues when their care becomes more complex.

Findings from a study by Elizabeth Phelan and colleagues included in the JAGS series appear to support having geriatricians both focus on older patients at “greatest need” and assist generalists in the care of other older patients. The study finds that the care provided by geriatricians and generalists differs, with geriatricians assessing patients for geriatric syndromes and taking steps to avoid improper prescribing slightly more often than generalists in ambulatory settings. This difference, though slight, would be of greater concern with the most complex patients, who are more likely to have geriatric syndromes and to take more medications.