Late last year Libby Bragg, Greg Warshaw, and colleagues at the Geriatrics Workforce Policy Studies Center published a daunting report on the state of academic geriatrics. I've been trying to come to grips with its meaning and implications for months now and have some thoughts I'd like to get feedback on.
The Policy Studies Center, which began life as the evaluator of the Donald W. Reynolds Foundation Aging and Quality of Life Program, is now funded by a grant to the American Geriatrics Society from the Hartford Foundation intended to make use of its expertise and body of evidence in state and national policy discussions of the geriatric workforce. Its report concludes that geriatric medicine is not producing the number of new faculty needed to train future providers. In other words, while our many grants programs have worked within their own limits and done good things, they have not solved the problems in creating even an adequate academic geriatrics workforce to ensure that all physicians have basic competence in care of their older patients.
Given that faculty production in geriatric medicine has been one of the Hartford Foundation's longest-standing objectives, this is disappointing news and likely to be scary and controversial. It is actually quite difficult to get accurate numbers on how many postgraduates are in preparation for a career in academic geriatrics, due in part to diverging views of what constitutes appropriate preparation. Because the geriatrics fellowship is only one year and focused on clinical training, the number of physicians in fellowships is not a good indicator--although there is little good news at this stage, with entering classes stuck under 300 and about 40% of fellowship positions unused. The official number of "fellows" in second year and beyond, which has fallen steadily since 1999, is nearly useless, because there is no consistent meaning of fellow when there is no national program. Bragg and colleagues directly surveyed program directors and asked how many "functional equivalent" fellows were in training (i.e., those with significant time protected from clinical work and career development goals). The finding was 65 people in the entire United States, 55 percent of whom were reported to be at just four institutions and 69 percent at the 28 institutions participating in the Foundation's Centers of Excellence program.
Even with some correction for trainees uncounted due to non-response from program directors, it is not clear to me that there are enough trainees in the pipeline to maintain the current number of faculty, much less grow the numbers to meet the broad array of society's needs for academically prepared geriatricians.
Our theory has long been that providing resources for protected time and additional money for training and academic development would help geriatricians develop sustainable academic careers. Simultaneously, we hoped that the high prestige awards in aging research like the Beeson Scholarship (about half of which have gone to geriatricians) would legitimize aging and geriatrics in the research grant “coin of the realm” in academic medicine and attract more talent to the field and support from institutions. Unfortunately, it has not worked; I suspect that our theory was not complete.
The production of faculty members in geriatric medicine is at the narrow end of a very long pipeline that starts out pretty skinny in generalist-oriented family or internal medicine residents. From the falling numbers of generalists we then draw those who go on to do clinical geriatrics fellowships and from them draw those who want to pursue an academic career (rather than going directly into practice). While the intellectual challenges of such a career are great, we don’t seem to have persuaded enough of the best and brightest to give it a shot.
So, I would like to invite our audience to help think through a revised theory of change and help us collectively design a new program to draw new blood into academic geriatrics. I don’t know when we might be able to implement it and at what scale, but “crowdsourcing” is all the rage, and I am really curious about what we can do together. On Thursday, I will propose the modification of the theory and a programmatic intervention. I invite modification of that proposal or other different proposals. A couple of caveats: No magic wand solutions and no appeals to grand powers will be accepted (i.e., "The Gates Foundation saves the day" is not a legitimate proposal--I've already tried it), and it has to be affordable with the resources we can reasonably expect to control.