Geriatric Medicine: A True Primary Care Discipline

An ever-urgent need exists for Federal policies to stimulate training experience in geriatric medicine and to encourage physicians to provide primary care services for the elderly. The US population of those 65 years of age or older from the turn of the century until 1990 has risen steadily from 3.1 to 31.6 million.1 Hidden in this dramatic increase is the even more marked increase in those 85 years or older, who numbered 3.3 million in 1990. This segment of the population is predicted to grow more rapidly than any other, and to nearly double in size by 2010.1 Individuals over 65, and especially those over 85, are the heaviest consumers of health care in the country today. While currently those over 65 make up only 12.6% of the population, they account for more than one-third of all health care expenditures. For example, over 40% of acute hospital days in 1987 and nearly 30% of physician office visits in 1989 were consumed by the elderly. In addition, the vast majority of nursing home beds are occupied by older adults, and between 1982 and 1984, nearly 37% of those over the age of 65 who died spent some time in a nursing home.1 In spite of this demographic health care imperative, most practicing physicians have not received any formal training in geriatric medicine. Even today, many training programs offer insufficient structured training in the care of the elderly. This inadequacy is likely to persist for some time since there are relatively few physicians within the discipline of internal medicine or family practice entering programs of fellowship training in geriatric medicine. It is fellowship-trained geriatricians who will provide the future teachers, researchers, and leaders who will focus attention on the special needs of the elderly. In 1989, for example, only 101 physicians entered fellowship training in geriatric medicine. While this compares well with the 82 entering advanced training for careers of teaching and research in general internal medicine, both numbers are dwarfed by the 772 entering cardiology training, a traditionally popular, highly specialized clinical discipline.2 The net result: an increasing population of elders needing health care and at the same time relatively few physicians entering career tracks that will lead to increased numbers of teachers to train other physicians in geriatric medicine and researchers to help advance knowledge about the health care problems of the elderly. The availability of trained primary care practitioners for the increasing population of elderly will be difficult for two additional reasons. First, increasingly few physicians are entering primary care training programs compared with those entering specialty disciplines. Between 1981 and 1989, for example, the proportion of medical students entering training programs fell substantially in the primary care disciplines of Internal Medicine and Family Practice while increasing significantly in Anesthesiology, Dermatology, Emergency Medicine, and Physical Medicine and Rehabilitation.3 Second, even those physicians who do practice primary care medicine often limit the number of Medicare patients they accept, sometimes to a level less than 20% of their practices. This limitation is imposed by practitioners because the reimbursement rate for primary care services provided Medicare recipients is often well below office overhead expenses. For these reasons it is imperative that there be federal incentives to: (1) stimulate medical students to enter primary care disciplines; (2) remove barriers that cause primary care physicians to limit the number of Medicare patients they will accept; (3) encourage more training for medical students and physicians in geriatric medicine; and (4) foster the education of more fellowship-trained geriatricians to provide the necessary teachers and researchers for now and the future. While there are those who argue geriatric medicine could be considered a subspecialty and perhaps, therefore, not a primary care discipline, most would argue strongly that geriatric medicine is first and foremost a primary care discipline. It cannot be called a subspecialty any more than pediatrics can be so called. In fact, geriatric medicine has been called a “supraspecialty”4 to imply its overriding and general nature. In 1978, the Institute of Medicine distilled from existing definitions five cardinal characteristics required of good primary care: . Accessibility—Accessibility implies that the physician is first in line whenever a patient encounters any difficulty. This access must be easy and direct. . Comprehensiveness—Comprehensive care is that which is not limited to a specific organ or disease group and which includes preventive care. . Coordination of services—It is the responsibility of the primary care physician to coordinate services a patient has received, whether they be consultations from other physicians or care provided by allied health professionals. . Continuity of services—Providing comprehensive care for patients continually over long periods of time is characteristic of primary care. . Accountability—The primary care physician is accountable for all aspects of an individual's care. The practice of geriatric medicine readily meets all of these criteria. Items 3 (coordination of services) and 4 (continuity of services) apply critically to the care of the elderly. Geriatric medicine is arguably the prototype of care coordination since it depends regularly on an interdisciplinary team of health care professionals (nursing, social work, and many others). It must function this way because a frail older person typically has multiple health problems and sources of disability; geriatric medicine is correspondingly multidimensional in approach. Further, continuity of services is especially critical for the elderly because of the common presence of multiple diseases and disabilities. It is of the utmost importance that continuous oversight be provided by physicians in order to avoid problems that go unattended or that are dealt with redundantly or perhaps even inappropriately by a specialist who may not be alert to a frail elder's multiple problems involving several organ systems. Beyond these five features of good primary care, one might add that the primary care physician is the first health provider to whom the patient would go when a new symptom has developed. This is especially true when a patient may have no idea as to the underlying cause of the complaint. The need for primary care for the elderly is especially valid in this regard. Older patients often manifest subtle signs and symptoms, and frequently presentations of illness are non-specific and different from the presentation of similar illnesses in younger patients (myocardial infarction is a classic example). Geriatric medicine, therefore, must be broad-based and general in nature. More than any group of patients, the frail elderly are especially vulnerable to iatrogenic complications, which result when care is too highly focused or uncoordinated. Good primary care for the elderly is the only mode of practice that will minimize fragmentation or iatrogenic problems. Providing care for frail elderly patients with multiple diseases and disabilities, constantly evolving problems, and high risk for iatrogenesis represents a clinical situation wherein the best of primary care is absolutely critical. Primary care is not necessarily the exclusive domain of general physicians (general internists, family practitioners, geriatricians, or pediatricians). Some subspecialty physicians, eg, endocrinologists or nephrologists, provide primary care to some of their patients. For example, an endocrinologist may serve as a primary care physician for a patient with severe diabetes or a nephrologist may be the primary care physician for a patient with chronic renal failure. However, to be defined as a true primary care physician, a subspecialty physician, like the general physician, would need to be accessible on a primary basis to many patients for illnesses outside the specialist's area of clinical concentration. The Board of Directors of the American Geriatrics Society at its November 19, 1992 meeting, in discussing the character of geriatric medicine, confirmed unanimously and enthusiastically that geriatric medicine, indeed, is a primary care discipline first and foremost and commissioned this editorial as a way of disseminating that position. The American Geriatrics Society represents over 6,000 physicians and other health professionals who concentrate their clinical activities in the care of the elderly. The vast majority of members come from the discipline of internal medicine or family practice. The Society's primary mission is to improve the health and well-being of all older adults. Encouraging excellent primary care for the elderly by lobbying for adequate numbers of geriatricians and all other general physicians is one very important method of achieving this goal. Physicians providing care and concentrating their clinical activities in geriatric medicine are typically involved in many different clinical sites, including the acute hospital, the office, the nursing home, the patient's home, continuing-care retirement communities, and day-care centers. While some geriatricians concentrate their energies in one or two of these sites, most act as personal physicians and follow patients longitudinally in a variety of sites. Especially important is the provision of excellent primary care services at home or in long-term care facilities, as these areas of clinical practice have been, over the years, underserved by physicians. While most geriatricians may occasionally perform consultations and, thereby, could be considered specialists, there are two items of evidence that indicate this practice is consistent with the primary care nature of geriatric medicine. First, consultations concerning elderly patients of other physicians are typically a very small part of geriatric clinical responsibility. To this point, several geriatricians recently reported to the American Geriatrics Society that their overall billings for consultative services were less than 5% of their total billings.5 In one large academic practice of 11 geriatricians, only 2.2% of all clinical billings were for consultative services (unpublished data, John R. Burton, MD). Second, geriatric medicine consultations are almost always focused on frail, elderly individuals who have multisystem disease and multiple disabilities. The consultation is invariably multidimensional, and often the referral is made by a physician who wishes the geriatrician to assume primary care responsibility for the patient. It is true that a minority of geriatricians may limit their clinical responsibilities largely to performing consultations for other physicians who have referred older patients with complex problems. This consultative role is, in fact, not different than the consultative role of some general internists, a practice pattern very common earlier in this half-century. Furthermore, performing comprehensive geriatric assessment does not necessarily define a physician as a subspecialist. Comprehensive geriatric assessment is a recently developed procedure for evaluating a frail elderly patient with the aims of reversing illness whenever possible, always preserving or improving function to the extent possible, and providing advice and education to both the patient and caregiver(s) as to how to access appropriate support.6,7 Comprehensive geriatric assessment can be performed by a properly trained general physician who is willing to commit the necessary time and effort. Even in an academic practice, comprehensive geriatric assessment is not regularly performed on patients referred by other physicians. In fact, 90% of patients who undergo geriatric assessment are self-or family-referred. Often the stated reason for requesting evaluation is that too many physicians have already seen the patient and that confusion in care exists. Therefore, even performing comprehensive geriatric assessment typically does not involve acting as a subspecialist who is providing consultation to another physician, and these evaluations can and should be provided by any properly trained general physician when initially encountering a frail or functionally unstable elder. In summary, geriatric medicine in academic and non-academic settings is a true general medical discipline which is clearly dominated by practitioners providing primary care services to the elderly. Since an increasing population of older adults require these services, and since the current reimbursement systems do not encourage appropriate numbers of clinicians to enter the primary care disciplines, including geriatric medicine, new nationwide approaches are urgently needed to remedy the current situation.