The increasing age of the U.S. population has been well documented, and people 65 and older now account for 39.1% of all hospital discharges, up from @20% in 1970, according to figures released in June by the National Center for Health Statistics (NCHS). Physicians who specialize in geriatrics are well aware that frail elders often become ill or fail to improve when doctors do not consider important principles of geriatric medicine. Geriatricians, however, are few in number. According to the National Graduate Medical Education (GME) census (reported in the Journal of the American MedicalAssociation, Sept. 4,2002), fewer than 4% of internal medicine trainees choosing a subspecialty fellowship in 2001 selected geriatric medicine.
Geriatrics remains an unpopular specialty, perhaps, because it lacks glamour or because it pays less than specialties that are procedure-driven. For example, cardiology drew more than 28% of internists seeking subspecialty training, according to the GME census. Training more geriatricians is only part of the solution, though. NCHS numbers show that of all physician visits by people age 65 or older, 45% are to primary care physicians and 55% are to specialists. Research has established that most older Americans will receive primary care from nongeriatricians for the foreseeable future.
A MANDATORY ROTATION
The amount of geriatrics education at U.S. medical schools is highly variable, show statistics for 2001 from the American Association of Medical Colleges. One program with a substantial track record is the four-week clinical rotation in geriatric medicine at New York Medical College (NYMC). It involves approximately 80% of the fourth-year class of about 200 future doctors. This rotation is mandatory for all but students who elect to take chronic pediatrics. About 50 of these NYMC students per year come to our hospital for this program, which consists of direct patient contact in many settings, as well as a series of lectures and seminars. The goal of the experience is to sensitize students to geriatric issues and instill principles they will use regardless of their specialty.
Nothing has a greater effect on the health of older adults than the complications or misuse of medications, an important cause of chronic conditions in late life. Research published in the early 1990s found that one in six hospitalized elders was admitted due to an adverse drug reaction. An additional one of nine admissions occurred because of patient failure to adhere to a prescribed drug.regimen, either because of the large number or high cost of the medications. Adverse drug reactions are very common in elderly patients for many reasons. A disturbing-though not surprising-possibility revealed in previous research is that physician lack of knowledge about the principles of aging is an important factor. How many problems could be avoided by greater skill in geriatric prescribing?
Pharmacology, or "pharm" rounds, provide us an opportunity to pique the interest of future doctors who will not specialize in geriatrics. The program aims to help them see geriatrics through the eyes of the specialist they will become. Each student is assigned a St. Vincent's Hospital patient taking risky medications. The student evaluates the patient and presents the evaluation for discussion. During the presentation, we encourage the student to shift gears and visualize the patient in the context of the student's planned specialty. Following are some examples of how we try to challenge students by having them consider the consequences of decisions that affect elder patients:
* "Leanne, you are going to train in emergency medicine. A go-year-old patient with Alzheimer's disease was brought in by ambulance because of a fainting spell. She is now alert but you are called because she is agitated. Why is your decision to administer lorazepam (Ativan), a highly effective sedative, a grievous error?" …