Dutch Elderly Care Physician: A New Generation of Nursing Home Physician Specialists

To the Editor: In a recent article, Katz and colleagues emphasized the urgent need for more-specialized medical care for the growing population of frail elderly patients with complex healthcare problems in nursing homes, as well as the need of a nursing home medicine specialty that recognizes this setting as a unique practice site.1 The authors refer to the Dutch model, where such specialty has existed since 1990. We agree with their views that there is a need for new medical professions in the care of elderly people, because governments worldwide are searching for viable solutions to meet the healthcare demands of a growing elderly population. In January 2008, the Health Council of the Netherlands concluded that the Dutch healthcare system is not properly organized to meet the multimorbidity of elderly people, primarily because of its fragmented approach to caring for older adults and to a serious lack of coordination, communication, and continuity of care.2 Until 2007, three geriatric specialists existed in the Netherlands: hospital geriatricians, who undergo a 5-year training program in internal medicine, neurology, old age psychiatry, and geriatrics; community geriatricians, with a training program focused mainly on old age psychiatry but with no formal certification; and nursing home physicians, with a 2-year training program in nursing homes focusing on psychogeriatrics, patients with somatic impairments, palliative care, and geriatric rehabilitation. The Netherlands began training specialists in “nursing home medicine” in 1989.3,4 This specialty has recently been merged with community geriatric medicine to form the new medical specialty: elderly care medicine (ECM). The inclusion of new competencies for working in and outside the nursing home setting has lengthened the original 2-year specialist training program for nursing home physicians by 1 year and has resulted in a new certification. In addition to the need to limit the number of geriatric specialties, creating a broader specialty than nursing home medicine matches the changing attitudes of Dutch society toward care for older adults. The desire of older adults to live in their own homes for as long as possible is a major driving force behind these changes, resulting, for example, in smaller nursing home units being situated in local residential neighborhoods and the construction of small-scale housing units especially for people with dementia. This is directly associated with the concept of the elderly care physician (ECP), namely, a medical practitioner who has specialized as a primary care expert in geriatric medicine and qualified as a basic specialist with expertise in geriatric medicine. Over the past 20 years, unique problem-oriented methods for training ECPs have been developed.5–7 The training program for ECPs is based on the acquisition of specific competencies according to the Canadian Medical Education Directions for Specialists framework. This framework describes seven physician roles: medical expert, communicator, collaborator, manager, health advocate, scholar, and professional. Physicians must master new and extended competencies, especially those specifically related to the knowledge and skills required for treating elderly individuals with complex medical problems who live at home. The basic ECP training program consists in general of an 18-month training period in a teaching nursing home, 6 months on one or two hospital wards, and 6 to 12 months working with psychogeriatric patients or patients with mental health problems who live at home. Finally, there is a 3-month internship of choice. Trainees can combine two training blocks and create individual, tailor-made learning trajectories (Figure 1). Main structure of the new 3-year elderly care physician training program. Individual trajectories are possible with another sequence of training blocks. PG=nursing home psychogeriatric ward; PDP=nursing home ward for physically disabled patients; AMB=day clinic, outpatient clinic; choice=rehabilitation center, hospice, GP practice. A theoretical course supports the practical learning process. Trainees typically begin an education day with a meeting during which practical experiences are exchanged and personal learning objectives discussed. Learning objectives, didactic learning methods, and preparation tasks in the form of research papers, guidelines, and study tasks form part of the ECP trainee program. Several educational (formative) and selective (summative) assessments take place during the program. Trainees are also required to make a portfolio as a learning tool, which enables the trainee and the supervisors and tutor–staff members visualize progress in the learning process. University medical centers in Amsterdam, Nijmegen, and Leiden currently offer the training program. Since 2009, these institutions have been working together within the framework of a national foundation—Samenwerkende Opleidingen tot specialist Ouderengeneeskunde Nederland (http://www.soon.nl). An organization financed by the Dutch Ministry of Health employs trainees. The specialist training program can be followed full time or part time. The Netherlands is taking steps to face the challenge of meeting the medical requirements of increasing numbers of frail older adults by developing a new medical specialty that encompasses generalist and specialist competencies. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this letter. Author Contributions: RK and JL wrote the first version of the letter, JFH, PW, and JS reviewed it, added comments and revised it. Sponsor's Role: No sponsors.