No geriatric fellow needs a lecture on the challenge presented by the onrushing wave of aging baby boomers. Your first session in geriatric clinic, your first patient on the ACE unit, or your first home care visit no doubt left a sobering, indelible impression in this regard. No doubt there will be some response - in one form or another -- from the health care system, the government, or American society when the wave crashes with full force about 20 years from now.
Our challenge -- your challenge -- will be to deal with that response with skill and poise as a geriatrician prepared by your fellowship training and your experience in managing the most complex, frail, and vulnerable older patients across the continuum of care. But what, exactly, will your contribution be? How should your training be tailored to optimize that contribution? Here, I emphasize the critical need to leverage your efforts to maximize their impact on optimizing care for older Americans. For there is simply no way --- even if it were possible or, for that matter, desirable --- for fellowship-trained geriatricians to contribute more than a small fraction of the total effort that will be required.
For one thing, there will simply not be enough of us. Accordingly to the ADGAP Longitudinal Study of Training and Practice in Geriatric Medicine, ever since certification via the practice pathway ended in 1994, the number of CAQ-certified geriatricians has progressively declined. Only about half of those initially certified have been re-certified 10 years later. And the number of newly-certified geriatric fellow graduates has settled at approximately 300 per year. Even after making our discipline more welcoming to graduating internal medicine and family residents by reducing the duration of fellowship to the 1-year minimum, fully a third of fellowship positions remain vacant. Over half of those filled are occupied by international medical graduates whose long-term contributions to geriatric health care in the US are uncertain. Hence, short of a major turnaround in fellow recruitment and retention of trained geriatricians in the field, the number of certified US geriatricians will never come near the figure of 30,000 often quoted as the optimal target in the steady state.
I have consistently maintained that geriatric healthcare should, and must, be an all-hands effort (Fig. 1) wherein the care of the elderly becomes a central priority in all health and social care disciplines. This effort should be led by geriatricians, perhaps, but deeply involve all medical, surgical, neurological, psychiatric, and physiatric disciplines as well as nurses, social workers, etc. For geriatrics represents the ultimate "supraspecialty," and involving the rest of our health care "system" in meeting the health and social care needs of the elderly is our core mission. Hence we must concentrate our effort on generating that all-hands approach in every way possible: as vigorous leaders and advocates, educators, researchers, and practitioners in model programs that inform and advance that care. Quite a challenge. Quite an agenda!
At the level of your fellowship, therefore, I would urge a focus on your future as a leader, a skilled and charismatic teacher and Pied Piper for medical students, residents, and succeeding cohorts of fellows. I would urge you to dedicate your efforts not only to geriatrics per se but also to fostering education and research in the geriatric aspects of all specialties and subspecialties. I would also encourage you to invest your energies in helping advance the geriatrics scientific knowledge and practice base as a trained and productive researcher.
To prepare to meet this daunting challenge, I would urge you to pursue advanced training as a 2nd and 3rd year fellow and beyond and in an academic career wherein you can best leverage your talents and efforts (there's that word again!). This is surely an ambitious agenda and not for the indolent or the ambivalent. However, this is actually the most conservative approach to making the most of your opportunity to make a difference while enjoying what is sure to prove a long and supremely fulfilling career. Because anyone who helps to advance the field of geriatrics in the era of the advancing age wave is sure to make an important and lasting difference. What more could we ask of the opportunity that lies before us?
Yes, it's time to stop playing wave tag with the aging tsunami and assume our critical roles in helping to lead our nation and the world in successfully meeting this unprecedented, defining challenge of the 21st century.
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