National survey of geriatric medicine fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs Geriatrics Workforce Policy Studies Center

This article documents the development of geriatric medicine fellowship training in the United States through 2009. Results from a national cross-sectional survey of all geriatric medicine fellowship training programs conducted in 2007 is compared with results from a similar survey in 2002. Secondary data sources were used to supplement the survey results. The 2007 survey response rate was 71%. Sixty-seven percent of responding programs directors have completed formal geriatric medicine fellowship training and are board certified in geriatrics, and 29% are board certified through the practice pathway. The number of Accreditation Council for Graduate Medical Education-accredited fellowship programs has slowly increased, from 120 (23 family medicine (FM) and 97 internal medicine (IM)) in 2001/02 to 145 in 2008/09 (40 FM and 105 IM), resulting in a 21% increase in fellowship programs and a 13% increase in the number of first-year fellows (259 to 293). In 2008/09, the growth in programs and first-year slots, combined with the weak demand for geriatrics training, resulted in more than one-third of first-year fellow positions being unfilled. The number of advanced fellows decreased slightly from 72 in 2001/00 to 65 in 2006/07. In 2006/07, 55% of the advanced fellows were enrolled at four training programs. In 2008/09, 66% of fellows were international medical school graduates. The small numbers of graduating geriatric medicine fellows are insufficient to care for the expanding population of older frail patients, train other disciples in the care of complex older adults, conduct research in aging, and be leaders in the field.     

Teaching Geriatric Fellows How to Teach: A Needs Assessment Targeting Geriatrics Fellowship Program Directors

The entire healthcare workforce needs to be educated to better care for older adults. The purpose of this study was to determine whether fellows are being trained to teach, to assess the attitudes of fellowship directors toward training fellows to be teachers, and to understand how to facilitate this type of training for fellows. A nine‐question survey adapted from a 2001 survey issued to residency program directors inquiring about residents‐as‐teachers curricula was developed and administered. The survey was issued electronically and sent out three times over a 6‐week period. Of 144 ACGME‐accredited geriatric fellowship directors from geriatric, internal medicine, and family medicine departments who were e‐mailed the survey, 101 (70%) responded; 75% had an academic affiliation, 15% had a community affiliation, and 10% did not report. Academic and community programs required their fellows to teach, but just 55% of academic and 29% of community programs offered teaching skills instruction as part of their fellowship curriculum; 67% of academic programs and 79% of community programs felt that their fellows would benefit from more teaching skill instruction. Program directors listed fellow (39%) and faculty (46%) time constraints as obstacles to creation and implementation of a teaching curriculum. The majority of fellowship directors believe that it is important for geriatric fellows to become competent educators, but only approximately half of programs currently provide formal instruction in teaching skills. A reproducible, accessible curriculum on teaching to teach that includes a rigorous evaluation component should be created for geriatrics fellowship programs.     

The development of academic geriatric medicine: progress toward preparing the nation's physicians to care for an aging population

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full-time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy-one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.     

Geriatric medicine and geriatric psychiatry clinical services affiliated with U.S. academic medical centers

U.S. academic medical centers are providing many geriatric medicine (GM) and geriatric psychiatry (GP) clinical services at Veterans Health Administration (VHA) and non-VHA sites. This article describes the distribution and scope of GM and GP clinical services being provided. Academic GM leaders of the 146 U.S. allopathic and osteopathic medical schools were surveyed online in the spring of 2004. One hundred four program directors (71.2%) responded. These medical schools provided 1,325 GM and 376 GP clinical services, which included 654 VHA and 1,014 non-VHA GM and GP services, affiliation with 21 Programs of All-Inclusive Care for the Elderly, and 12 other specialized services. The mean number+/-standard deviation of distinct clinical services at each medical center was 16.4+/-8.2. More geriatrics faculty full-time equivalents, more time spent on training fellows, and designation as a GM Center of Excellence were associated with providing a wider range of geriatric clinical services. Using data from the survey, the first directory of GM and GP clinical services at academic medical centers was created (http://www.ADGAPSTUDY.uc.edu).     

The development of academic geriatric medicine in the United States 2005 to 2010: an essential resource for improving the medical care of older adults

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full‐time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.     

Strengthening the fellowship training experience: findings from a national survey of fellowship trained geriatricians 1990-1998

Geriatric fellowship training has significantly advanced in the past 2 decades in number, organization, and accreditation of formal fellowship programs. A recent survey examined career decision-making, fellowship training, and current professional activities of fellowship trained geriatricians. This paper focuses upon further desired fellowship training identified by these individuals. The responses reflect skills relevant to four aspects of professional performance: administration, management, clinical geriatrics, research, and education. More than half of the respondents documented the need for increased training in administration, including long-term care medical directorship and Medicare/managed care. Regarding clinical training, 66% recommended additional subspecialty training, particularly in psychiatry, neurology, rehabilitation, and hospice/palliative care. Seventeen percent identified a need for training in research methodology, grant writing, and mentorship. Some 6% indicated a need for further training in education, citing teaching skills and program/faculty development. This article provides examples of opportunities to strengthen each of the four defined areas, including formal training in medical administration by the American Medical Director's Association, model strategies for incorporating subspecialties, hospice/palliative care, programs to pursue graduate level training in research at many universities, and faculty development programs such as those offered by Harvard and Stanford. Accredited geriatric fellowship programs as well as fellows should recognize potential gaps in training, and make available opportunities to strengthen these areas critical to preparing for future careers in geriatric medicine.     

Creating a geriatric medicine fellowship program in 10 "easy" steps

The aging of the U.S. population poses one of the greatest future challenges for family medicine and internal medicine residency training. One important barrier to providing quality education and training in geriatric medicine to residents is a serious and growing shortage of practicing geriatricians and geriatrics faculty. The Accreditation Council for Graduate Medical Education currently accredits 45 family medicine-based and 107 internal medicine-based geriatric medicine fellowships in the United States. There are 13 American Osteopathic Association-certified geriatric medicine fellowship programs. In this article, the authors examine the rationale for the development of additional geriatric medicine fellowship programs and offer some practical suggestions and pointers for those interested in developing their own geriatric medicine fellowships. The authors write from the perspective of their own recent experiences with the development and accreditation of a family medicine residency-affiliated fellowship in geriatrics. Other residencies may find this article useful in determining the feasibility of developing a geriatric medicine fellowship for their programs and communities and will find practical guidance for beginning the process.     

Geriatric medicine in the United States. The current activities of former trainees

To improve the health care received by frail older persons, an effort has been made in the United States to increase the number of physicians trained in geriatric medicine and geropsychiatry. The goal of training has been to create leaders in education, research, and patient care. To assess the progress of this effort, we surveyed physicians (284 in geriatric medicine and 91 in geropsychiatry) who graduated from U.S. geriatrics fellowship programs. Responses were obtained from 224 medicine (79% response) and 59 psychiatry fellows (65% response). Sixty-five percent of former geriatric medicine fellows report spending 10% or less time on teaching; 44% report doing no research, and 44% report spending more than half their time in patient care. Compared to other primary care specialties, the geriatricians reported caring for larger proportions of older patients and spending more time per patient visit. However, their role in teaching, research, and long-term care is minimal.     

Assessing the Accessibility of Content for Geriatric Fellowship Programs

The information available on program websites concerning geriatric fellowships in internal medicine and family medicine is a crucial factor in generating applicants' interest in individual programs. Our study aimed to quantify the accessibility and quality of information available on accredited geriatric (family medicine and internal medicine) fellowship program websites and further analyze the implications of the results obtained. A list of geriatric (family medicine and internal medicine) fellowship programs was analyzed through quantified measures after being verified for accreditation. Certain criteria were evaluated for each of these programs, such as website accessibility and whether critical information was available on online program websites. These criteria were centered on academic, administrative, and application-based factors. Hundred and fifty eight Family Medicine and Internal Medicine geriatric fellowship programs were identified in total, of which only 150 were accredited by the Accreditation Council for Graduate Medical Education and considered for analysis. Of these, 20 (13.33%) programs had website links that were nonfunctional and only 145 programs had websites at all. On programs' websites, information regarding aspects such as contact information—including phone number or email for the program—were lacking. Other information regarding past and current fellows, research, and curriculum were also generally lacking. Geriatric Fellowship websites in Family Medicine and Internal Medicine can gain better traction from those interested in applying for their programs by updating information more often and providing more and better information concerning critical aspects of the programs themselves online.     

Academic career development in geriatric fellowship training

Career development is rarely formalized in the curricula of geriatric fellowship programs, and the training of new generations of academic leaders is challenging in the 1 year of fellowship training. To effectively prepare fellows for academic leadership, the University of Rochester's Division of Geriatrics, in collaboration with the Warner School of Graduate Education, created a yearlong course to achieve excellence in teaching and career development during the 1-year geriatric fellowship. Nine interdisciplinary geriatric medicine, dentistry, and psychiatry fellows completed the course in its initial year (2005/06). As participants, fellows gained the knowledge and experience to successfully develop and implement educational initiatives in various formats. Fellows acquired teaching and leadership skills necessary to succeed as clinician–educators in an academic setting and to communicate effectively with patients, families, and colleagues. Fellows completed a series of individual and group education projects, including academic portfolio development, curriculum vitae revision, abstract submission and poster presentation at national meetings, lay lecture series development, and geriatric grand rounds presentation. One hundred percent of fellows reported that the course positively affected their career development, with six of nine fellows choosing academic careers. The course provided opportunities to teach and assess all six of the Accreditation Council of Graduate Medical Education core competencies. This academic career development course was intended to prepare geriatric fellows as the next generation of academic leaders as clinician–teacher–scholars. It could set a new standard for academic development during fellowship training and provide a model for national dissemination in other geriatric and subspecialty fellowship programs.     

The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990 to 1998

The rapid growth of the older population has focused national attention on the need for physicians trained in geriatric medicine. To gain insight into the evolving status of the field, with particular focus on career decision-making and academic career development of trainees, we conducted a survey of physicians recently completing geriatric fellowships. The 107 accredited extant geriatric fellowship programs in the United States and Puerto Rico were contacted to identify trainees from 1990 to 1998. A mailed survey addressed relevant career development and training issues. Four hundred ninety out of 787 (62%) physicians responded; 20% completed 1 year and 80% 2 or more years of training. Half made the decision to pursue a career in geriatrics during residency, 27% decided before/during medical school, and a mentor influenced 48%. Currently, 80% have a Certificate of Added Qualifications in geriatric medicine, 69% hold academic appointments, 78% teach, 39% participate in research, and 44% author publications. Most are doing predominantly clinical work in multiple settings. Further analysis of the 1996-to-1998 cohort revealed that those completing fellowships of 2 or more years are more likely to identify all geriatrics as their professional focus, conduct and author research, work with multidisciplinary teams, and participate in professional geriatric societies. This national survey documents career decision-making and the academic and clinical profiles of physicians completing geriatric fellowship training in the past decade. Longer fellowship training is associated with academic career development. Although there is a national need to train clinical geriatricians, the additional need to train and fund future geriatric academic leaders requires increased attention.     

National Study of Internal Medicine Manpower: X. Internal medicine residency and fellowship training: 1985 update

The number of medical school graduates entering internal medicine residency training was at an all-time high in 1984-85. Although the number of first-year residents who were foreign-trained physicians did not differ greatly from the 1983-84 census, the number of first-year residents who were U.S. medical school graduates was much higher than the previous year largely because the number of graduates from U.S. medical schools increased substantially in 1984. The number of internal medicine fellowship programs and the number of fellows in 1984-85 were also at an all-time high. Foreign-trained physicians represent 22% of those in residency training and 20% of those in fellowship training. Of every 100 who completed residency training, 61 went on to a first year of subspecialty fellowship training, a number up slightly from the previous year. The increasing numbers of residents and fellows being trained in internal medicine, combined with the preference for subspecialization and the substantial proportion of foreign-trained physicians being trained, are discussed against the background of pending legislation to reduce federal assistance for graduate medical education.     

The Training of Geriatricians in the United States: Three Decades of Progress

During the past 3 decades, significant progress has been made in preparing U.S. physicians to care for the growing elderly population. This paper reviews progress in training and certifying internists and family physicians in geriatric medicine. The establishment of the National Institute on Aging, a series of Institute of Medicine reports, Veterans Health Administration initiatives, and leadership and investment by the public sector and private foundations have supported the development of geriatric medicine training programs. In 1988, the Accreditation Council for Graduate Medical Education initially accredited 62 internal medicine (IM) and 16 family practice (FP) geriatric medicine fellowship programs. By academic year 2001–2002, 120 geriatric medicine fellowships were training 338 fellows. A recent survey of U.S. medical schools found a total of 869 full-time equivalent (FTE) geriatrics faculty members. Their geriatrics programs had a median of 5.0 FTE physician faculty members, with a range of 0 to 42. Recent surveys of IM and FP residency programs found 803 geriatrician faculty members teaching in IM residency programs (53% response rate) and 453 teaching in FP residency programs (75% response rate). From 1988 through 2002, 10,207 Certificates of Added Qualifications in Geriatrics were awarded. The distribution of these practicing geriatricians varied considerably by state, with the national average being 5.5 per 10,000 persons aged 75 and older. Individual state rates ranged from 2.2 to 15.9. Although geriatric medicine training has grown remarkably over the past 3 decades, this growth is still not producing the number of geriatricians needed to care for the growing elderly population. Thus, expanded investment in the training of geriatricians as faculty and practitioners is needed.     

Geriatric medicine curriculum consultations for family practice residency programs: american academy of family physicians residency assistance program/hartford geriatrics initiative

Increasing the quality and quantity of geriatric medicine training for family practice residents is a particular challenge for community-based programs. These programs have an average of only seven full-time equivalent physician faculty. This report summarizes results of the Residency Assistance Program/Hartford Geriatric Initiative (RAP/HGI) geriatric medicine curriculum consultations for family practice (FP) residency programs conducted from 1996 to 2001. This project was developed as part of the RAP in family practice. Ten experienced FP educators were selected and trained as special consultants. Between 1996 and 2001, 39 FP residency programs participated in the 1- to 4-day RAP/HGI consultations. The programs were diverse in size and location. The consultations reached 308 family practice residency faculty members involved in training 807 residents. Program evaluations of the consultants were uniformly in the very good to excellent range, with a mean rating of 4.6 (5-point scale, with 5 indicating excellent). At the end of the initial consultation visit, the residency program faculty and the consultant developed short-term goals for geriatrics program development. Eighty-five percent (33/39) of the programs submitted their curriculum goals in writing. The mean number of goals per program was 4.8 (range = 3-11). Of the 33 programs with written goals, follow-up was documented for 29 programs. Seventy-nine percent of the programs' self-defined educational goals were met during the 6 to 12 months of follow-up (range 50-100%). Ten of the programs implemented all of their educational goals. The RAP/HGI project demonstrated that achievable geriatric medicine curriculum improvements could occur as part of an onsite consultation process.     

Strength in Numbers: A National Monthly Case Conference Series for Fellows

Small fellowship programs face challenges in providing learners with sufficiently diverse experiences and patient populations. The Fellows Most Difficult Case Conference is designed to broaden geriatric medicine fellows' exposure to cases and to faculty and fellows from around the country through a monthly telephone conference. We describe this innovative approach to a national monthly complex case conference that fellows from almost one‐third of geriatrics fellowship programs attend, including its value to geriatric fellows and faculty and administrative costs. Once per month, a fellow presents a case, a moderator leads the discussion, and 2 faculty members provide teaching points during the 60‐minute session. Participants rated the conference's value using an 11‐item on‐line survey followed by a debriefing held during a regularly scheduled 2017 monthly conference. Thirty‐six percent of eligible participants responded to the survey (67/186), with 75% of respondents reporting that they applied knowledge gained from the conferences to their patient care at least 1 or 2 times per month and 41% that they applied it at least once per week. Participants appreciated the inclusion of multiple programs, the duration of the conference, and the interactive approach. Our administration time was less than 5 hours per month, plus a few additional hours annually to create the academic year schedule. We believe that this national case conference, the first of its kind in the country, involving almost one‐third of geriatrics fellowship programs, is an innovative and valuable way for fellows to explore complex cases and variations in regional perspectives and to connect with additional colleagues.     

An Assessment of Oral Health Training Among Geriatric Fellowship Programs: A National Survey

Oral health (OH) has profound effects on the overall health of elderly people. While oral disease is prevalent in the geriatric population and access to care is a major issue, it is unclear the extent of OH training among US geriatric fellowship programs. A 19‐item electronic survey was sent to all 148 accredited geriatric fellowship training programs via the Association of Directors of Geriatric Medicine. Directors were asked about hours of trainings, barriers, and evaluation of trainees among other topics. Univariate and bivariate analyses were performed. Seventy‐five directors completed the survey (51% response rate). Sixty‐three percent (46/73) report their fellows receive 1 to 2 hours of OH instruction (ie, lectures, workshops) during their training. Almost a quarter (23%; 17/73) reported 0 hours of OH content. Only 17% (13/75) have clinical experiences in a dental setting. Barriers to more OH education include competing priorities or lack of time (57%; 43/75), lack of faculty expertise (55%; 41/75), and no clear geriatric national educational competencies (44%; 33/75). Programs with an OH champion or dental school/residency affiliation had more hours of OH instruction. Geriatric fellowships appear to need more OH training, which could be achieved by creating OH champions and connecting fellowships with dental schools/residencies. Barriers could be overcome by exposing fellowships to existing resources and creating national competencies. J Am Geriatr Soc 67:1079–1084, 2019.     

National study of internal medicine manpower: IV. Residency and fellowship training 1977-1978 and 1978-1979.

The National Study of Internal Medicine Manpower gathered data on the number of residents in training in internal medicine and the number of fellows in subspecialty training, for 1977-1978 and for 1978-1979. In the latter period, there were 16720 residents in all years of training. The 7.2% average annual increase in the number of first-year residents during the earlier half of the 1970s slowed in 1977-1978 and 1978-1979 to 4.6% and 4.2%, respectively, reflecting a similar decline in the number of medical school graduates. The most important finding of the study is that the steep rise (10.6% per year) in the number of subspecialty fellowship trainees characteristic of the years 1972-1973 through 1976-1977 has abated. The number of fellows in subspecialty training has remained essentially constant in the past 2 years. Thus, although the number of residents continued to increase and the number of fellows remained constant, the number (and percentage) of internists in training who intend to practice general internal medicine rose.     

National study of internal medicine manpower: III. Subspecialty fellowship training 1976-1977.

Questionnaire II of the National Study of Internal Medicine Manpower was directed to all of the 1502 subspecialty training programs in the United States and Puerto Rico. The overall response rate was 86%. For the years 1972-1973 through 1976-1977 the number of fellows in subspecialty training grew at an average rate of 10.6% per year, or one and one-half times greater than the growth rate of 7.2% in the number of first-year residents in training for the same time period. In 1976-1977 there were 5826 fellows in subspecialty fellowship training, of whom 26% were foreign medical graduates. Stipends for subspecialty fellows in 1976-1977 amounted to $90 million, 40% of which was derived from direct federal funds and 33% from hospital revenues. Most of the subspecialty fellowship programs were in large teaching hospitals, which are closely affiliated with the nation's medical schools. The 1976-1977 professional activities of former subspecialty trainees who had finished their training between 1972 and 1976 were distributed roughly in thirds between research-teaching, teaching-practice, and practice. We discuss public policy implications of the data.