Training in Geriatric Psychiatry Benjamin Uptzin, M.D. Robert H. Friedman, M.D. Dan G. Blazer, M.D., Ph.D. The objective of this study was to determine the extent and the barriers to expansion of geriatric psychiatry training in psychiatry training programs in theUnited States. We mailed aquestionnaire to the training directors ofall 216 psychiatry residency programs listed withtheAccreditation Council for Graduate Medical Education. We received and analyzed 127 responses. Seventy-nine percent ofthe respondents reported having at least one geriatric specialist on their faculty, and almost halfof allreported psychiatry residents take ageriatric rotation. Rates in other medical specialties range from 71 % of internalmedicine departments to 13% ofgeneral surgery departments withanyfaculty geriatric specialists and from 62% infamily practice residents to3% of neurology residents who take ageriatric rotation. Reported factors inhibiting the introduction of geriatrics intopsychiatry residency programs include limited time, insufficient numbers of trained faculty, andinsufficient funds. More direct funding supporting the research of geriatric faculty may be needed to stimulate the development ofgeriatric training.

t is well known that the American population is aging. This trend will continue over the next 30 years so that the elderly (persons over age 65) will account for almost 20% of the population in the year 2020 compared with their present 12% (1). Among the elderly, the number of the oldest of the elderly, or "old-old," is increasing most rapidly. The elderly are the greatest users of health care services, although they tend to underutilize specialized mental health services (2). These demographic data have led to questions about whether practicing physicians have the requisite knowledge, skills, and attitudes to care for the elderly. This concern over qualifications has led to calls for increased training of specialists in geriatric medicine (3) and increases in the number of medical faculty specializing in geriatrics (4). Within the specialty of psychiatry, there has also been growing interest in geriatric psychiatry training for residents and fellows

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(5-9). The National Institute of Mental Health (NIMH) has stimulated the development of fellowship programs through training grants to departments of psychiatry.These programs included specific training grants for geriatric psychiatry fellowship programs from 1979-89 when the grant initiativewas terminated.Interest in fellowship training has also been stimulated byapproval of the American Board of Psychiatry and Neurology for a "Certificate of Added Qualifications in Geriatric Psychiatry" with the Dr. uptzin is chairman, Departmentof Psychiatry, Baystate Medical Center, Springfield, MA, and pr0fessor and deputy chair, Tufts University School of Medicine; Dr. Friedman is chief, Medical Information Systems Unit, Boston UniversitySchoolofMedidne;Dr. Blazer is J. P. Gibbons professor of psychiatry and interim chairman, Department of Psychiatry, Duke University School of Medicine. Address correspondence to Dr. Uptzin. Chairman. Department of Psychiatry, Baystate Medical Center, Springfield, MA 01199. Copyright C 1991 Aaulemic Psychilztry.

first examination given in April 1991 (10). In 1990, the Department of Veterans Affairs (DVA) began to fund a small number of geriatric psychiatry fellowships. Although interest in geriatric training for general psychiatry residents and specialized geriatric psychiatry fellowships has been growing, the funding for such programs hasbeen limited. To address the funding problem and encourage the expansion of geriatric programs, the U.S. Congress requested a study of graduate medical education activities necessary to meet the projected health care needs of Medicare beneficiaries. (The study was done by the Boston University School of Medicine under contract to the Bureau of Health Professions, Health Resources and Services Administration, U.S. Public Health Service; the final report is available from the Public Health Service.) Questionnaires were sent to training directors in 10 medical specialties (family practice, general surgery, internal medicine, neurology, obstetrics and gynecology, orthopedic surgery, otolaryngology, physical medicine and rehabilitation, psychiatry, and urology). The questionnaires included cover letters from distinguished collaborators in the recipients' medical specialties that encouraged their participation in the study. In this article, we report the findings relevant to graduate medical education training programs in psychiatry. METHODS

A questionnaire containing items about the content of residency training in geriatric psychiatry was mailed in April 1989 to the directors of all psychiatric residency training programs listed in 1988 by the Accreditation Council for Graduate Medical Education (ACGME). The questionnaire contained 28 multiple-part questions regarding the faculty, geriatric psychiatry rotations, types of settings and patients, curriculum, and the program directors' views on the importance of geriatric psychiatry and future plans. As

part of the larger study of geriatric education, similar questionnaires were mailed to training directors in the nine other medical specialties mentioned above. Nonrespondents were followed up after the first mailing with a letter and a phone call. Data from the psychiatry residency survey were analyzed and compared with the results for other medical specialties.

RESULTS The response rate from the questionnaire was 127 (59%) of the 216 psychiatry programs polled. The programs that responded had an average of 27.5 residents; therefore, the total resident sample covered was over 3,500. Of the 127 respondents, 100 (79%) reported having at least one geriatric specialist on their faculty. This was a higher proportion than in any other medical specialty (see Table 1). Of the programs with any geriatric specialists, there was an average of 2.5 geriatric psychiatrist faculty members, which accounted for approximately 8% of all psychiatrist faculty. Of these 100 programs, 55% reported that their geropsychiatrist faculty had been in a formal geriatric psychiatry training program for at least 6 months. Fiftyeight (46%)of the responding psychiatry departments had a geriatric psychiatry section or division in contrast to 48 (59%) of the internal medicine and 22 (23%) of the family practice departments responding. Unlike other medical specialties, a relatively low proportion of psychiatry residents' patients are elderly: 19% on inpatient services and 13% in ambulatory services. These proportions ranged in other specialties from 14% inpatient and ambulatory in obstetrics and gynecology to 54% inpatient and 47% ambulatory in urology. Forty-five (36%) of the psychiatry departments had a required rotation in geriatric psychiatry and another 27 (21%) had elective rotations. Overall, 48% of psychiatry residents took a geriatric rotation with an average duration of almost 15 weeks. These

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TABLE 1. Number and proportion of training programs by medic:alspecialty with geriatric:specialist faculty

Specialty

Psychiatry Intemal medicine Family prae:tic:e

Ob/Gyn Urology Neurology Orthopedics Physical medicine Otolaryngology General surgery

Programs With Geriatric: Spedaliab I NUIIlbu of Programs Reporting (~)

Averase Number of Geriatric SpedaIist Fac:ulty in ParticipatiDg Programs

100/127 (79) 111/156 (71) er /136 (64)

33

2.5 1.8

50/106 (47)

2.1 23

48/113 (43)

35/86

(41)

3.7 3.8 2.7 3.0

43/133 (32)

14/46

(30)

22/90 (24) 16/119 (13)

proportions are somewhat lower than in family practice but higher than in internal medicine, neurology, or physical medicine (see Table 2). Eighty-eight percent of psychiatry training programs used.special training settings such as geriatric inpatient or outpatient services, rehabilitation units/hospitals, or long-term care facilities in their required or elective geriatric rotations. Thirty-seven (29%) psychiatry departments reported having a geriatric fellowship program, a figure comparable to the 33 (40%) in internal medicine and the 37 (25%) in neurology, but higher than the 14 (15%) in family practice. Ninety-four percent of psychiatry departments provide formal training in mental statusassessment of the elderlyand reported that their residents are knowledgeable in this skill. In contrast, only 65% of internal medicine programs reported that their residents are knowledgeable about mental status assessment. Sixty-nine percent of psychiatry departments reported that they evaluate their residents' knowledge and skills in the care of the elderly, and 96%of psychiatry departments reported that their residents are knowledgeable about medication use in the elderly. Neurology departments had the highest average number of faculty with research interests in problems of the elderly (3.1 compared with 1.9 in psychiatry), but psychiatry

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TABLE 2. Proportion of residents who take a geriatric: rotation and average duration of rotation by specialty

Specialty

Percentage of Residents Who Take Geriatric: Rotation

Familypractice

62

Psychiatry Internal medicine Physical medicine Neurology

48

26 17 3

Average Duration of Rotation. Weeks

5.7 14.8 43 9.7 5.0

departments had the highest proportion with some faculty members (61 %) who had published an article on problems of the elderly. In contrast, only 53% of internal medicine, 40% of neurology, and 32% of family practice departments had any faculty who had published in geriatrics. Sixty-eight (54%) psychiatry departments reported having clinical research projects that involve elderly patients and, on average, 1.5 residents participate in these projects each year. Overall, 74% of psychiatry training directors indicated that there is a need. for additional training in geriatrics for their trainees and 63% thought this training should include fellowships. Seventy percent reported that their own interest in geriatrics had grown over the previous 5 years. With respect to factors inhibiting the introduction

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of geriatrics into psychiatry residency programs, 82% of the program directors indicated that limited time was a problem, 82% cited insufficient numbers of trained faculty, and 78% cited insufficient funds. Only 3% reported that there was no need to teach geriatric psychiatry, 21% reported an insufficient.knowledge base, and 23% said they were not interested. DISCUSSION Departments of psychiatry have done a relatively good job of developing geriatric training activities relative to other medical specialties. This is especially impressive given that the elderly represent a smaller proportion of the patient population seen by psychiatry residents than by other residents. Over three-quarters of the responding psychiatry programs have faculty with specific geriatric expertise and almost half have a section or division of geriatric PSychiatry. A surprisingly high proportion (55%) of geriatric psychiatrist faculty had at least 6 months of formal training in the specialty, perhaps as a result of the decade of NIMH funding for fellowships in geriatric psychiatry. Required or elective rotations in geriatric psychiatry were reported to reach almost half of all psychiatry residents. This figure is impressive (especially compared with other medical specialties). However, with a reported rotation average duration of almost 15 weeks, it is likely that most of these rotations are part-time, perhaps as little as one morning or one afternoon per week. Given the probable part-time nature of the psychiatric rotations, it is likely that residents in other specialties are receiving more intensive geriatric training. A high proportion (88%) of residents who take rotations do so in specialized geriatric settings. However, given the growing numbers of elderly, training directors and the public should be concerned about the half who do not participate in a specialized rotation, particularly because a relatively low proportion of their

inpatients and outpatients are geriatric. It is also doubtful that the specialized knowledge, skills, and attitudes relevant to geriatric psychiatry can be taught as well by general faculty as they could by geriatric specialists. The development by the American Board of Psychiatry and Neurology of an examination for added qualifications in geriatric psychiatry suggests that there should be a recognition that there is a specialized body of knowledge and skills in the field. Although Lipowski (11) has suggested that consultation-liaison psychiatry is geriatric psychiatry, that opinion is not universally accepted. Furthermore, certain aspects of geriatric psychiatry may be more appropriately taught in a community mental health context that includes work with other community agencies and assessments of patients in their own homes or in nursing homes (12). Nursing homes in particular have been receiving increasing attention as sites for psychiatric intervention given the high prevalence of psychiatric disorders in nursing home residents (13). Residency training programs should involve residents with patients in nursing homes. It is unclear whether funding changes in Medicare have had or could have much impact on the development of geriatric psychiatry training programs. The money collected by hospitals under Medicare graduate medical education provisions usually does not flow back to departments of psychiatry but, rather, is used for general educational purposes. As geriatric psychiatry fellowship programs becomeaccredited, hospitals with such programs should be able to collect Medicare education funds (14). The impact of this funding mechanism is certainly less direct and measurable than that which resulted from the previous NIMH fellowship training grants or the current OVA-funded fellowship programs. Resources to support geriatric specialists on the faculty who can act as role models, teachers, and investigators may come from NIMH, OVA, the National Institute on Aging's Geriatric Aca-

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