GERONTOLOGISTS OR GERIATRICIANS? THAT IS THE QUESTION Theodore R. Brooks, MD, MSEd, MS Los Angeles, California
Gerontology, at present, is not a licensed specialty. Employment opportunities are limited by a degree that prepares the student only for the field of aging. Some institutions, such as the Leonard Davis School of Gerontology at the University of Southern California, offer dual degrees in social work and gerontology, public administration and gerontology, and urban development and gerontology. How did the discipline begin? British scientists in 1939 established the first scholarly organization, the International Club for Research on Aging. In the same year, the American Research Club was organized with the support of the Josiah Macy Foundation. In 1945, this organization was incorporated as the Gerontological Society.' This society remains the major professional scientific organization on aging and maintains a strong interest in the physiological and medical aspects of the field. However, it is now dominated by individuals who are more concerned with programs and policy. Other major organizations include the International Association of Gerontology in Belgium, which was established in 1950, and the Division of Maturity and Old Age, which was established in 1946 as a part of the American Psychological Association,2 as well as regional organizations such as the Western Gerontological Society, which was founded nearly 30 years ago, and the Association for Gerontology in Higher Education, which was incorporated in 1974.3 The Gray Panthers also represent an action-filled aging organization. The emergence of gerontology as a study at the From the Charles R. Drew University of Medicine and Science, Los Angeles, California. Requests for reprints should be addressed to Dr Theodore R. Brooks, 3701 Stocker St, Ste 104, Los Angeles, CA 90008. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
college level began in 1967 and continues to the present. The first stage of gerontology education actually occurred before 1966 and involved training in research in aging at a few universities. Monies were supplied by the National Institute of Mental Health and the Institute of Child Health and Human Development. In 1966, the US Administration on Aging (a division of the US Department of Health, Education, and Welfare) began giving grants for training in aging. Funds were made available under the Older Americans Act to prepare practitioners for jobs to be created by community programs sponsored by the Act. In 1972, the Administration on Aging reopened competitive career grants. Also in 1972, for the first time, several undergraduate programs were initiated, and instruction at predominantly black or minority colleges was funded. In 1976, Title IV-C of the Older American Act, providing for multidisciplinary centers of aging, was funded. This Title encouraged the planning and implementation of multifaceted programs of research, service, and education to be developed at several universities. In 1978, the National Institute on Aging was formed. Its major purpose is to conduct and support biomedical, social, and behavioral research related to the aging process and diseases, as well as to other problems and needs of the aged. Four early entrants into teaching and research in gerontology were: the University of Chicago, the University of Michigan, Duke University, and the University of Southern California.4 The University of Chicago was one of the first institutions of higher learning to become involved in the early 1950s. Several research projects were started and continue to this date 749
GUEST EDITORIAL
to train faculty and students. The University of Michigan began studies on the needs of older people in 1948. From the above sources, researchers and policy makers emerged. In 1954, Duke University began developing gerontological research. The Center for the Study of Aging and Human Development was established. The Center enjoys a history of high-quality medicopsychological
research.5 The University of Southern California established the Roosmoor-Cortese Institute for the Study of Retirement and Aging in 1964. This center was renamed the Ethel Percy Andrus Gerontological Center in honor of the founder and first president of the American Association of Retired Persons/National Retired Teachers' Association. Today, this center is one of the largest gerontology research, service, and educational centers in the world. The Leonard Davis School of Gerontology, which was founded in 1975, is located in the Andrus Center. The Administration on Aging offered grants in 1966 and 1967 for existing programs in social work, education, and public administration. The Universities of South Florida and North Texas State used their funds to develop masters degree programs in gerontology, which emphasized social science and housing administration, respectively. Other universities, such as Wayne State, Arizona, Brandeis, UCLA, Maryland, Pennsylvania, and Oregon State, to name a few, offer programs in aging. However, hundreds of universities still have few or no courses. The Leonard Davis School of Gerontology at the University of Southern California started offering the first PhD in gerontology in the fall of 1989, with an emphasis on the political aspects of aging.5 Geriatric medicine is the diagnosis, treatment, and prevention of the physical and mental diseases of the elderly. Here again, as in gerontology, a controversy exists as to whom is better qualified to be called geriatricians. The family doctor specialists argue that they have specialty training (3 years of residency training) and that they deal with the immediate family and the extended family more than other specialists. They maintain that subspecialists can be called in to treat specific problems (eg, cardiologists, endocrinologists, and surgeons) as needed. The general internist claims to be more qualified (3 years of residency training) to handle the more common diseases of the elderly. These two specialties agree that at the present time neither would like a new specialty board established. To temporarily solve this issue, the board certified primary care providers from each specialty 750
who met certain requirements, and it allowed them to take a written geriatric board examination. The board will be repeated every 2 years. In the future, only physicians who have completed a 2-year fellowship in a qualified geriatric program may sit for the examination. Those who pass will have the title of "Additional Qualification in Geriatric Medicine." The examination is only given every 2 years. A successful repeat examination every 10 years is required to maintain this title. Because gerontology deals with normal biological aging processes (senescence) and geriatric medicine deals with diseases that can affect this so-called normal process, there is often only a fine line separating these two disciplines. To illustrate this controversy, contrast these statements: Longevity is only desirable if it increases the duration of youth, and not that of old age. The lengthening of the senescent period would be a calamity. -Alex Carrel Some people try to achieve immortality through their offspring or their works. I prefer to achieve immortality by not dying. -Woody Allen Some years before birth, advertise for a couple of parents belonging to long-lived families. -Oliver Wendell Holmes, Sr Death in old men, when not from fever, is caused by the veins which go from the spleen to the valves of the liver, and which thicken so much in the walls that they become closed up and leave no passage for the blood that nourishes it. The incessant current of the blood through the veins thicken and become callous so that at last they close up and prevent the passage of the blood. -Leonardo da Vinci
Few people appear to die of old age. One of the many diseases common in old age generally cuts the last thread of life. Aging and disease in the body often have overlapping manifestations. Unfortunately, the general medical community is resistant to learning and treating diseases of old age. Most of these diseases are chronic and cannot be cured; consequently, immediate selfrewards to the physician are not there. It was just the ignorance of old age on the part of the medical community that inspired Ignaz L. Nascher, a medical student of the 1880s, to spend his life trying to remedy the situation. In 1919, Nascher wrote6: During my student days, an instructor took a number of students to the almshouse to see cases. An old woman hobbled up to the instructor with some trivial comJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
GUEST EDITORIAL
plaint. He afterwards told us that she was suffering from "old-age." And what could be done for her? "Nothing." Suffering from old age and nothing could be done to relieve her suffering! Is old age, then, a disease from which those who had reached advanced life were doomed to suffer? This incident, as vivid today as it was nearly 38 years ago, laid the foundation for the branch of medicine which I gave the name "Geriatrics."
Nascher postulated that "senility [senility in this context refers to "old age" and not to "senile dementia"] is a physiologic state of maturity." "Diseases in senility are pathologic in a normally degenerating body; not diseases such as occur in maturity complicated by degenerations." "The object of treatment of disease in senility is to restore the diseased organ or tissue to the state of normal in senility; not to the state of normal in maturity."6 In the United States today, there are approximately 28 million men and women over the age of 65, and this number is increasing. The total number of American blacks aged 65 years and older is estimated to be approximately 2.3 million, and the black elderly population will continue to increase throughout the remainder of this century. Rejection of the aged is quite real in modern America. For the physician, the subject of aging is difficult to think about. For the aged, it is difficult to think of the infirmity associated with gradual or sudden loss of independent identity that has taken so much time to acquire. To look forward to depending on the young for care leaves most older people with a bitter taste in their mouths. Finally, the elderly present the physician with a challenge in a way that is not necessarily consistent with traditional medical education and training. A limited curriculum in nursing and medical schools has contributed to the low number of physicians prepared to treat the elderly in their offices and in nursing homes.7 In fact, only about 27.6% of American physicians visit nursing homes to care for patients, and these physicians are cardiologists, general practitioners, and internists, in
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
that order. This low number of physicians attending nursing home patients is not fully understood but it may be the low reimbursement for time spent, ageism, excessive "paper work," or that the individuality of the aging patient conflicts with the understanding of how aging has developed. Geriatrics, which focuses on disease, tends to equate aging with disease. Gerontology, on the other hand, looks for developmental changes associated with the aging process. The geriatric tradition tends to overlook the role of the environmental and social factors in the disabilities manifested by the aged. The gerontologic tradition tends to discount the importance of medical intervention in the restoration and maintenance of the impaired older person. A quote attributed to Sir William Osler sums up the problem we face: "It is more important to know the patient who suffers from the disease, than to know the disease from which the patient suffers." Literature Cited 1. Adler M. History of Gerontological Society, Inc. J Gerontol. 1958;13:94-102. 2. Anderson JE, ed. Psychological Aspects of Aging. Washington, DC: American Psychological Association; 1956. 3. Donahue W. Recruiting and Training of Personnel Required by the Organization of Gerontology. First International Course in Gerontology. Paris, France: International Center of Social Gerontology; 1970. 4. Hickey T. Association for Gerontology in Higher Education-a brief history. In: Seltzer MM, Sterns H, Hickey T, eds. Gerontology in Higher Education. Perspectives and Issues. Belmont, Calif: Wadsworth Publishing; 1978. 5. Peterson DA, Bolton RB. Gerontology Instruction in Higher Education. New York, NY: Springer Publishing Co; 1979. 6. Nascher IL. Introduction. In: Thewlis MW. Geriatrics: A Treatise on Senile Conditions, Diseases, Diseases of Advanced Life, and Care of the Aged. St Louis, Mo: CV Mosby Co; 1919. 7. AOA Occasional Papers in Gerontology: Manpower Needs in the Field of Aging: The Nursing Home Industry. Washington, DC: National Clearinghouse on Aging; 1976. US Dept of Health, Education, and Welfare.
751
Gerontology, at present, is not a licensed specialty. Employment opportunities are limited by a degree that prepares the student only for the field of aging. Some institutions, such as the Leonard Davis School of Gerontology at the University of Southern California, offer dual degrees in social work and gerontology, public administration and gerontology, and urban development and gerontology. How did the discipline begin? British scientists in 1939 established the first scholarly organization, the International Club for Research on Aging. In the same year, the American Research Club was organized with the support of the Josiah Macy Foundation. In 1945, this organization was incorporated as the Gerontological Society.' This society remains the major professional scientific organization on aging and maintains a strong interest in the physiological and medical aspects of the field. However, it is now dominated by individuals who are more concerned with programs and policy. Other major organizations include the International Association of Gerontology in Belgium, which was established in 1950, and the Division of Maturity and Old Age, which was established in 1946 as a part of the American Psychological Association,2 as well as regional organizations such as the Western Gerontological Society, which was founded nearly 30 years ago, and the Association for Gerontology in Higher Education, which was incorporated in 1974.3 The Gray Panthers also represent an action-filled aging organization. The emergence of gerontology as a study at the From the Charles R. Drew University of Medicine and Science, Los Angeles, California. Requests for reprints should be addressed to Dr Theodore R. Brooks, 3701 Stocker St, Ste 104, Los Angeles, CA 90008. JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
college level began in 1967 and continues to the present. The first stage of gerontology education actually occurred before 1966 and involved training in research in aging at a few universities. Monies were supplied by the National Institute of Mental Health and the Institute of Child Health and Human Development. In 1966, the US Administration on Aging (a division of the US Department of Health, Education, and Welfare) began giving grants for training in aging. Funds were made available under the Older Americans Act to prepare practitioners for jobs to be created by community programs sponsored by the Act. In 1972, the Administration on Aging reopened competitive career grants. Also in 1972, for the first time, several undergraduate programs were initiated, and instruction at predominantly black or minority colleges was funded. In 1976, Title IV-C of the Older American Act, providing for multidisciplinary centers of aging, was funded. This Title encouraged the planning and implementation of multifaceted programs of research, service, and education to be developed at several universities. In 1978, the National Institute on Aging was formed. Its major purpose is to conduct and support biomedical, social, and behavioral research related to the aging process and diseases, as well as to other problems and needs of the aged. Four early entrants into teaching and research in gerontology were: the University of Chicago, the University of Michigan, Duke University, and the University of Southern California.4 The University of Chicago was one of the first institutions of higher learning to become involved in the early 1950s. Several research projects were started and continue to this date 749
GUEST EDITORIAL
to train faculty and students. The University of Michigan began studies on the needs of older people in 1948. From the above sources, researchers and policy makers emerged. In 1954, Duke University began developing gerontological research. The Center for the Study of Aging and Human Development was established. The Center enjoys a history of high-quality medicopsychological
research.5 The University of Southern California established the Roosmoor-Cortese Institute for the Study of Retirement and Aging in 1964. This center was renamed the Ethel Percy Andrus Gerontological Center in honor of the founder and first president of the American Association of Retired Persons/National Retired Teachers' Association. Today, this center is one of the largest gerontology research, service, and educational centers in the world. The Leonard Davis School of Gerontology, which was founded in 1975, is located in the Andrus Center. The Administration on Aging offered grants in 1966 and 1967 for existing programs in social work, education, and public administration. The Universities of South Florida and North Texas State used their funds to develop masters degree programs in gerontology, which emphasized social science and housing administration, respectively. Other universities, such as Wayne State, Arizona, Brandeis, UCLA, Maryland, Pennsylvania, and Oregon State, to name a few, offer programs in aging. However, hundreds of universities still have few or no courses. The Leonard Davis School of Gerontology at the University of Southern California started offering the first PhD in gerontology in the fall of 1989, with an emphasis on the political aspects of aging.5 Geriatric medicine is the diagnosis, treatment, and prevention of the physical and mental diseases of the elderly. Here again, as in gerontology, a controversy exists as to whom is better qualified to be called geriatricians. The family doctor specialists argue that they have specialty training (3 years of residency training) and that they deal with the immediate family and the extended family more than other specialists. They maintain that subspecialists can be called in to treat specific problems (eg, cardiologists, endocrinologists, and surgeons) as needed. The general internist claims to be more qualified (3 years of residency training) to handle the more common diseases of the elderly. These two specialties agree that at the present time neither would like a new specialty board established. To temporarily solve this issue, the board certified primary care providers from each specialty 750
who met certain requirements, and it allowed them to take a written geriatric board examination. The board will be repeated every 2 years. In the future, only physicians who have completed a 2-year fellowship in a qualified geriatric program may sit for the examination. Those who pass will have the title of "Additional Qualification in Geriatric Medicine." The examination is only given every 2 years. A successful repeat examination every 10 years is required to maintain this title. Because gerontology deals with normal biological aging processes (senescence) and geriatric medicine deals with diseases that can affect this so-called normal process, there is often only a fine line separating these two disciplines. To illustrate this controversy, contrast these statements: Longevity is only desirable if it increases the duration of youth, and not that of old age. The lengthening of the senescent period would be a calamity. -Alex Carrel Some people try to achieve immortality through their offspring or their works. I prefer to achieve immortality by not dying. -Woody Allen Some years before birth, advertise for a couple of parents belonging to long-lived families. -Oliver Wendell Holmes, Sr Death in old men, when not from fever, is caused by the veins which go from the spleen to the valves of the liver, and which thicken so much in the walls that they become closed up and leave no passage for the blood that nourishes it. The incessant current of the blood through the veins thicken and become callous so that at last they close up and prevent the passage of the blood. -Leonardo da Vinci
Few people appear to die of old age. One of the many diseases common in old age generally cuts the last thread of life. Aging and disease in the body often have overlapping manifestations. Unfortunately, the general medical community is resistant to learning and treating diseases of old age. Most of these diseases are chronic and cannot be cured; consequently, immediate selfrewards to the physician are not there. It was just the ignorance of old age on the part of the medical community that inspired Ignaz L. Nascher, a medical student of the 1880s, to spend his life trying to remedy the situation. In 1919, Nascher wrote6: During my student days, an instructor took a number of students to the almshouse to see cases. An old woman hobbled up to the instructor with some trivial comJOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
GUEST EDITORIAL
plaint. He afterwards told us that she was suffering from "old-age." And what could be done for her? "Nothing." Suffering from old age and nothing could be done to relieve her suffering! Is old age, then, a disease from which those who had reached advanced life were doomed to suffer? This incident, as vivid today as it was nearly 38 years ago, laid the foundation for the branch of medicine which I gave the name "Geriatrics."
Nascher postulated that "senility [senility in this context refers to "old age" and not to "senile dementia"] is a physiologic state of maturity." "Diseases in senility are pathologic in a normally degenerating body; not diseases such as occur in maturity complicated by degenerations." "The object of treatment of disease in senility is to restore the diseased organ or tissue to the state of normal in senility; not to the state of normal in maturity."6 In the United States today, there are approximately 28 million men and women over the age of 65, and this number is increasing. The total number of American blacks aged 65 years and older is estimated to be approximately 2.3 million, and the black elderly population will continue to increase throughout the remainder of this century. Rejection of the aged is quite real in modern America. For the physician, the subject of aging is difficult to think about. For the aged, it is difficult to think of the infirmity associated with gradual or sudden loss of independent identity that has taken so much time to acquire. To look forward to depending on the young for care leaves most older people with a bitter taste in their mouths. Finally, the elderly present the physician with a challenge in a way that is not necessarily consistent with traditional medical education and training. A limited curriculum in nursing and medical schools has contributed to the low number of physicians prepared to treat the elderly in their offices and in nursing homes.7 In fact, only about 27.6% of American physicians visit nursing homes to care for patients, and these physicians are cardiologists, general practitioners, and internists, in
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 84, NO. 9
that order. This low number of physicians attending nursing home patients is not fully understood but it may be the low reimbursement for time spent, ageism, excessive "paper work," or that the individuality of the aging patient conflicts with the understanding of how aging has developed. Geriatrics, which focuses on disease, tends to equate aging with disease. Gerontology, on the other hand, looks for developmental changes associated with the aging process. The geriatric tradition tends to overlook the role of the environmental and social factors in the disabilities manifested by the aged. The gerontologic tradition tends to discount the importance of medical intervention in the restoration and maintenance of the impaired older person. A quote attributed to Sir William Osler sums up the problem we face: "It is more important to know the patient who suffers from the disease, than to know the disease from which the patient suffers." Literature Cited 1. Adler M. History of Gerontological Society, Inc. J Gerontol. 1958;13:94-102. 2. Anderson JE, ed. Psychological Aspects of Aging. Washington, DC: American Psychological Association; 1956. 3. Donahue W. Recruiting and Training of Personnel Required by the Organization of Gerontology. First International Course in Gerontology. Paris, France: International Center of Social Gerontology; 1970. 4. Hickey T. Association for Gerontology in Higher Education-a brief history. In: Seltzer MM, Sterns H, Hickey T, eds. Gerontology in Higher Education. Perspectives and Issues. Belmont, Calif: Wadsworth Publishing; 1978. 5. Peterson DA, Bolton RB. Gerontology Instruction in Higher Education. New York, NY: Springer Publishing Co; 1979. 6. Nascher IL. Introduction. In: Thewlis MW. Geriatrics: A Treatise on Senile Conditions, Diseases, Diseases of Advanced Life, and Care of the Aged. St Louis, Mo: CV Mosby Co; 1919. 7. AOA Occasional Papers in Gerontology: Manpower Needs in the Field of Aging: The Nursing Home Industry. Washington, DC: National Clearinghouse on Aging; 1976. US Dept of Health, Education, and Welfare.
751
