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Keywords:

  • academic geriatric programs;
  • geriatric education;
  • centers of excellence

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full-time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy-one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.

Medical school educators are developing new training and research programs to ensure that physicians will be adequately prepared to care for an aging population. Physicians certified in geriatric medicine and geriatric psychiatry are leading this effort, and although much progress has been made over the past 20 years, the training of geriatricians for research, teaching, health system leadership, and clinical practice is not yet adequate. To fulfill these varied roles, experts have estimated that the nation will need significantly more geriatricians by 2030 than are now available.1 Currently, there are only 7,084 certified geriatricians in the United States.2

The ability to train physicians in geriatric care is dependent on the growth and development of academic geriatric medicine programs in U.S. medical schools. In 2001, the first national survey of academic geriatrics programs at U.S. allopathic and osteopathic medical schools was conducted.3 The 2001 survey gathered baseline information regarding resources (budgets and faculty), program priorities, and obstacles to implementing geriatric academic programs. The results indicated that only 30% of U.S. medical schools had developed geriatrics programs with nine or more geriatric physician faculty, the minimum number of faculty recommended by the Institute of Medicine to develop an effective program.4 On average, 40% of these geriatric medicine faculty members' efforts were directed toward patient care, allowing less than optimal time for teaching and research.3

This article reports the results of a 2005 follow-up survey of the status of U.S. academic geriatric medicine programs.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Study Design

This study, conducted during the winter of 2005, was a cross-sectional survey of academic geriatric medicine programs at all 145 accredited allopathic and osteopathic medical schools in the United States. To document the longitudinal development of these programs, the survey results were compared with the study conducted in the spring of 2001.

This survey is part of the Association of Directors of Geriatric Academic Programs (ADGAP) Status of Geriatrics Workforce Study. It was conducted by the Office of Geriatric Medicine and the Institute for the Study of Health at the University of Cincinnati Academic Health Center. A national oversight panel provided guidance. The University of Cincinnati Institutional Review Board—Social and Behavioral Sciences approved the project, and ADGAP cosponsored the survey. The Donald W. Reynolds Foundation in Las Vegas, Nevada, and the John A. Hartford foundation in New York City funded this research as part of ADGAP's Status of Geriatrics Workforce Study (previously known as the Longitudinal Study of Training and Practice in Geriatric Medicine). These foundations had no role in the design, conduct, analyses, or reporting of the study or in the decision to submit the manuscript for publication.

Study Participants

Directors of geriatric academic programs (DGAPs) at all 145 allopathic and osteopathic medical schools accredited by the Liaison Committee on Medical Education or the American Osteopathic Association were included in the study.

Survey Instrument

The survey instrument was similar to the one used in 2001 so that comparative data could be obtained. The 2005 survey was divided into nine parts: program organizational structure, program faculty and staff, obstacles to program goals, medical student curriculum, questions regarding geriatrics program interactions with other clinical departments, program budgets, information about the academic leader, questions regarding possible changes in the geriatric medicine certification process, and an open-ended question regarding other program information.

Procedure

The survey was available only on-line—housed on a secure server and password protected to prevent unauthorized access. Reminder e-mails were sent to all DGAPs 6 days after the February 8, 2005, initial mailing and to nonresponders 13 and 22 days later. A second letter was sent to all nonresponders at 29 days, and reminder e-mails were sent 2, 12, 19, and 34 days after that mailing.

Statistical Methods

Medians, means, and standard deviations or ranges were used to describe continuous data. Categorical data were described using frequencies and percentages. Differences in continuous variables within the 2005 survey data (responders vs nonresponders, supported by foundation(s) vs not supported by foundation(s)) were tested using the Mann-Whitney U-test. Differences in continuous variables between 2001 and 2005 survey data were tested using the PROC MIXED two-sample t-test in SAS (SAS Institute, Inc., Cary, NC) by treating year as a fixed effect and school as a random effect, because some schools had responded only in 2001 or 2005, whereas the remaining had responded in both years. A paired t-test was used for the analysis of the 87 schools that responded to the surveys in both 2001 and 2005. Differences in proportions were tested using the Fisher exact test. Analyses were performed using SAS version 9.1 and SPSS version 14 (SPSS, Inc., Chicago, IL). P-values of .05 or less were considered significant for analysis.

To estimate the total number of geriatrics physician faculty in 2005 at all 145 medical schools (99 responding and 46 nonresponding schools), responding and nonresponding schools were each categorized based on whether they were funded by the Hartford Foundation as a Center of Excellence, by the Veterans Health Administration of the Department of Veterans Affairs as a Geriatric Research, Education and Clinical Center (GRECC), or by the Donald W. Reynolds Foundation as part of their Geriatric Training Initiative Grants. The number of funding sources for each school could range from 0 to 3. Responding schools were placed in one of four categories according to the number of funding sources, and the mean number of faculty per school for each category was determined. This mean number was then applied to the nonresponding schools that fell within the same category. Using this procedure, the estimated total number of geriatrics faculty was calculated.

Secondary Data Sources

To supplement the results from the DGAP surveys, data were also obtained from the Association of American Medical Colleges (AAMC) 2003 and 2004 Medical School Graduation Questionnaire. Data on the numbers of certified geriatricians were obtained from the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM).

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

The 2005 survey response rate was 68%, with 99 DGAPs responding (10/20 (50%) of osteopathic schools and 89/125 (71%) of allopathic schools). Of the 121 schools that responded to the 2001 survey (84% response rate) and the 99 schools that responded to the 2005 survey, only 87 responded to both surveys, although data comparing years 2001 and 2005 include all respondents each year.

There were no differences between responding and nonresponding schools with regard to enrollment (median 515 for nonresponders and 534 for responders; U=3,185.0, P=.51), National Institutes of Health ranking (allopathic schools only) (median 72.0 for nonresponders and 58.5 for responders; U=2,303.0, P=.15), ownership of school (public vs private; Fisher exact test P=.28), or geographical census region (northeast, midwest, south, and west regions; Fisher exact test P=.11).

Program Structure

Academic geriatric medicine programs were organized in a variety of structures that included departments; divisions or sections within a department; sections within a division; an academic geriatric unit within two or more departments; and a separate program, center, or institute. Eight percent of the medical schools did not report an identifiable structure. The most common academic unit was a division or section within a department, a structure existing at 64 of the schools. As of October 2006, there were 11 departments of geriatric medicine—seven in allopathic schools (East Tennessee State University, Johnson City; Florida State University, Tallahassee; Mt. Sinai School of Medicine, New York; University of Arkansas, Little Rock; University of Hawaii, Honolulu; University of Oklahoma, Oklahoma City; and Wright State University, Dayton, Ohio) and four in osteopathic schools (Edward Via Virginia, Blacksburg; Nova Southeastern University College of Osteopathic Medicine, Ft. Lauderdale, Florida, Philadelphia College of Osteopathic Medicine, Philadelphia; and Ohio University College of Osteopathic Medicine, Athens). In 2001, six departments of geriatric medicine were identified.

Program Leadership

Thirty-two percent of the DGAPs in 2005 had been in their current position for 4 years or less and 26%, from 5 to 8 years, compared with 44% and 21%, respectively, in 2001. Of the 99 DGAPs who responded in 2005, 44 (44%) reported completing formal geriatric medicine fellowship training and earning board certification. Thirty-eight (38%) had earned their certification through the practice pathway, and the remaining 17 (17%) had neither completed fellowship training nor earned certification. In 2001, 23% of the DGAPs were board certified.

Program Resources

Number of Faculty and Staff

In 2005, there was a mean of 9.6 full-time equivalent (FTE) physician faculty, compared with a mean of 7.5 in 2001 (t=−1.92, P=.06) in the responding academic geriatric programs, which were defined as an entire geriatrics program within a medical school, excluding unpaid, volunteer, or clinical support faculty. The number of geriatric physician faculty varied considerably between the programs in 2005, with a range of 0 to 40 FTEs per school. Thirty-eight programs (38%) had fewer than six FTE physician faculty, 25 (25%) had six to 11, 23 (23%) had 12 to 17, and 11 (11%) had 18 or more. Forty-eight programs (48%) had nine or more geriatric physician faculty. The numbers of FTE physicians and other faculty and staff employed in 2001 and 2005 in geriatric academic programs are shown in Table 1.

Table 1. Academic Staff in Geriatric Programs (Full-Time Equivalents) (Clinical Support Staff Not Included)
Academic Staff2001 (n=116)2005 (n=98)t-Statistic and P-Value
Mean ± Standard Deviation
  1. MD=medical doctor.

Physician faculty (MD, doctor of osteopathic medicine, or equivalent)7.5 ± 7.89.6 ± 8.0t=−1.92, P=.06
Geriatric medicine and geriatric psychiatry first-year fellows2.4 ± 2.52.7 ± 2.9t=−0.90, P=.37
Geriatric medicine and geriatric psychiatry fellows, second year and beyond, and MD postdoctoral faculty0.9 ± 1.50.9 ± 1.6t=0.07, P=.95
PhD postdoctoral staff without faculty appointment0.9 ± 2.61.0 ± 2.4t=−0.27, P=.79
Research faculty (not including MDs or faculty included in another category)2.5 ± 5.73.0 ± 7.5t=−0.62, P=.53
Physician assistants0.3 ± 0.80.3 ± 0.9t=−0.16, P=.88
Nurse practitioners1.9 ± 2.81.8 ± 2.3t=0.15, P=.88
Clinical nurse specialists0.7 ± 1.30.6 ± 1.5t=0.19, P=.85
Pharmacists0.3 ± 0.60.5 ± 1.1t=−1.89, P=.07
Social workers1.0 ± 1.41.3 ± 1.8t=−1.41, P=.16
Other professional support staff0.9 ± 2.72.5 ± 8.9t=−1.84, P=.07

The number of physician and research faculty from the responding schools in 2005 were extrapolated to arrive at an estimated national number that included the 46 nonresponding schools. Based on these calculations, in 2005, there were 1,292 FTE geriatric medicine physician faculty and 399 FTE research faculty working in all 145 U.S. medical schools.

Table 2 describes faculty and staff time allocation in 2001 and 2005. As in 2001, clinical practice remained the largest commitment (mean 36.9%) of many academic geriatric medicine programs, with education (medical students, residents, and fellows) (mean 34.6%) a close second. Research programs continued to be small, with 55% of the programs reporting 0% to 10% effort spent in research and only six reporting more than 40% effort. Considerable variability exists between programs, with some medical schools reporting balanced efforts and others emphasizing research, clinical, or education programs.

Table 2. Total Faculty and Staff Time (% Effort) Allocated According to Program Mission
Category2001 (n=116)2005 (n=96)t-Statistic and P-Value
Mean ± Standard Deviation
  1. NA=not available.

Medical student education in geriatrics13.6 ± 17.013.1 ± 13.6t=0.22, P=.82
Residency education in geriatrics12.6 ± 10.811.6 ± 11.1t=0.60, P=.55
Fellowship training in geriatrics10.7 ± 11.39.9 ± 9.4t=0.51, P=.61
Continuing education in geriatrics3.9 ± 4.44.4 ± 8.1t=−0.51, P=.61
Clinical practice in geriatrics36.6 ± 20.536.9 ± 18.2t=−0.05, P=.96
Research or scholarship in geriatrics18.2 ± 17.215.3 ± 13.0t=1.36, P=.18
AdministrationNA8.4 ± 5.5NA
Other4.4 ± 11.20.4 ± 3.1t=3.36, P<.01
Program Budgets

Program budgets also varied between academic geriatrics programs. In 2005, of the programs that provided information about their budgets, 18 (19%) had annual budgets of less than $250,000, and 53 (56%) had budgets of $1 million or more. In 2001, 28 programs (26%) had budgets less than $250,000, and 46 (42%) had budgets of $1 million or more. In 2005, 63 programs (66%) had no reserves or less than $125,000, and 14 programs (16%) had at least $1 million in reserve.

Table 3 lists the sources of revenue for each school for 2001 and 2005. Most schools had diverse revenue sources, although revenue from clinical practice was the most important source of program revenue. Additionally, a combination of research and educational grants and contracts (not including GRECC support) provided 22.5% of program revenues. Although not statistically significant, since 2001, there was a downward trend in the percentage of support that the geriatrics programs received from their college of medicine's budget.

Table 3. Sources of Geriatric Programs Revenues for 2001 and 2005
Category2001 (n=115)2005 (n=96)t-Statistic and P-Value
Mean %± Standard Deviation
  1. DVA=Department of Veterans Affairs; GRECC=Geriatric Research, Education and Clinical Center.

College of medicine required geriatrics support12.3 ± 25.49.7 ± 19.8t=0.82, P=.41
College of medicine discretionary geriatrics support11.7 ± 21.810.3 ± 16.1t=0.55, P=.58
Direct hospital support8.8 ± 14.810.2 ± 18.1t=−0.62, P=.54
Income from endowments4.4 ± 11.35.1 ± 8.0t=−0.52, P=.60
Clinical practice26.8 ± 26.227.1 ± 26.2t=−0.08, P=.93
DVA independent of the college of medicine support and excluding research support11.3 ± 21.8NANA
DVA independent of the college of medicine and including GRECC educational supportNA8.3 ± 17.8NA
DVA independent of the college of medicine and including GRECC research supportNA2.0 ± 6.5NA
Research grants and contracts, direct and indirect15.2 ± 21.212.8 ± 17.2t=0.90, P=.37
Educational grants and contracts, direct and indirect8.4 ± 16.49.7 ± 15.5t=−0.60, P=.55
Other0.3 ± 2.94.9 ± 20.1t=−2.38, P=.02

Program Obstacles

The DGAPs rated nine potential obstacles to achieving their programs' goals; 74% and 63% rated limited reimbursement for clinical care and lack of research faculty and fellows, respectively, as obstacles. These were also the top two rated obstacles in 2001 (Figure 1).

image

Figure 1.  Obstacles to achieving goals of geriatric programs as reported by directors of geriatric academic programs (DGAPs) in 2001 and 2005. Respondents were asked to rate each item on a scale of 1–5, with 1=never an obstacle and 5=major obstacle. Data presented are the percentage of DGAPs that rated each item 4 (almost always an obstacle) or 5 (major obstacle); 2001 survey used a 7-point Likert scale, and values were recoded into a 5-point scale.

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Geriatric Medicine Training for Non–Primary Care Residents and Fellows

In 2005, the DGAPs reported that geriatric medicine faculty from 74 medical schools (75%) taught principles of geriatric care to trainees in other specialties (median 4.0 disciplines, range 0–10). Obstacles to geriatric medicine faculty teaching principles of geriatrics to other specialties included that they were not asked (81%) or they did not have enough available geriatric medicine faculty (52%).

Medical Student Training in Geriatric Medicine

Twenty-three (23%) of the DGAPs reported that their medical school required a geriatrics clerkship. Forty-eight (48%) reported that the geriatric experience was integrated into a required clinical rotation with specific lectures on geriatric topics or that faculty with geriatric training directly supervised medical students during a clinical rotation. Thirty-four (34%) reported a selective geriatric experience that depended upon the site of the student's clinical rotation or availability of faculty interested in geriatrics. Seventeen (17%) reported that their school had some exposure to older patients but without a structured curriculum or objectives. Some medical schools had more than one type of geriatric clinical experience.

In the 2001 AAMC Medical School Graduation Questionnaire, 14% of graduating medical students strongly agreed that the attending faculty exposed them to expert geriatric care.5 By 2004, that percentage had increased to 20%. Likewise, in 2001, 12% strongly agreed that they were prepared to care for older adult patients in acute settings, and by 2004, that percentage had increased to 16%.6

The AAMC also asks graduating seniors specific questions related to adequate geriatrics subject matter in other specialty clerkships. From 2001 to 2004, the percentage who strongly agreed that geriatrics was covered adequately in their specialty clerkships increased, although the positive responses to this question remained low. In family medicine, the increase was from 22% to 29%; internal medicine, 30% to 36%; gynecology, 9% to 12%; psychiatry, 17% to 23%; and surgery, 17% to 21%.5,6

Medical Schools Funded by the Reynolds Foundation and the AAMC/Hartford Foundation

Two significant initiatives began in 2000 to encourage the training of medical students in geriatrics. In 2000 and 2001, the AAMC, with funding from the John A. Hartford Foundation, funded 40 U.S. medical schools to enhance their predoctoral geriatrics curricula.7,8 The second initiative to strengthen physicians' geriatrics training, including training for medical students, began in 2001, when the Donald W. Reynolds Foundation funded 10 schools. The Reynolds Foundation funded a second set of 10 schools in 2003.9 (The Reynolds Foundation funded a third set of 10 schools in 2006; these schools are not included as funded in this analysis.) The 2005 survey data were analyzed to determine whether there was a difference between schools funded by either of these foundations and schools that were not funded with regard to medical student chapters of the American Geriatrics Society (AGS) and the basic science and clinical portions of the geriatrics curriculum. Forty-four (44%) of the responding schools were funded by one or both foundations. Schools that were funded by foundations differed (Fisher exact test P<.01) from other schools regarding presence of a medical student chapter of the AGS. Eighty-six percent (38/44) of the schools funded by one of the foundations had a medical student chapter of the AGS, compared with 49% (27/55) of the other schools.

DGAPs were asked to choose from among three categories that best described the basic science portion of their geriatrics curriculum (structured curriculum with specific objectives, unstructured curriculum (geriatrics is implicit and under the umbrella of other topics or without specific objectives), or minimal geriatrics curriculum). Schools that were funded by foundations differed (Fisher exact test P=.02) from other schools regarding the basic science portion of their geriatrics curriculum. Fifty-percent (22/44) of foundation-funded schools reported a structured curriculum, versus 29% (16/55) of other schools.

DGAPs were also asked to describe the clinical portion of their geriatrics curriculum. (They could report more than one training experience.) The foundation-funded schools did not differ from nonfunded schools regarding the requirement of a clinical experience in geriatric medicine (Fisher exact test P=.16). Fifty-seven percent (25/44) of the foundation-funded schools required a clinical experience in geriatric medicine, compared with 42% of nonfunded schools (23/55). Twenty percent (9/44) of the foundation-funded schools had a required geriatric clerkship, compared with 25% (14/55) of the other schools (Fisher exact test P=.64). Sixty-eight percent (30/44) of foundation-funded schools had their geriatric experience integrated into a required clinical rotation, compared with 33% (18/ 55) of other schools (Fisher exact test P<.01).

ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Data from the 87 schools that responded in both years were analyzed using the paired t-test comparison to see whether the results differed from the primary mixed model comparative analysis. This secondary analysis compared academic staff, allocation of faculty and staff time, and sources of budget revenue between 2001 and 2005. Two statistically significant, but minor, differences from the primary and secondary analyses were found. The secondary analysis found a statistically significant difference (t=−2.91, P=.005) in FTE physician faculty between 2001 (mean 8.7) and 2005 (mean 10.3). The primary analysis did not find a statistically significant difference (t=−1.92, P=.06) for the same between 2001 (mean 7.5) and 2005 (mean 9.6). Similarly, the secondary analysis found a statistically significant difference (t=−2.51, P=.01) in research effort between 2001 (mean 19.6%) and 2005 (mean 14.8%). The primary analysis did not find a statistically significant difference (t=−1.36, P=.18) for the same between 2001 (mean 18.2%) and 2005 (mean 15.3%).

Academic Geriatrics Programs and Community Geriatricians

In addition to training faculty, academic geriatrics programs train geriatricians for community practice. The ABFM and the ABIM established geriatric medicine certification in 1988. From 1988 through 2005, there were 11,116 physicians certified in geriatric medicine: 3,231 in family medicine and 7,885 in internal medicine. Eight thousand two hundred seventy-two (74%) were awarded when the practice pathway option existed. Since 1994, only graduates from accredited geriatric fellowship programs can sit for the certification examination. Geriatric medicine board certification is time limited, and diplomates must recertify every 10 years. The initial certification of the 8,272 diplomates certified in 1988, 1990, 1992, and 1994 has now expired, and only 47% (2,690) of diplomates certified by the ABIM and 60% (1,551) of those initially certified by the ABFM have recertified2 (Figure 2). The trends for geriatric psychiatry certification are similar to those for geriatric medicine.2

image

Figure 2.  Comparison of number of certificates of added qualifications (CAQs) awarded in geriatric medicine to number of active CAQs.

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DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Recent studies and anecdotal reports have documented that the quality of the current care provided by physicians to older adults can be improved.10–12 Geriatric medicine programs in academic medical centers are the primary source of the trained faculty and clinicians needed to address this growing educational and clinical challenge. This study documents modest progress in the development of academic geriatrics programs from 2001 to 2005.

Medical schools are organized around discipline-specific departments, with department leaders holding most of the power and control for negotiating resources from the dean. Although this study reveals that medical schools are establishing a variety of geriatric program structures, most medical schools' geriatric programs remain a division or a section within a division. Even though there are currently only 11 departments of geriatric medicine, one third of the academic leaders (e.g., division directors or office directors) reported directly to their dean. This typically creates access to new resources and continued interdepartmental influence.

There remains a relatively low percentage (44%) of fellowship-trained DGAPs. The other DGAPs are drawn from senior faculty who completed their formal training before the availability of fellowship programs or who do not have a certificate in geriatric medicine. The development of midcareer geriatric medicine faculty for future leadership is a high priority for the discipline. The John A. Hartford Foundation is currently funding a national mentoring program for newly appointed directors of geriatric academic programs and an annual networking and educational opportunity for program directors who are current members of ADGAP.13

From 2001 to 2005, there was a significant increase in the mean number of geriatric physician faculty in medical schools, yet half of the responding academic medical centers in the survey had fewer than nine FTE geriatric physician faculty, the minimum number recommended by the Institute of Medicine.4 There was little growth in geriatrics research faculty. The DGAPs consistently rated the lack of research fellows and research faculty high as an obstacle to achieving the goals of their programs. Faculty effort in many programs was concentrated in clinical care, leaving little time for teaching and research. Support for research training and junior research faculty is not available or is limited in many geriatric programs. To expand aging research at these schools, the geriatric programs could collaborate more actively with established related research programs on their campuses. Opportunities exist to work successfully with research-oriented general medicine, family medicine, community medicine, or health outcomes programs.

Although, on average, 34.6% of faculty members' time is devoted to teaching medical students, residents, and fellows, the colleges of medicine typically provide only 20% of the programs' budgets. Other sources of educational support for some programs include GRECC support and educational grants, which provide approximately 18% of revenue. Programs may have difficulty recruiting additional faculty, because 19% have annual budgets of less than $250,000, and many programs have limited financial reserves. Other significant sources of program revenue include research and educational grants and contracts (22.5%) and Department of Veterans Affairs GRECCs educational and research support (10%). There are currently 21 GRECCs, all of which are affiliated with academic medical centers.14

A commonly reported obstacle to program growth is poor clinical reimbursement for patient care. The relative value of Medicare physician payments compared with those from commercial insurance varies geographically. In some areas, where commercial insurance reimbursement is low, Medicare reimbursement rates are viewed as competitive. Also, geriatric programs that rely on traditional outpatient primary care services may have difficulty covering their expenses. Programs with efficient hospital services, long-term care, and home care practices are more likely to generate sufficient revenue to cover faculty time.

Private foundation investments have assisted some medical schools in building stronger geriatrics programs. Since 1988, the John A. Hartford Foundation of New York City has designated and funded geriatric medicine Centers of Excellence (CoEs).15 The goal of the CoE program is to enhance the training and research productivity of selected academic geriatric programs. The Hartford Foundation has targeted programs at academically strong medical schools. These schools have the tradition and research training resources to create an environment in which geriatric medicine can flourish. A recent study documents the success of this effort.15

The effect of the more recent Hartford Foundation/AAMC medical student training initiative and the $60 million investment by the Donald W. Reynolds Foundation to develop Physician Training Centers at 30 U.S. medical schools will be further evaluated over the next several years, but early findings suggest that these schools are creating robust geriatric medicine training experiences for medical students. It was found that nonfoundation-funded schools were more likely to have a required geriatric clerkship than foundation-funded schools. This finding may be attributed to the AAMC/Hartford grants, which required the geriatrics curriculum to be integrated throughout the 4 years of medical school and did not encourage creation of a separate required course. The AAMC leadership was concerned that, once the champion of such courses is gone, it may be too easy to dispense with the course (personal communication, M. Brownell Anderson, AAMC, September 5, 2003).

According to the June 2005 AGS report, the Future of Geriatric Medicine, core training in medical schools and postgraduate training must include substantial geriatrics training to ensure competency in caring for older persons.16 This report also states that medical students should have ample experience with healthier older persons in community settings to improve their attitudes toward caring for older adults. Although some medical schools are developing outstanding student curricula, overall, only 10% (median) of geriatric programs' faculty and staff time is allocated to teaching medical students about geriatrics.

The AGS estimates that, in the clinical years of medical student training, 15 dedicated lecture hours, 4 weeks of block rotation, and 9 weeks of longitudinal clinic time would be required for core geriatrics training.17 Forty-eight medical schools currently require a median of 4 weeks (range <1–10 weeks) of geriatric clinical experience. There is an encouraging trend for graduating medical students to report that the adequacy of geriatrics training in the required clerkships is increasing.5,6

CONCLUSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

Has progress been made toward preparing the nation's physicians to care for an aging population? Some has. More fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased.

Will the nation's physician workforce be prepared to provide quality care for the aging baby boomers by 2030, less than 25 years from now? Probably not, unless an accelerated effort to expand the workforce is undertaken during the next few years. Few academic geriatricians are pursuing research careers, the number of practicing geriatricians is declining, and not enough is being done to train the many medical and surgical subspecialists who now provide the majority of care that older adults receive. The small number of geriatricians and geriatric psychiatrists, as well as other specialists with training in caring for older adults, limits the availability of expert chronic care to the oldest and frailest Americans. Even with the significant contributions of nurse practitioners, physician assistants, and other healthcare professionals, the expected need for geriatric expertise will not be met without an expanded investment in training the clinician workforce to care for older adults.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES

The authors would like to thank Greg Roth, BS, for Web development of the online survey; Anthony Leonard, biostatistician; and Geri Thelen, BSN, RN, and Mary Choate for administrative support.

Conflict of Interest: This work was supported by grants from the Donald W. Reynolds Foundation, Las Vegas, Nevada, and the John A. Hartford Foundation in New York City.

Author Contributions: Gregg Warshaw and Elizabeth Bragg: study concept and design, acquisition of subjects and data, analysis and interpretation of data, and preparation of manuscript. David E. Brewer and Mona Ho: study concept and design, analysis and interpretation of data, and preparation of manuscript. Karthikeyan Meganathan: analysis and interpretation of data, and preparation of manuscript.

Sponsor's Role: The Donald W. Reynolds Foundation and the John A. Hartford Foundation had no role in the design, methods, subject recruitment, data collections, analysis or preparation of this paper.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. ANALYSIS OF MEDICAL SCHOOLS RESPONDING TO BOTH THE 2001 AND 2005 SURVEYS
  6. DISCUSSION
  7. CONCLUSION
  8. ACKNOWLEDGMENTS
  9. REFERENCES
  • 1
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