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msJAMA
April 1, 1998

Reframing the Geriatric Patient

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JAMA. 1998;279(13):1034. doi:10.1001/jama.279.13.1034-JMS0401-2-1

Who wants to be a geriatrician? Hardly anyone, by recent estimates. Despite projected shortfalls in the number of physicians trained to care for problems of old age, only half of the available residency positions in geriatrics were filled last year.1 Since 1987 the number of first-year fellows has been stable at about 100, despite a spate of new programs in geriatrics.2

Already people older than 65 years account for 13% of the population, and their numbers will double in the next 30 years.3 Yet medical students seem unmoved by the opportunity.

Reluctance to pursue a career in geriatrics may be due to fiscal policies that discourage development of academic training programs in geriatrics.3 Geriatric medicine involves long-term care and disease management, endeavors that do not pay as well as the more interventional subspecialties. Because of low reimbursement, some physicians limit the number of Medicare patients in their practices or do not accept Medicare at all.4 Undoubtedly, part of the ennui relating to geriatric medicine stems from persistent ageist attitudes—the perception that older patients are difficult, their medical care is often futile, and the prognosis is depressing.5

Yet as people live longer, healthier lives, geriatric practice promises to become even more multidimensional in the future, requiring physicians to discuss issues such as sexuality, exercise, and rehabilitation with their older patients. While some may feel that older patients are time-consuming, their care tangential, and taking a patient history an exercise in frustration, such patients can also be seen as historical treasures. A typical woman in her 90s may have shocked her parents by listening to jazz; she remembers D-Day, and witnessed the desegregation of the South. In her lifetime alone, the novelty of radio made way for satellite broadcasts; space shuttle launches became commonplace.

Caring for older patients needs to be reframed in terms of the wealth of historical, cultural, psychological, and medical complexity that it is. Geriatric patients do not need geriatric specialists as much as they need competent, caring physicians with skills in managing multisystem chronic conditions over an extended period of time. They need physicians who are informed about the physical and psychological aspects of aging, and how these changes apply to their area of practice. Changing our view of aging begins with medical students, such as those at the University of Kansas School of Medicine, where the curriculum addresses the common myths of aging through lectures and small-group sessions with elderly people. In this issue of Pulse authors examine geriatric education in the preclinical and clinical years and revisit the shortage of physicians trained in geriatrics to see how residencies are encompassing geriatric education. The spotlight is on the complex social aspects of loss associated with aging and dementia. Whether one practices plastic surgery or gynecology, the emotional toll of caring for the elderly infirm permeates all fields.

The current generation of physicians has led public health efforts that have had dramatic results: substantially lower infant mortality rates, higher rates of pediatric immunization, and greater freedom and independence for mentally or physically disabled adults. Isn't it time to do the same for the elderly?

References
1.
Lawlor  EFLyttle  CSMoldwin  E The state of geriatrics training programs: findings from the National Study of Internal Medicine Manpower (NASIMM). J Am Geriatr Soc. 1997;45108- 111
2.
Dunn  MRMiller  RS US graduate medical education, 1996-1997. JAMA. 1997;278750- 784Article
3.
Administration on Aging, Profile of older Americans: 1997. Available at: http://www.aoa.dhhs.gov/aoa/dhhs/stats/profile/#table1. Accessed December 17, 1997.
4.
Benson  JA Educating the work force for geriatric care. Am J Med. 1994;97 ((suppl 4A)) 3S- 5SArticle
5.
Lee  DWGillis  KD Physican responses to Medicare payment reform: an update on access to care. Inquiry. 1994;31346- 353
6.
Brooks  TR Attitudes of medical students and family practice residents toward geriatric patients. J Natl Med Assoc. 1993;8561- 64
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