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EDUCATION IN GERIATRIC MEDICINE* IRVING S. WRIGHT, M.D. Chairman, Section on Geriatric Medicine The New York Academy of Medicine Emeritus Clinical Professor of Medicine Cornell University Medical College New York, New York

',/p are in a new world. Never before has 10% of a major population group been more than 65 years of age. In the past it has been considered desirable to live to be old, but we now find ourselves unprepared to meet the problems which this success presents. We do not know what to do with healthy citizens who are able and want to work or to live a life of ease. We do not know how to provide them with satisfying jobs and at the same time employ the young and hungry. Our too few perceptive political, industrial, labor, and educational leaders are gradually awakening to the fact that we cannot support this ever-growing segment of our population in unproductive idleness for 20, 25, or 30 years. But so far the alternatives proposed are too anemic to be effective. We must do better or our social security system, indeed our economic structure, will collapse. As physician leaders, we have not shown that we are prepared to handle elderly people who suffer from multiple diseases and who, unlike the young, do not recover or die quickly but often live for months or years, requiring more hospitalization time than those less than 50 years of age and who further require an approach and kind of care that differ from what physicians of this technical age are presently being trained to give. In a few decades those classified as elderly by our already obsolete standard of 65 years will constitute 20% of our population. Physicians cannot resolve the economic and social problems involved, but must address the health problems of this age group. The primary approach must be to educate physicians and other healthcare personnel in three related but neglected segments of present programs: *Presented before the Committee on Medical Education of the New York December 8, 1977.

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1) Gerontology, the study of the aging process, biological, biochemical, genetic, and involving numerous other basic sciences 2) Geriatrics, the care of the elderly, the prevention and treatment of their multiple characteristic diseases and maintaining physical and mental health as long as possible. (Long life is desirable only if life is pleasant or, at least tolerable.) 3) Thanatology, the study of dying and death-a phase of life many physicians are poorly prepared to meet. These three subjects have been neglected in our medical school curricula, and even more since our approach concentrates on disease rather than patients. Certainly, the study of the process of aging distinguished from the diseases with which we are familiar is basic and must be intensified. The genetic aspects of aging are fascinating and of the utmost importance. Why do some families commonly live beyond the 80s while others rarely exceed 50? This and related questions should be addressed, but such studies will not help us resolve the pressing problems of geriatric medicine in the near future. Demographic studies should help us to understand the long-term effects of environment, life patterns, and diet. We are already reaping information from comparative dietary patterns. Geriatrics, the actual care of the elderly, is already a pressing need, and has had a few pioneers far ahead of their time. Dr. Ingatz Leo Nascher (1863-1944), credited as the first to use the term "geriatrics" (1909), also published the first important American textbook on this subject in 1914,1 but little attention was paid to his work. Although a few volumes dealing with this general area appeared in the interim, the next major work, Edward Stieglitz's Geriatric Medicine, appeared in 1943.2 This represented a real advance in thinking. He was extremely perceptive in seeing the problems, and his book remains well worth consulting today. Although at his request I contributed a chapter, I can honestly say that I did not appreciate his monumental effort to alert the medical profession to its future challenge. Dr. Stieglitz pursued his objectives doggedly, but in his later years appeared frustrated and disillusioned by the lack of acceptance of his vision by others. At present, fewer than a quarter of our medical schools offer an elective in this subject. Robert Butler,3 director of the National Institute on Aging, recently pointed out that the United States has only two formal medical school programs and very few centers in which any sort of training for research in clinical gerontology can be obtained. No medical school in this country Vol. 54, No. 10, November 1978

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requires systematic training in nursing homes, long-term-care institutions, or home-care programs. It has been frequently suggested in answer to criticism that many teachers treat the subject in their specialty courses, but investigation usually reveals casual or superficial references, not a comprehensive treatment of the subject. One result of this neglect is that we are practically without well-trained leaders equipped to develop sound courses for our medical schools. A few exceptions have been self taught out of personal interest. Most physicians now caring for the elderly are fairly far along in their careers and developed their interest by chance. Few can be considered trained geriatricians. Although interest is increasing, fewer than 25 physicians in the United States have been trained specially in this field. The logical place to begin is in medical schools, where the future interests and attitudes of physicians are formed; but we cannot wait 10 or 15 years to develop a new crop of physicians. Needs are immediate and can be met in part by continuingeducation programs for physicians. Britain has actively developed programs to meet this critical need. Brockelhurst4'5 estimates that 50% of British medical students receive instruction in geriatrics. Sir Ferguson Anderson, professor of geriatric medicine, University of Glasgow, and Professor A. N. Exton-Smith, professor of geriatric medicine, University College Hospital, London, are leaders in developing young men to assume teaching and care in this field. Possibly because of its National Health Insurance program, British organization of geriatric care has been primarily hospital based. Autonomous geriatric units are headed by physician-consultants with house officers, social workers, and rehabilitation personnel. There are more than 600 geriatricians in Britain, many evolved from general practitioners, internists, or psychiatrists. They too are in an evolutionary phase, although considerably farther along than we are. Other facilities include day-care hospitals (probably about 150 units in Britain today), rehabilitation units, psychogeriatric units, health centers, and home-care services. American medical schools became disease oriented about 50 years ago, when we began to develop new diagnostic techniques and specific treatment for numerous diseases. Concentration on specific diseases has controlled or eliminated the killers of my student days, including pernicious anemia, typhoid, syphilis, tuberculosis, and rheumatic fever, but contributed to the growth of our present population of patients who live long Bull. N.Y. Acad. Med.

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enough to accumulate multiple chronic diseases for which we have no equally effective treatment but which require special care. Physicians must be prepared to help an elderly patient who may have hypertension, coronary artery disease, cholelithiasis, prostatic hypertrophy, arthritis, and several other diseases. These patients are most sensitive to favorable and unfavorable comments or unfriendly acts by those caring for them, are easily depressed by medical problems and institutional confinement, and may lose their will to fight. Experienced clinicians and surgeons know that this may decisively affect the outcome of a serious illness or operation. The oncoming generation of physicians seems to be progressively dividing into those who are research or technically oriented such as biochemists, geneticists, radiologists, and experts in sonography or computer techniques and, increasingly, surgeons who perform highly skilled procedures but otherwise have only brief contact with their patients. In contrast, a physician who cares for elderly patients must be well trained in diagnosis and therapy but must also be prepared to become involved in the psychiatric, social, and often legal and religious aspects of their problems. Many elderly patients are alone in their world, without relatives or helpful friends. This is especially true with elderly women who may be the victims of fraud and abuse or may be taken advantage of in other ways. Their physician may become the most authoritative person in their lives. All this is rarely mentioned in medical schools, and many young physicians, confronted with a generation gap and such problems as I have mentioned, are unprepared and may become antagonistic, defensive, and even abusive in rejecting the patient. We have all seen examples of this type of behavior. Some, further, become panic-stricken at direct confrontation with death, and turn from the patient when compassion, understanding, and frank discussion are needed most. Carefully selected and experienced clinicians can completely change these attitudes and are often much appreciated by the students. Where students have guidance of this type, they usually respond well.* Should we follow the highly organized programs of England or Sweden, which are so depersonalized that patients often complain of being treated as numbers instead of persons? I doubt that we are ready for that type of approach as yet. Should we strive to develop a new specialty of *Notable examples have been the New York University program and the North Dakota program under Dr. Theodore Reiff. At Cornell University we are beginning to formulate programs. The Harriman Foundation has generously provided the funds for the first endowed geriatrics professorship in the United States, and the candidate is to be announced soon.

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geriatrics with its own certification board? Some argue that we have not made more progress in the past 70 years because there has been no central board to develop, organize, and perpetuate knowledge in this field. I should like to suggest the following steps to broaden our horizons and more rapidly meet the impending crisis as local circumstances and support permit. Progress can proceed along several fronts simultaneously. 1) A department or section should exist in each medical school to indoctrinate students early in the curriculum (preferably beginning in the first year) and during later years in the care of elderly patients, whose disease patterns are often both complicated and fascinating. 2) This unit can be well integrated into the departments of internal medicine or of family practice if the chairman is interested and supportive. It can develop into a very important section of the department but if, as has been the case quite generally in the past, the chairman is disinterested, the alternative is the British system of an independent unit, which I do not regard as a first choice. 3) The chief of geriatrics must be broadly trained in internal medicine, and some background in psychiatry will be helpful. He should be trained in clinical research methods so that new knowledge can be developed, especially important now because of the problems of drug interactions in patients who are likely to be very sensitive to drugs and usually are getting multiple drugs. He should be interested in and support basic studies in gerontology. He must have the good judgment to use all appropriate specialists for his patients and to mobilize them for consultations and conferences on his service. 4) All aspects of social-service and home-nursing care must coordinate to meet the needs of the geriatric section. Compliance with treatment is a joint responsibility. 5) Teaching in geriatrics should be given wherever applicable throughout the medical school curriculum, with the cooperation of other departments, e.g., surgery, radiology, biochemistry, psychiatry, pathology, physiology, ophthalmology, gynecology, otology, dermatology, and urology. 6) A continuing relation with a nursing home and/or chronic disease service should be encouraged, and students should have structured experience in such institutions. 7) Thanatology, the subject of dying and death, should be discussed in lectures and conferences so that the young physicians get some idea of how Bull. N.Y. Acad. Med.

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to handle these critical problems with the patient and the family. Hospices such as those of St. Christopher's of London, Yale New Haven, St. Lukes, and St. Rose's are setting examples of the care of the terminally ill, and physicians can learn much from their experience. A few medical schools in the United States are recognizing geriatrics, and continuing medical education in this field is beginning to increase. The American Geriatrics Society and the American Gerontological Society are increasing their activities, but have yet to achieve their potential. The New York Academy of Medicine's new Section on Geriatric Medicine will assume an important role. Physicians' attendance at geriatric meetings is beginning to increase, and, with new, stimulating leadership should improve. Opportunities for graduate training in geriatrics in this country are too scarce. A notable model is Dr. Leslie Libow's Fellowship-Residency Training Program at the Jewish Chronic Disease Hospital and Downstate Medical Center. He is developing well-trained geriatricians, and at present we need 50 such training centers in this country. The American Medical Association's Impact reported that in a 1976 survey 75% of practicing physicians responded affirmatively when asked, "Do M.D.'s need special training in geriatrics'?" This is especially significant, coming largely from physicians on the front lines of care for these patients. Members of curriculum committees are too often composed of physicians not personally confronted with problems of this type and with little emotional involvement or indeed understanding of them. The American Medical Student Association recently held a workshop in Chicago on Health Care for the Aged at which the dearth of American medical school curricula in geriatric medicine was pointed out. Following this meeting, that organization formally backed the Burdick Bill S-2287, now before the U. S. Senate, to assist medical schools to establish and operate educational programs in geriatrics through grants in amounts not less than the sum necessary to carry such programs for not less than five years. Under Dr. Reiff's leadership the North Dakota Medical School now receives funds for a Geriatric Education Program at its Dean's Committee Veterans Administration Hospital. Other Veterans Administration hospitals associated with medical schools, notably in Arkansas, Alabama, and California, are actively developing new programs. Finally, it can be said that the problems involved in the care of the elderly are great, and demand more concentrated attention by physicians. Vol. 54, No. 10, November 1978

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Each medical school should establish a section dealing with geriatrics, gerontology, and thanatology to introduce students to these problems early in their careers. Greater support should be given to residencies and fellowships to train geriatricians. Continuing medical education programs in geriatrics should be increasingly presented, and the New York Academy of Medicine should play an important role in meeting this challenge. REFERENCES 1. Nascher, I. L.: Geriatrics: The Diseases 3. Butler, R.: Geriatric medicine: The of Old Age and their Treatment, Including imperatives. N. Y. State J. Med. 77:1470, 1977. Physiological Old Age, Home and Institutional Care and Medico-Legal Relations. 4. Brockelhurst, J. C.: Psychogenic care as a Philadelphia, Blakiston, 1914. specialized discipline in medicine. Bull. N.Y. Acad. Med. 53:702, 1977. 2. Stieglitz, E.: Geriatric Medicine: Diagnosis and Management of Diseases in the 5. Brockelhurst, J. C.: Geriatric Medicine Aging and in the Aged. Philadelphia, for Students. London, Churchill-Livingston, 1976, p. 220. Saunders, 1943.

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Education in geriatric medicine.

944 EDUCATION IN GERIATRIC MEDICINE* IRVING S. WRIGHT, M.D. Chairman, Section on Geriatric Medicine The New York Academy of Medicine Emeritus Clinica...
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