Foreword

The John A. Hartford Foundation of New York City was founded in 1929 and represents the legacies of John and George Hartford, who both served as chief executives of the Great Atlantic and Pacific Tea company, better known as the A&P grocery store chain. Their mandate to the foundation that would bear the family name was to “carve from the whole vast spectrum of human needs one small band that the heart and mind together tell you is the area in which you can make your best contribution.” For the last 20 years, this has led the Hartford Foundation to pursue the mission of enhancing the nation's capacity to deliver quality care to its older citizens. Older people need this care—already people over 65 account for 50% of hospital usage and large shares of other medical services. It is because of advances in public health and medical care that people are able to live longer and healthier lives. However, with life extension and the demographics of the domestic post-war baby boom will come a large number of older adults who are reliant on excellent care to be active and independent, despite the burden of the chronic diseases of late life. The current 12% of Americans above 65 will reach 20% by the time the future doctors who are today's high school students will finish advanced medical training in 2020. Moreover, people over 85, until recently a demographic novelty, are now the fastest-growing segment of the population and have unique medical needs. As it has in the face of earlier technological and social changes, medical education will need to adapt to meet the challenges of an aging population. Increased emphasis on chronic as opposed to acute care, broader awareness of the physiological changes associated with aging, and better ability to help people negotiate the treacherous border between under- and over-treatment are among the issues that are obvious to us even now, but probably are only part of what will be needed in the uncertain future. To try to address these issues in medical training, the Foundation has supported a variety of prior efforts with medical students, residents, faculty, and current practitioners. A large part of our effort and funding has been focused on the development of academic geriatrics as a way of advancing new knowledge in the care of older people and producing faculty who can teach and inspire future physicians to provide the best possible care. However, the ultimate goal is not the creation of a new specialty, but rather to ensure that all future physicians are able to meet the needs of their older patients. In our work, we have learned that it is easier to help physicians develop good skills and practices early in their training, particularly in overcoming the stigma and sense of futility sometimes associated with the care of older people. We also know that the process of change in medical education is very difficult and needs to balance a wide set of interests within institutions and compete with other advocates for change from without. We have come to believe that the appropriate role of a foundation is to catalyze change through funding the development of innovative models and educational practices rather than underwriting the direct costs of training. Therefore, when the Foundation's board of trustees decided to support a broad program addressing undergraduate medical curriculum, we naturally wanted to partner with the Association of American Medical Colleges (AAMC) to ensure the best possible results of our effort. Our goal for this project was originally to give an award to the AAMC to enable it to select ten medical schools in 2000 and again in 2001 and support each cohort for two years with funding, networking, and technical assistance to increase geriatrics and gerontology education in all four years of undergraduate medical training. Given larger- than-expected and very strong applicant pools, the Foundation was able to expand its funding to support 40 schools in total. While allowing flexibility to applicant institutions, the selection process emphasized developing new training approaches that would foster attainment of the core competencies needed for caring for older people and the knowledge, skills, and attitudes that would prepare students to learn more in the course of their further professional training. We also felt that it was very important that learning on this topic be reinforced with some attention in each year of training, rather than segregating the content into a particular year or course. Given the fact that caring for older people will be a core part of all medical practice for the vast majority of future physicians, we also felt that creating additional undersubscribed geriatrics elective experiences was unlikely to be useful—while at the same time, we recognized that finding time and resources for new required courses would probably be too difficult for most institutions. As you will see in the astounding content of this special supplement, our hopes for this program have been met and exceeded. The 40 participating institutions have created innovative ways to teach about the care of older people and help students attain needed competencies. Each one has created valuable materials and models that are available for use, further development, and the improvement of the field of medical education. While all the content here will reward careful study, several training methods stand out as particularly notable. There are a variety of “senior mentor” programs wherein students partner with lay older adults and through structured, longitudinal learning experiences can develop critical skills ranging from medication review to humanism. Home visit programs, which incorporate work with an interdisciplinary team, give insight into the complex interplay of medical, environmental, and social factors in health and an appreciation of the roles of other health professionals. Advances using computer technology and interactive media efficiently increase students’ opportunities to learn at a time and place most convenient to their needs. However, the true test of the success of the Foundation's initiative is whether these advances can be sustained at the funded institutions and gradually adopted at the remaining medical schools around the country. The Foundation's mission of enhancing the nation's capacity to care for its older citizens will be complete only when all future physicians have excellent training to meet the needs of their older patients and our aging society. Corinne H. Rieder, EdD Executive Director, The John A. Hartford Foundation, Inc.