PERSPECTIVE

Geriatric Medicine: Whose Specialty? JAMES WILLIAMSON, M.B., Ch.B.; Edinburgh, Scotland The recommendation of the 1978 report of the Institute of Medicine, Washington, D.C., states that there should not be "a formal practice specialty in geriatrics." The United Kingdom has a comprehensive geriatric service based on a separate specialty of geriatric medicine. This speciality was developed before the National Health Service in 1948. The future of geriatric medicine is not clearly defined. It should continue, I believe, as a separate speciality but with deliberate policies to bring it back into "mainstream medicine." This will involve closer integration with family practice, internal medicine, and psychiatry. While I realize that the operation of the geriatric service in Edinburgh, where I work, could not simply be transplanted into an American setting, the principles of geriatric care ought to be applied within a specialist service if the increasing problems of the aging in American society are to be adequately met.

IN the 1978 report of the Institute of Medicine (1), the committee recommends "that a formal practice specialty in geriatrics be not established but that gerontology and geriatrics be recognized as academic disciplines within the relevant medical specialties." This message seems to imply that the medical needs of the aging in American society will be adequately met by increased emphasis on education in gerontology and geriatrics through the formation of cadres of teachers and leaders; that the influence and example of academia will suffice to change attitudes among existing professionals; and that undergraduate education will ensure future doctors are sufficiently interested and knowledgeable in the problems of old age to meet the needs of the people. This matter obviously must be settled by the American academic community, but perhaps I, from a different health-care system, can put matters into perspective. Specialization in Medicine

There are three main reasons for the development of specialization in medicine: [1] A body of knowledge becomes so large as to demand the exclusive attention of the specialist, for example, neurology, cardiology, and other "traditional" specialties; [2] the development of highly complex and sophisticated techniques of diagnosis and treatment, for example, nuclear medicine and endoscopy, calls for specialization; and [3] an extraordinary community need develops that requires specialization in response, for example, the need for tuberculosis control in the 19th and early 20th centuries. The medical profession often has seemed slow to respond to community needs, probably because senior med• F r o m the University D e p a r t m e n t of Geriatric Medicine, City Hospital; Edinburgh, Scotland.

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ical educators and "pacesetters" at any given time are apt to reflect professional fashions and attitudes that prevailed when they were students and young doctors. It seems to me that this factor combined with the remarkable and dramatic advances in medical science during the last 30 years explains why our profession has been so tardy in responding to the challenges of demographic and social changes. Historical Development of Geriatric Medicine in the United Kingdom

It is usually glibly assumed that the main reason for the development of a medical speciality in geriatrics in the United Kingdom has been the National Health Service (NHS), but I should emphasise that the infant speciality was alive and thriving before the inception of this service in 1948. In my opinion the N H S merely provided suitable soil upon which the seeds could readily grow. This was probably largely attributable to the fact that our medical profession could not avoid seeing first-hand what was occurring in the community, since teaching hospitals were also the district general hospitals and through their doors flowed a cross-section of the sick, the needy, and the unhappy from the surrounding population. It seems to me that geriatric medicine has evolved in three phases and we are now entering the fourth phase. PHASE I

This phase was inaugurated by Dr. Marjory Warren of West Middlesex Hospital, London, who made the fundamental observation that direct admission to any chronic care facility was unsatisfactory and inevitably led to the high risk of serious misplacement of old people (2). She instituted a system of total patient assessment based on full clinical, psychological, and social diagnosis followed by rational therapy and rehabilitation. Only after such systematic inquiry and treatment could decisions on future management be made, and very often patients who seemed to require continuing institutional care could be managed more appropriately in their homes. This remains the fundamental tenet of geriatric care. She also pointed out that the ordinary acute medical ward environment was generally inimical to the recovery of elderly patients. Finally she emphasized the ignorance of most doctors about the fundamentals of care of the elderly and made a plea for special educational efforts—otherwise "there is no hope that future generations will be any more knowledgeable in the care of these patients than is the average doctor of today." © 1979 American College of Physicians

PHASE II

This represented the logical development of Phase I and was still very much the "Warren era." An exclusive hospital orientation, it was realized, could achieve only limited success because just one in 20 elderly persons were in any form of institution at any time. Dr. Warren established the practice of preadmission home assessment of patients, and it immediately became apparent that a significant proportion of patients referred for admission could readily be managed at home by provision of domiciliary services and later by various forms of day care. This led to a stimulus for better community and domiciliary services and closer working relationships with general practitioners. The educational process was now started as general practitioners, nurses, and the public realized this was a better way of treating old people with health problems. This phase was particularly difficult because these early pioneers were swimming against the strongly running tide of narrower specialism in medicine. We were trying to preach the virtues of generalism at the same time that most of medicine (and medical education) was increasingly involved with "organ" or "system" specialism and the development of complex medical technology. Medical schools vied with each other over the acquisition of the latest techniques, and the highest prestige was accorded to the most highly specialized workers. This was a time when a doctor who declared his interest was not only in the whole patient as a unique individual but also in the family and the local caring community was apt to be classed as out of step with medical progress. Claims to have access to medical students in their undergraduate curriculum fell upon deaf ears or were drowned out by the clamor of the narrower specialist that students must know all about the very latest techniques of scientific medicine. PHASE III

This phase provided the first glimpse of hope as public and political support for the concept of a modern comprehensive geriatric service gradually developed. It was realized that preventive measures could indeed help to keep old people healthy, delay and minimize disability, and reduce the otherwise overwhelming demands for institutional care. The realization of the iceberg of unmet medical and social needs (3) led to the development of case-finding programs using public health nurses and the concept of special surveillance of high-risk groups such as the aged living alone, the widowed, the rehoused, and those recently discharged from hospital. This trend occurred because of the remarkable resuscitation of general practice in the United Kingdom during the 1960s that resulted in the development of primarycare teams of general practitioners and community nurses. The educational breakthrough was a gradual process and received its greatest boost through the establishment of the first University Chair of Geriatric Medicine in Glasgow in 1965. There are now 12 such chairs in the United Kingdom, and geriatric medicine is a part of all

undergraduate curricula, although to a variable extent thus far. PHASE IV

This represents the road ahead, and it is not yet clear how things will develop. There appear to be three main possibilities. Option 1: Abandon the specialty by "giving it back" to general internists. This was suggested in 1976 (4) because geriatrics had no "special techniques" and had experienced difficulty in attracting doctors to its ranks. No one seriously supported this suggestion, either in the columns of the British Medical Journal or elsewhere. This would represent a most retrograde step in my country and would certainly lead to the demolition of the carefully developed teams that now form the geriatric service. It would also mean an immediate return to hospital orientation in care of the elderly that the early pioneers so laboriously sought to alter. The truth is that modern geriatric medicine really has much closer affinity with primary care and general practice than with internal medicine. Sure, there have sometimes been severe difficulties in attracting suitable recruits to the specialty, but this is explicable by the enormous expansion that has occurred and the fact that until very recently we have had little or no chance to put our case to medical undergraduates, and thus to change the highly negative attitude to old age that the traditional medical curriculum creates (5). Option 2: Make geriatrics an age-related specialty, as in pediatrics. This idea has been much canvassed in England and Wales but not in Scotland, and the reasons for this are not entirely clear. The argument is that we should develop a geriatric service that will provide all the hospital needs of the 70 and older age group, from acute and intensive care to nursing homes and continuing care. In this way, doctors and nurses in the geriatric service will have the satisfaction of dealing with acutely ill patients and those with "interesting" diagnostic problems in addition to the less rewarding usual geriatric fare. The objections to this option are, to my mind, obvious and fundamental. First, it would lead to two separate services—one for the young and middle aged and the other for the old, and no one need doubt which would be the "poor relation"! An equally cogent objection is that once again it seems to suggest that care of the elderly is mainly a hospital activity whereas, as argued previously, it clearly is not. In addition, it would perpetuate and accentuate the isolation of geriatric medicine. Option 3: Integrate geriatrics with "mainstream" medicine. Thus we shall seek closer cooperation with related branches of medicine while preserving the essential elements of the specialty. This is the course I personally favor and I hope we shall pursue in Scotland. It will involve the continuation of specialist geriatric medicine departments staffed by doctors with a full-time commitment to the subject, although there may be a limited place for the "internist with a special interest in geriatric medicine" (6). Such a geriatric service would be based on the district general hospital and teaching hospital. There would be encouragement for rotation of interns and resiWilliamson

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dents between geriatric medicine and other specialties (including general or family practice). Special cooperation and collaboration would be fostered with internal medicine, psychiatry, and orthopaedic surgery. This process of integration has been occurring already in Edinburgh, and we have had, for example, geriatric medicine attached to each acute internal medicine ward of the largest teaching hospital. Since this attachment, the mean stay of elderly female patients in acute wards has been reduced by up to 5 0 % (7)

What is Geriatric Medicine?

A common definition is "that branch of medicine concerned with the clinical, psychological, and social aspects of old age." To achieve this aim we require a coordinated service based on a multidisciplinary team, and the effective operation of such a team is the "special technique" that our opponents claim we do not possess. This team comprises doctors, nurses, physical and occupational therapists, social workers, and a range of others as required, including speech therapists, dietitians, and chiropodists. The geriatric patient is one who has varied health problems because of multiple diseases, in addition has social problems, and very frequently has disturbances of mental health. Another way to categorize the geriatric patient is as one who requires the approach of the multidisciplinary team for the assessment of his or her needs and to meet them appropriately.

Features of a Modern Geriatric Service

A modern geriatric service is based on a defined catchment population and must attempt to provide a comprehensive service for the elderly resident in that population. The resources needed for such a task may be measured by taking account of local demography, social conditions, and family structure. The geriatric team must study this population and learn the strengths and weaknesses of available resources and services within the community. Close-working relations must be established with community workers and related medical specialties. Collaboration between health and social services must be strengthened to ensure cordial and mutually respectful relations at each level of provision. Cooperation in planning and provision of services should be sought to prevent gaps on the one hand and wasteful duplication on the other. A comprehensive range of activities must be provided, [a] Home visiting for clinical, social, and psychiatric assessment in the patient's own setting; [b] day hospital care for more detailed assessment, diagnostic procedures, and rehabilitation; [c] inpatient care for acute assessment, rehabilitation, and continuing care as needed; and [d] respite admission for families to help them continue their support. Respite admissions are indicated to provide occasional breaks, to allow for intercurrent illness in caring relatives, or simply to allow families to have a much needed holiday. 776

Special Features of the Geriatric Service

Everything to do with the elderly is a matter of urgency. Although this statement is contrary to accepted notions, I wish to emphasise it most strongly. If an old lady is not well on Monday, the chances are she will be worse on Tuesday, and by the end of the week she may have become bedridden, dehydrated, confused, and incontinent (to say nothing of the accompanying process of demoralization). All her organs and body systems have been operating on low or no reserves of function so that when one fails, as with a respiratory tract infection, the stress on others leads to secondary effects, and the whole functioning of the individual is prejudiced. Likewise the caring relatives often are operating close to their limits of tolerance, and any additional burden may lead to a breakdown—the syndrome of the "end of the tether" as I have called it. Clearly once a family has been taken beyond its limits of tolerance, an irreversible breakdown and so-called rejection will ensue. This is another reason for speed and urgency. The corollary is that we must respond to requests for help immediately and with a flexible range of resources to meet the varying needs of the patient and family. In my own department we make it a rule that requests for help are dealt with on the same day through a house call and by immediate admission where indicated. It is always asked, how can we possibly do this without large numbers of beds? The paradoxical answer is that only by operating in this dynamic and flexible way can relatively small numbers of hospital beds suffice. Thus if we are asked for help with an old lady who is living alone but visited regularly by her daughter (and a homemaker service), we will visit her immediately. Suppose the problem is that she has mild confusion, falls, and has been incontinent for a week or two: She will be admitted forthwith and after, say, 10 d has recovered her usual mobility, the confusion has settled, and she is continent once more. (Most cases of this sort are reversible if of short duration and promptly and expertly dealt with.) Since help was immediately available from our service, we can confidently request that the daughter (and the community services) receive her back into her home with the offer that we will keep in touch and a guarantee of further prompt help if needed. Contrast this with another kind of service where the old lady has to wait for an appointment to be seen, her name is put on a waiting list for a nursing home, and all the while she is deteriorating and becoming demoralized and her daughter's attitude less and less caring. Once admitted, her return home is improbable. The other requirement of this type of service is for efficient after-care arrangements so that the changing needs of the patient and family may be monitored. Appropriate action, where indicated, is generally carried out by the public health nurse who, as a member of the primary-care team, is well placed to keep both the general practitioner and us informed of the need for early assistance. Educational Aspects

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Underlying all our activities is an educational purpose.

Indeed the mere existence of such a service is a most powerful educational force because it helps old people, their relatives, other doctors, and primary-care workers to see the achievements expected by applying the principles of geriatric medicine and the effectiveness of multidisciplinary team effort. Our medical students now receive 4 weeks of geriatric medicine, and their course has been carefully designed to create a more positive attitude towards old age, to show the student how to deal with the commoner problems in older patients, and to give an understanding of the skills and roles of other health and social professional workers. There has been a very favorable response from the students, and we are encouraged in our belief that given this opportunity at the outset of their careers our undergraduates are fully capable of meeting the challenge of the aging population that will dominate medicine for the next few decades.

problems are so much greater in the United States, surely this would be an even stronger argument for special measures to be taken. I do not suggest that our type of service can be transplanted into a different cultural and medical scene, but the principles of geriatric care as I have attempted to outline them certainly can be applied anywhere. It would be foolish to claim that our specialist geriatric service is perfect—the poor old National Health Service is experiencing plenty of difficulties at present! It does seem, however, that where the principles have been properly applied, we are getting closer to realization of the goals of geriatric care and for much less expenditure. This paper was based on one presented by the author at the Second Aesculapian Society Medical Symposium, University of Ottawa, Ottawa, Canada, February 1979. • Requests for reprints should be addressed to James Williamson, M.B., Ch. B.; University Department of Geriatric Medicine, City Hospital, Greenbank Drive; Edinburgh, EH 10 5SB, Scotland. Received 11 June 1979; revision accepted 19 July 1979.

Conclusion

It will be argued correctly that the geriatric service I have advocated is for a British setting and hence not applicable to the United States. Usually when I have discussed this with American colleagues, they have gone on to say that we have fewer problems in Scotland because we are all "white, Presbyterian, and from similar backgrounds"! This, of course, is only partly true, but we have our own problems of inner-city decay, social isolation, and family dispersal, and it is only through providing our specialist service, particularly the multidisciplinary team approach, that we manage to cope. In any case, if the

References 1. Aging and Medical Education: Report of a Study. Washington, D.C.: Institute of Medicine, National Academy of Sciences; 1978. (Publication 10M-78-04). 2. W A R R E N MW. Care of the chronic aged sick. Lancet. 1946;1:841-3. 3. W I L L I A M S O N J, STOKOE IH, G R A Y S, et al. Old people at home: their

unreported needs. Lancet. 1964;1:1117-20. 4. LEONARD JC. Can geriatrics survive? Br Med J. 1976;1:1335-6. 5. G A L E J, LIVESLEY B. Attitudes towards geriatrics: a report of the King's survey. Age Ageing. 1974;3:49-53. 6. Report of the Working Party on Medical Care of the Elderly. London: Royal College of Physicians of London; 1977. 7. B U R L E Y LE, C U R R I E CT, S M I T H RG, W I L L I A M S O N J. Contribution

from geriatric medicine within acute medical wards. Br Med J. 1979;2:90-2.

Williamson

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Geriatric medicine: whose specialty?

PERSPECTIVE Geriatric Medicine: Whose Specialty? JAMES WILLIAMSON, M.B., Ch.B.; Edinburgh, Scotland The recommendation of the 1978 report of the Inst...
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