Eletters
Topic:
Book Review
Laura J. Niedernhofer
J. Clin. Invest. 2008;
118(10):3245
Geriatricians: Experts and advocates for system-based approaches to health-care delivery and aging research
George A. Kuchel | Kuchel@uchc.edu
UConn Center on Aging, University of Connecticut Health Center, Farmington, Connecticut, USA
Published on October 22, 2008
I would like to congratulate Dr. Niedernhofer on a most insightful review
of Dr. David Hamerman’s timely book Geriatric Bioscience: The link
between aging and disease (1). Nevertheless, I believe
that Dr. Niedernhofer’s description of Geriatric Medicine does not
correctly reflect the current state of this discipline, in some cases
contradicting major professional organizations, the Institute of Medicine,
and the NIH. Dr. Niedernhofer feels that Geriatric Medicine
is miscategorized as a specialty of Internal Medicine and that the field
has thus been compromised by presuming that an elderly patient and a
younger adult with the same disease should receive the same treatment.
I believe that several corrections are needed.
Both
family physicians and internists are eligible for training and certification
in Geriatric Medicine. Among US medical schools, eight have well-established
Departments of Geriatric Medicine. In the remainder, a mixed-governance
model is most common with both a Division of Geriatric Medicine within
a Department of Medicine and a much broader institutional structure
such as a Center with direct reporting to a Dean, Provost or President.
While each model has its proponents (2,3), all Geriatricians share a
common approach to relevant clinical and research issues irrespective
of the governance structure at their institution. In distinct
contrast to the organ-based focus taken by most other specialties, a
systems-based approach that emphasizes functional outcomes lies at the
very core of Geriatric Medicine (4). Moreover, much of what Geriatricians
do as clinicians and as investigators involves multidisciplinary efforts
designed to overcome traditional organ- and discipline-based barriers
(4).
With
the exception of Pediatricians, nearly all health professionals will
be involved in the care of older adults in future years (5). Geriatricians
must continue to play leadership roles in helping to define a society’s
capacity to address the specific health needs of older adults.
Moreover, aging of our population represents one of the main reasons
why biomedical research must move beyond a disease-based focus if we
are to meet the needs of our patients in the 21st century (6).
From the perspective of aging research, we must not only seek to “add
years to life”, but to also “add life to years”. Thus, common
geriatric syndromes such as frailty, sarcopenia, delirium, incontinence,
falls, and loss of functional independence must also be addressed (4).
Given the multifactorial nature of these conditions, innovative approaches
for dealing with such complexity will be required in order to define
their pathophysiology and to discover novel innovative intervention
strategies (4,7).
The
NIH has played an important role in supporting a move in this direction
with the creation of the Aging Systems and Geriatrics (ASG) Study Section
(8). Other notable efforts include the report on the Future Health
Care Workforce for Older Adults recently issued by the Institute of
Medicine (5). As noted in the report, the geriatric competency of our
entire workforce must be enhanced (5). This is certainly true
for divisions of Internal Medicine and Surgery, where innovative funding
initiatives are beginning to make an impact. For example, the
T. Franklin Williams Scholars Program and the Dennis W. Jahnigen Career
Development Awards Program provide salary support for internists and
surgeons, respectively, who wish to develop academic careers addressing
the geriatric aspects of their own discipline. The Paul B. Beeson Career
Development Award in Aging provides a much more substantial K08/K23
National Institute on Aging/NIH training award for physicians from any
discipline who wish to undertake intense mentored research training
in aging. Finally, the American Geriatrics Society has developed a number
of educational partnerships with sister professional organizations in
both Medicine and Surgery with the goal of developing a state-of-the-art
geriatrics curriculum and research agenda for all of their Divisions.
References
- Niedernhofer, L.J. 2008.
Geriatric Bioscience: The link between aging and disease. J. Clin.
Invest. 118:3245.
- Hazzard, W.R. 2000. The
department of internal medicine: hub of the academic health center response
to the aging imperative. Ann. Intern. Med. 133:293–296.
- Cassel, C.K. 2000. In
defense of a department of geriatrics. Ann. Intern. Med. 133:297–301.
- Inouye, S.K., Studenski,
S., Tinetti, M.E., and Kuchel, G.A. 2007. Geriatric syndromes: clinical,
research, and policy implications of a core geriatric concept. J.
Am. Geriatr. Soc. 55:780–791.
- Committee on the Future
Health Care Workforce for Older Americans, I.O.M. 2008. The Future of
Health Care Workforce for Older Americans; http://www.iom.edu/CMS/3809/40113.aspx.
The National Academies Press. Washington, DC.
- Tinetti, M.E., and Fried,
T. 2004. The end of the disease era. Am. J. Med. 116:179–185.
- Loscalzo, J., Kohane,
I., and Barabasi, A.L. 2007. Human disease classification in the postgenomic
era: a complex systems approach to human pathobiology. Mol. Syst.
Biol. 3:124.
- Center of Scientific Review
NIH 2008. Aging Systems and Geriatrics Study Section [ASG], http://cms.csr.nih.gov/PeerReviewMeetings/CSRIRGDescription/BDAIRG/ASG.htm.
Response to Kuchel
Laura Niedernhofer | niedernhoferl@upmc.edu
Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.
Published on October 22, 2008
Thank
you kindly for your letter expressing your expert opinion on the current
state of Geriatric Medicine. You were able to provide detailed information
about training in, and NIH support of, Geriatric Medicine. I am delighted
to learn that eight medical schools have Departments of Geriatric Medicine.
In my review of Dr. Hamerman’s book, Geriatric bioscience: The
link between aging and disease
(1), I in no way meant to imply that the quality of Geriatric Medicine
has been compromised. In fact, aged Americans have never been healthier
(2). My intention was to echo Dr. Hamerman’s concern that the current
number of trainees in geriatrics and the level of funding for aging
research are insufficient in light of the rapidly changing demographics
in the United States.
The
number of individuals aged 65 or older will double between 2000 and
2030 (2), at which point, 20% of the American population will be greater
or equal to 65 years of age (2). Eighty percent of those individuals
will have at least one chronic health condition, while 50% will have
two or more (2). At the turn of the 21st century, there were 5.5 geriatricians
per 10,000 persons greater or equal to 75 yrs of age (3). The ratio
of pediatricians to patients was twice that (4). Furthermore, only 3%
of medical trainees eligible for specialization in Geriatric Medicine
entered a fellowship program and the number of geriatricians seeking
re-certification has declined by greater than 30% (3). Therefore
the timeliness of Dr. Hamerman’s text, which should spark interest
in clinical geriatric medicine and research, could not be better.
The
Association of Directors of Geriatric Academic Programs attributes the
dearth of Board-certified geriatricians to a preference of trainees
to enter procedure-oriented specializations, which offer a higher income
at a time when the cost of a medical education is sky-rocketing. If
Geriatrics were developed as in independent department, like Pediatrics
and Internal Medicine, with its own sub-specializations, the field might
attract a larger fraction of medical trainees and funding for research.
This could also be justified based on the fact that the elderly are
an increasingly large segment of our population and that recent research,
elegantly summarized by Dr. Hamerman’s in Geriatric bioscience
has revealed that the elderly have a distinct and complex physiology
that contributes to their increased incidence of chronic disease.
References
- Niedernhofer, L.J. 2008. Geriatric
Bioscience: The link between aging and disease. J. Clin. Invest.
118:3245.
- He, W., Sengupta, M., Velkoff,
V.A., and DeBarros, K.A. 2005. 65+ in the United States: Current Population
Reports, Special Studies. US Department of Health and Human Services,
National Institutes of Health, National Institute on Aging, US Department
of Commerce, Economics and Statistics Administration, US Census Bureau
(P23-209). p. 1–254.
- Warshaw, G.A., Bragg, E.J., and
Shaull, R.W. 2002. Geriatric medicine training and practice in the United
States at the beginning of the 21st century. The Association of Directors
of Geriatric Academic Programs. p. 1–115.
- Freed, G.L., Nahra, T.A., and Wheeler,
J.R. 2004. Relation of per capita income and gross domestic product
to the supply and distribution of pediatricians in the United States.
J. Pediatr. 144:723–728.
