The Paradoxical Decline of Geriatric Medicine as a Profession

The social construction of time and its influence on medical education

INTRODUCTION

Few sociocultural constructs exist that are so deeply embedded in our daily lives and able to influence our thoughts, behaviours and interactions than time itself. Time spans all cultures, and yet many of us have not critically engaged with how time effects what we do, how we perceive and the ways in which we interact. As such, our relationship to time remains almost invisible running in the background nearly unnoticed until it is somehow brought into conscious awareness.

CONTEXT

In this paper, we draw on Levine's concepts of clock time and event time as different perspectives on time, demonstrating how they play out in medical education and clinical practice within the United States and Brazil. Clock time treats time as something external to our lives, fixed by the natural world and measured by clocks. Event time is conceptualised more flexibly, where the duration of activities depends on internal cues related to the flow and progression of events rather than strict schedules.

DISCUSSION

By contrasting these differences, we hope to make visible the way that time influences our choices for educating physicians and provide a foundation for medical education to begin questioning how time is positioned, experienced and understood as a powerful force in the shaping of our profession. Additionally, we consider these perspectives within the concepts of Taylorism and Slow Medicine to better understand their links to medicine's formal and hidden curriculum in hopes of raising awareness and create new visions for medical education.

The Road To Value Can't Be Paved With A Broken Medicare Physician Fee Schedule

Value-based payment has been promoted for increasing quality, controlling spending, and improving patient and practitioner experience. Meanwhile, needed reforms to fee-for-service payment (the Medicare Physician Fee Schedule) have been ignored as policy makers seek to move payment toward alternatives, even though the fee schedule is an intrinsic part of Alternative Payment Models. In this article, we show how value-based payment and the fee schedule should be viewed as complementary, rather than as separate silos. We trace the origins of embedded flaws in the fee schedule that must be fixed if value-based payment is to succeed. These include payment distortions that directly compromise value by overpaying for certain procedures and imaging services while underpaying for services that add value for beneficiaries. We also show how the fee schedule can accommodate bundled payments and population-based payments that are central to Alternative Payment Models. We draw two conclusions. First, the Centers for Medicare and Medicaid Services should correct misvalued services and establish a hybrid payment for primary care that blends fee-for-service and population-based payment. Second, Congress should alter the thirty-five-year-old statutory basis for setting Medicare fees to allow CMS to explicitly consider policy priorities such as workforce shortages in refining fee levels.

Is geriatric medicine teaching homogeneous? The analysis of geriatric medicine courses at Polish undergraduate medical programmes

PURPOSE

We aimed to analyse the characteristics of geriatric courses offered to undergraduate medical students in higher educational institutions (HEIs) in Poland.

METHODS

We searched the official websites of the HEIs offering the medical degree programmes and directly contacted the dean's offices and HEIs representatives to retrieve the relevant information. The documents were analysed for course content, teaching methods, duration, and recommended texts. We also checked the obtained curricula for the reference to of the learning objectives related to geriatric medicine, selected from the currently endorsed Polish educational standards (ES) provided by the Ministry of Science and Higher Education.

RESULTS

Geriatric medicine courses were obligatory at all included HEIs (n = 19), but the courses differed in structure and content. The courses varied in duration from 11 to 60 h and were primarily lecture based. Simulation was utilized at only one HEI and e-learning at two institutions. Out of 315 learning objectives, we acknowledged only 9 as geriatric. They were not always found in all curricula. Two HEIs included self-described learning objectives in their curricula. Across all HEIs, a total of 29 recommended texts (published between 1995 and 2021) were identified, including 2 English-language texts.

CONCLUSION

Geriatric medicine was a mandatory subject for medical students of the included HEIs. However, there was a lack of uniformity in the offered courses. This leaves room for the development of a unified undergraduate geriatrics curriculum to effectively address diverse geriatric issues across Europe. The importance of this matter is highlighted by demographic trends and workforce challenges.

Avoiding Locoregional Overtreatment in Older Adults With Early-Stage Breast Cancer

Advances in the treatment of older women with early-stage breast cancer, particularly opportunities for de-escalation of therapy, have afforded patients and providers opportunity to individualize care. As the majority of women ≥65 have estrogen receptor-positive, HER2-negative disease, locoregional therapy (surgery and/or radiation) may be tailored based on a patient's physiologic age to avoid either over- or undertreatment. To determine who would derive benefit from more or less intensive therapy, an accurate assessment of an older patient's physiologic age and incorporation of patient-specific values are paramount. While there now exist well-validated geriatric assessment tools whose use is encouraged by the American Society of Clinical Oncology when considering systemic therapy, these instruments have not been widely integrated into the locoregional breast cancer care model. This review aims to highlight the importance of assessing frailty and the concepts of and over- and undertreatment, in the context of trial data supporting opportunities for safe deescalation of locoregional therapy, when treating older women with early-stage breast cancer.

Towards a better uptake of home dialysis in Europe: understanding the present and looking to the future

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery.

Healthcare on the brink: navigating the challenges of an aging society in the United States

The US healthcare system is at a crossroads. With an aging population requiring more care and a strained system facing workforce shortages, capacity issues, and fragmentation, innovative solutions and policy reforms are needed. This paper aims to spark dialogue and collaboration among healthcare stakeholders and inspire action to meet the needs of the aging population. Through a comprehensive analysis of the impact of an aging society, this work highlights the urgency of addressing this issue and the importance of restructuring the healthcare system to be more efficient, equitable, and responsive.

Reinvigorating geriatrics: An urgent call for prompt action

See related articles by Ouslander et al., Colenda and Applegate, and Ross et al. in this issue.

The value proposition for geriatrics

In response to some of the challenges that have been articlulated about the future of Geriatrics, we describe a more positive view and value proposition for the field. Health professionals with specific training in Geriatrics are a natural fit for a variety of roles in value-based care (VBC) programs and health systems. These roles include serving as educators for primary care health professionals and specialists in person-centered care of older adults, serving as consultants on geriatric conditions and syndromes in a co-management model of care, becoming effective leaders in VBC programs and health systems, and conducting quality improvement initiatives to build on the evidence-base for the management of common conditions in the older population. We further recommend that VBC programs and systems support Centers of Excellence or Institutes to implement these strategies within and Age-Friendly, learning system approach.

Gluing Together a Fragmented Healthcare System for Geriatrics Will Be Hard. It's Time for United Action

"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.

Fellowship-trained physicians who let their geriatric medicine certification lapse: A national survey

BACKGROUND

Only 62.6% of fellowship-trained and American Board of Internal Medicine (ABIM)-certified geriatricians maintain their specialty certification in geriatric medicine, the lowest rate among all internal medicine subspecialties and the only subspecialty in which physicians maintain their internal medicine certification at higher rates than their specialty certification. This study aims to better understand underlying issues related to the low rate of maintaining geriatric medicine certification in order to inform geriatric workforce development strategies.

METHODS

Eighteen-item online survey of internists who completed a geriatric medicine fellowship, earned initial ABIM certification in geriatric medicine between 1999 and 2009, and maintained certification in internal medicine (and/or another specialty but not geriatric medicine). Survey domains: demographics, issues related to maintaining geriatric medicine certification, professional identity, and current professional duties.

RESULTS

153/723 eligible completed surveys (21.5% response). Top reasons for not maintaining geriatric medicine certification were time (56%), cost of maintenance of certification (MOC) (45%), low Medicare reimbursement for geriatricians' work (32%), and no employer requirement to maintain geriatric medicine certification (31%). Though not maintaining geriatric medicine certification, 68% reported engaging in professional activities related to geriatric medicine. Reflecting on career decisions, 56% would again complete geriatric medicine fellowship, 21% would not, and 23% were unsure. 54% considered recertifying in geriatric medicine. 49% reported flexible MOC assessment options would increase likelihood of maintaining certification.

CONCLUSIONS

The value proposition of geriatric medicine certification needs strengthening. Geriatric medicine leaders must develop strategies and tactics to reduce attrition of geriatricians by enhancing the value of geriatric medicine expertise to key stakeholders.

Gluing together a fragmented healthcare system for geriatrics will be hard. It's time for united action

"Gluing" together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: (1) the US's historical fee for service (FFS) reimbursement system; (2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and (3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: (1) local political advocacy to implement health policy legislation; (2) expand geriatric physician and health professional workforce by nontraditional means; and (3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.

Aging populations and perspectives of geriatric medicine in Japan

It is well known that Japan's population is aging, and the number of people older than 75 years is increasing significantly. Since older people, especially old individuals, are often multimorbid and cannot be always successfully treated and cared for by individual organ-specific treatment, it is essential to utilize knowledge of geriatrics when treating such older patients. Therefore, it is indisputable that education on geriatric medicine is extremely important in Japan, which is the country with the largest aging population. However, the number of universities in Japan that offer geriatrics courses is decreasing. This means that many medical students become doctors without learning the essential characteristics of medical care for older patients despite the need for prompt treatment of older patients in clinical practice in Japan, which is a major obstacle to the development of geriatric medicine in Japan. Here, we review the current status of geriatrics in Japan and overseas and consider the future of geriatrics education to provide holistic and cost-effective medical care for older patients and improve their quality of life and well-being.

The role of Department of Veterans Affairs community-based outpatient clinics in enhancing rural access to geriatrics telemedicine specialty care

BACKGROUND

Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community-based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under-resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff.

METHODS

From February-April 2020, we interviewed CBOC clinicians and staff (N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi-structured interviews addressed patient population characteristics; CBOC location, staffing, and in-house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data.

RESULTS

Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in-person visits.

CONCLUSIONS

Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource-poor settings, and are largely unaware of VA telemedicine programs designed to support them.

Proving the Geriatrician's worth

This Editorial comments on the article by Vandergrift et al in this issue.

Enabling translational geroscience by broadening the scope of geriatric care

Geroscience poses that core biological mechanisms of aging contribute to chronic diseases and disabilities in late life and that health span and longevity can be modulated by pharmacological and behavioral interventions. Despite strong evidence from studies in model organisms and great potentials for translation, most geriatricians remain skeptical that geroscience will help them in the day-by-day battle with the consequences of aging in their patients. We believe that a closer collaboration between gerontologists and geriatricians is the key to overcome this impasse. There is evidence that trajectories of health with aging are rooted in intrinsic and extrinsic exposures that occur early in life and affect the pace of molecular and cellular damage accumulation with aging, also referred to as the "pace" of biological aging. Tools that measure the pace of aging currently allow for the identification of individuals experiencing accelerated aging and at higher risk of multimorbidity and disability. What we term "Translational Geroscience", i.e., the merger of fundamental and translational science with clinical practice, is thus poised to extend the action of geriatric care to a life course perspective. By targeting core mechanisms of aging, gerotherapeutics should be effective in treating patients with multimorbidity and disability, phenotypes that are all too common among geriatric patients nowadays. We call for initiatives that enhance the flow of ideas between gerontologists and geriatricians to facilitate the growth of translational geroscience. This approach can widen the scope of geriatric care, including a new role for geroscience in the promotion and operationalization of healthy longevity.