Centers of Excellence in Geriatric Medicine and Training

Developing the Faculty to Teach Tomorrow’s Doctors about Older Persons’ Health Needs A Brief History of Geriatrics Why Are Centers of Excellence Needed? Preparing Tomorrow’s Leaders in Geriatric MedicineCenters of Excellence Focus on Research and Training Centers of Excellence: Support for Basic Science Research Centers of Excellence: Support for Clinical Research Centers of Excellence: Support for Health Services and Outcomes Research Centers of Excellence: Support for Clinician Education Centers of Excellence: Infusing Aging into Clinical Speciaties The Hartford Foundation’s Continued Commitment to Geriatric Medicine

Download PDF Report

Get Adobe Reader

Why are Centers of Excellence Needed?

In 1987, Dr. Paul B. Beeson called for the creation of centers of excellence in geriatric medicine, and the John A. Hartford Foundation responded the following year. The necessity for such centers has only grown with time, particularly as the baby boomer generation moves ever closer to retirement age.

“Ready or Not, Boomers Turn 60”

This Newsweek cover story (November 14, 2005) reported that 3.47 million babies were born in 1946, a huge jump from 2.36 million in 1940. And that was just the beginning. Over the next 19 years 78 million more babies were born in the U.S.—the famous “baby boom” generation. In 2000, these adult baby boomers accounted for nearly 30 percent of the U.S. population. In 2006, the first wave of baby boomers will turn 60. Because of the sheer size of this demographic group, the baby boomers have influenced many aspects of society and culture throughout their lives. In 2006, Paul McCartney, an icon for the baby boom generation, who was born in 1942, may get the answer to the musical question, “Will you still need me when I’m 64?” As older age appears on the horizon for the baby boomers, they may be poised to have their greatest impact yet on this nation.

Popular culture has begun to explore the impact of an aging America, with geriatric medicine developing innovations to meet new demands. A November 14, 2005 Newsweek cover story heralds the first of 78 million baby boomers reaching age 60.

The large and weighty question is whether the massive health care needs of the growing population of adults over age 65 will be met in the coming years. By 2030, when the last of the baby boomers reach age 65, there will be more than 70 million Americans over 65, almost twice as many as in 2000.

Along with the boom in births in the middle of the 20th century, there also has been an increase in life expectancy over the past century. Americans who are 60 years old today have a life expectancy of 82.3 years. However, despite the overall increase in longevity, for many people an unavoidable aspect of the later phase of life is a growing need for and use of health care services, including medications, physician office visits, hospitalizations, and long-term care. More than 40 cents out of every health care dollar spent in the U.S. goes for the care of people over age 65. Research showed that in 2000, people age 65 and older spent four times as many days in the hospital as people younger than 65.  

Many older adults have at least one chronic condition and take several medications. Some have impairments, either physical or cognitive, that diminish their ability to function. Diseases such as heart disease, cancer, osteoporosis, Alzheimer’s, and others, become more prevalent with age. The health issues that face older adults can be complicated. “There’s more to geriatrics than just the diseases that affect older people,” says David B. Reuben, MD, Archstone Foundation Chair and Professor of Medicine/Geriatric Medicine and Chief, Division of Geriatrics at the University of California, Los Angeles, a Hartford-designated Center of Excellence in Geriatrics. “You might think that if you are able to manage these diseases one at a time—heart disease, diabetes, etc.—you’d have it pretty well licked, but that’s not true.”

Despite the advancements made in geriatric medicine in the past few decades, there are still gaps in knowledge about how best to take care of older people. Physicians often know how to treat individual diseases, but much of that knowledge comes from the study of younger people who have a single disease. Less is known about how to care for older people who may have multiple, often chronic, diseases, who may have a range of physical, social and environmental issues that impact their health, and who may have different treatment goals than their younger counterparts.

These knowledge gaps may lead to substandard care delivered to older adults. A recent study by RAND Health examined the quality of care older adults were receiving. They reported the following findings:

"Vulnerable elders receive about half of the recommended care, and the quality of care varies widely from one condition and type of care to another."

"Preventive care suffers the most, while indicated diagnostic and treatment procedures are provided most frequently."

"Care for geriatric conditions, such as incontinence and falls, is poorer than care for general medical conditions such as hypertension that affect adults of all ages."

"Physicians often fail to prescribe recommended medications for older adults."


In addition, “providers administered proper care to patients with conditions that demanded immediate treatment (acute conditions) far more frequently than to those with chronic health problems.” The experts at RAND Health attributed the short shrift given to geriatric conditions to several factors, including a lack of sufficient training in geriatric conditions in medical schools and primary care residency programs.



Carolyn Welty, MD, University of California, San Francisco, CA, with patient, Anna M. Turner.
As medicine extends life expectancy, physicians provide care for increasingly complex patients, often with multiple chronic conditions

There is also a need to prepare all physicians to care for older patients, whether or not geriatrics is their specialty. While more geriatricians clearly need to be trained, there’s no escaping the fact that most health care for older adults is, and will continue to be, delivered by non-geriatricians—primarily family physicians and internists.

“Even if we ramped up a hundred-fold, we would not have enough geriatricians to provide care for all the older folks in the U.S.,” says Rebecca A. Silliman, MD, PhD, Professor of Medicine and Public Health, Boston University Schools of Medicine and Public Health, and Chief of the Geriatrics Section at Boston Medical Center, a Hartford-designated Center of Excellence in Geriatric Medicine and Training.

According to Harvey Cohen, MD, Director, Center for the Study of Aging and Human Development, Duke University, Durham, North Carolina, “the role of geriatricians is best leveraged by having them in positions to do one of two things: one is to train other physicians to have an appropriate level of expertise to take care of older people, and the other is to generate new knowledge about the care of older people.”

Given all of these realities, the future direction of geriatric medicine and aging research must take several paths. Specifically, greater focus must be placed on:
  • Training larger numbers of medical researchers who are focused on specific geriatric health conditions and on issues of caring for people with multiple simultaneous conditions.

  • Providing adequate training in geriatrics to primary care specialists.
  • Encouraging physicians in almost all medical specialties to become more knowledgeable about age-related health issues.
  • Increasing the numbers of clinician educators qualified to train geriatricians and to teach primary care physicians and specialists about specific care issues regarding their older patients.
  • Fostering greater amounts of age-related research (basic science, clinical, health services) by encouraging more young physicians to pursue academic careers.

Our country’s federally-funded system, as it is set up today, contains little incentive to pursue these goals. In 1998, the American Board of Internal Medicine began to allow certification in geriatrics after one year of clinical training. The change from two years to one was intended to increase the number of geriatric fellows. In 1995, only 57 percent of first-year fellowship positions were filled. After the change went into effect, this number jumped to 91 percent. But the reduced length of fellowships in geriatrics had an unintended negative consequence. VA and Medicare Graduate Medical Education funding is restricted to the first year of fellowship, supporting specialized clinical training. Funding for second and third year fellowships, the time needed to produce the academic physicians who will conduct the research and train future generations of geriatricians and primary care doctors, is no longer automatically available.

As a result, academic medicine has lost critical resources needed to effectively teach geriatrics. In 2001, there were approximately 900 full- time academic geriatricians working in U.S. medical schools. However, the Alliance for Aging Research estimates that 2,400 geriatric academicians are needed to train new geriatric fellows, integrate geriatrics into other specialties, and conduct research.

While the first year of fellowship is usually funded by the VA and Medicare, support for the advanced years of fellowship training that are geared towards pursuing a career in academic medicine is harder to find. “There are funding gaps between the point in time when someone recognizes they want to do something in geriatrics and the point in time when NIH support is likely to be generated,” says Dr. Cohen.

Therefore, support for the crucial years of advanced fellowship from private sources, such as the Hartford Foundation, is essential to ensure the future growth and success of the field of geriatrics.