Training in the Care of Older Adults

Some things don't take a doctor. Small boys in the street can tell us, “Doctor, your patients are old.” In fact, the average age of the 24 patients admitted to my general medicine ward team so far this month is 69 years; 42% are age 75 years or older, and only 1 is too young to join AARP. Nationwide, older persons (by which I mean people age 65 years or older) account for 36% of acute hospitalizations and roughly 50% of hospital expenditures.¹

We see more older patients in the office, too: since 1975, the annual number of office visits to internists by older persons has doubled, while the number to family physicians has fallen by a third.^2,3 Older persons now account for 43% of office visits to internists, and more than half of these visits are made by those age 75 years or older. These trends will continue. Over the next 30 years—the professional lifetime of our current students and trainees—the number of older Americans will increase from 35 million to 71 million, with the fastest increase among those age 85 years or older.⁴ The proportion of the population age 65 years or older will rise, too, both in the United States (from 12% to 20%) and worldwide (from 7% to 12%).

These demographic facts create the “geriatric imperative”: there will be many more persons with aging-related chronic diseases, more with disability, more dying, more affected family and friends, and greater needs for medical and social services. The epidemic of age-related chronic disease and disability may be blunted, but it will not be stopped, even with breakthroughs in genomics and proteomics.

The geriatric imperative will likely prove good news for internists: our skills in caring for people with complex illness will be needed, as will our expertise in learning how to improve their care.^5,6 But are we ready? Three papers in this issue of the Journal indicate that we in internal medicine are far from ready to address the geriatric imperative.

In a national survey of internal medicine residency program directors, Warshaw et al. found good news and bad.⁷ The good news is that we are making progress: almost all residency programs have a required geriatric curriculum, thanks to the requirements of the Accreditation Council for Graduate Medical Education. The bad news is that these curricula may not be substantial. One third of the programs required 6 or fewer days of training in geriatric medicine, and no program required more than 18. Thus, required training in geriatric medicine is often less than 0.5% of the residency curriculum and never more than 1.3%, assuming that residents work 48 weeks each year, averaging 72 hours per week and that required geriatrics rotations require 8-hour workdays. Few programs teach geriatrics in the hospital, where most internal medicine training takes place.

In the second paper, Sullivan et al. found that medical education in end-of-life care is in worse shape.⁸ Although more than 90% of medical students, residents, and attending physicians thought physicians should be responsible for and able to care for dying patients, less than 20% of students and residents received formal end-of-life care education and most students felt unprepared to address patients' fears. Most faculty reported feeling well prepared to teach end-of-life care, but most students reported that the quality of teaching of end-of-life care was lower than the general quality of teaching at their hospital. Students also reported less training in end-of-life care than in a rare disorder, lupus erythematosus.

In the third paper, McCusker et al. found that delirium in hospitalized older persons is often a chronic condition, in contrast to the orthodox teaching that delirium is transient.⁹ Delirium not only was associated with increased risk of dying or deteriorating in cognitive and physical functioning during the year after discharge,^10,11 but also persisted for a year after discharge in more than one third of patients. Nearly all patients had 1 or more persistent symptom of delirium, most often memory impairment, disorientation, or inattention. Important aspects of what we knew about delirium have been proven wrong, illustrating how much we have to learn about how to care for older persons.

What needs to be done to get internal medicine ready to meet the geriatric imperative? This question is illuminated by 3 papers commissioned by the Society of General Internal Medicine and the John A. Hartford Foundation.^12–14 These papers identified 3 major challenges to improving training in the care of older persons¹⁵: the lack of adequately trained teachers and mentors; the hidden curriculum embodied in the belief that explicit training in geriatrics has little to offer the generalist; and inadequate funding.

We need faculty who are clinical experts in geriatrics and effective teachers, and who have the time to inspire, teach, and mentor. These faculty must be straight A—available, affable, and able—and it doesn't matter whether they are identified primarily as geriatricians or as general internists. The needed faculty are rare, as Warshaw et al. found.

We need a common ground about geriatrics in internal medicine, the shared conviction that the specialty of geriatrics has much to offer to residency training, faculty, teachers, and researchers, and general medical practice. The belief to the contrary, that geriatrics has little to add, is not new,¹⁶ and it has fueled a daunting hidden curriculum. Required geriatrics training remains “geriatrics-lite” in the time committed by residency programs. Many programs require 20 times as much training in intensive care as in geriatrics, even though few internists practice in intensive care units and many care for older persons in the office and the hospital. Residency program directors must be convinced that geriatrics training helps them and their trainees.

Finally, we need funding for teaching the comprehensive care of frail older adults as well as fair funding to provide this care. Funding has been inadequate to ensure the development and retention of skilled teachers to train internal medicine residents, fellows, and faculty. Adequate funding for geriatrics training may prove iatrotrophic, attracting trainees and faculty.

Several current initiatives have been undertaken to meet these needs. With the support of the Hartford Foundation, the Society of General Internal Medicine has funded 10 Collaborative Centers for Research and Education in the Care of Older Adults, undertaken a project with the Association of Program Directors in Internal Medicine to engage these key educational leaders, and supported a project to determine the geriatric content of the internal medicine certifying and in-training examinations. The Donald W. Reynolds Foundation has committed $40 million to fund 20 comprehensive centers to enhance geriatrics education in medical schools. The International Longevity Center is advocating for federal support of a program to place 10–20 geriatricians in every medical school in the country.¹⁷ The federal Health Resources and Services Administration has instituted the first career development award for physician-educators, the Geriatric Academic Career Award, and has increased funding for academic fellowships in geriatric medicine and for geriatric education centers.¹⁸

These initiatives are early steps for internal medicine in addressing the geriatric imperative. The papers by Warshaw, Sullivan, McCusker, and their colleagues indicate substantial challenges to training students, residents, and faculty in the care of older adults. Opening the door to advance this training and the underlying clinical science is an opportunity we cannot turn down.