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Rapid Responses: Rapid Responses published:
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generalist vs specialist
- ac massarotto (11 July 2008)
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Should geriatric medicine remain a specialty?
- Catherine E Yelland (15 July 2008)
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The growth of Geriatric Medicine cannot be ignored
- Om Prakash (15 July 2008)
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Yes, as a specialty in generalism...
- Kunal Shah, Scott Grier (16 July 2008)
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Geriatric medicine as aspeciality
- N.P. Viswanathan (16 July 2008)
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Should the English be allowed to edit medical journals?
- Kenneth Rockwood (18 July 2008)
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Geriatric Dentistry
- Eduardo M. Curbeira Hernández MSc, MDD, Eduardo E. Castillo Betancourt MSc MDD, Bienvenido Mesa Reynaldo MSc MDD (19 July 2008)
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ac massarotto, advanced trainee geriatric medicine perth
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Denaro and Mudge state that geriatric medicine will become obselete as the population ages,"The inverted pyramid is imminent". I have to disagree. As a young doctor i have had the opportunity to work extensively in both general medicine and geriatric medicine. there is still a very clear difference in the attitude, approach and most importantly, the expertise in dealing with older frail patients between the two fields of medicine. (probably why i chose geriatric medicine rather than general medicine!) Just because a generalist professes to have some knowledge about an area does not give them specialist status. Do Denaro and Mudge also predict the death toll of endocrinologists/diabetologists given the rising tide of type 2 diabetes? i doubt it. all medical (and surgical!) subspecialities in the future will be increasingly exposed to older and frail patients. and just as with a patient with poorly controlled diabetes, when managing these complex,frail patients, an expert opinion will be required. a generalist will just not do... Competing interests: I have worked for Prof Flicker. I have also worked as a medical registrar in brisbane. i know the difference between a multidisciplinary meeting run by geriatric medicine and general medicine! |
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Catherine E Yelland, geriatrician and general physician Princess Alexandra Hospital, Brisbane, Australia, 4102
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Should Geriatric Medicine remain a Specialty (BMJ 2008;337 a515, BMJ 2008;337a516) is a curious question. Should we be asking if neurology or cardiology or any other medical specialty is still necessary? Geriatricians have not questioned the basis for other specialties, but continue to be challenged to justify their own existence. We are quite clear what we do - how we are trained, what skills we have and what services we offer the community and health care providers. (Definition of a Geriatrician, Australian and New Zealand Society for Geriatric Medicine www.asgm.org.au) Of course our health services have changed over the past fifty years since geriatric medicine first recognized the unmet needs of older people who are now the major users of health care. As noted by Denaro and Mudge, all staff now need an understanding of geriatric princliples, and the success of multidisciplinary team care is no longer confined to geriatric wards, as others have recognized the value of this model, which was developed in many hospitals by pioneering geriatricians and then shared with their colleagues and junior doctors, who now regard this as usual practice. Now that many specialities are managing chronic illnesses effectively, geriatric medicine continues to develop innovative service models, research fundamental mechanisms of ageing such as frailty, as described by Flicker, and to care for those vulnerable older people, with conditions such as dementia, who have not been the focus of other specialities. Geriatricians also have a role in influencing attitudes towards illnesses which affect older people and resource allocation in health care and social policy. There is plenty of work to go around. Those doctors who are “enthusiastic supporters of advocacy innovation and teaching of health care for elderly people” (Denaro and Mudge) (who now prefer the term “older people”) should not be told that they are redundant, but should be encouraged to continue their efforts to improve our understanding of ageing, and our care for this increasing sector of heatlh care consumers. Catherine Yelland
Competing interests: I am the president of the Australian and New Zealand Society for Geriatric Medicine, the professional society for geriatricians, of which Professor Flicker is also a member |
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Om Prakash, Assistant Professor of Psychiatry Geriatric Clinic & Services, Department of Psychiatry, NIMHANS, Bangalore, INDIA
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Geriatric medicine specialty develops for the betterment of geriatric age group (which is going to become a major chunk of the World's population). This question is not relevant in the present scenario when Geriatric Psychiatry, Geriatric Cardiology, Geriatric Neurology etc subspecialties are in developed stage. There is no question of ignoring General Medicine/ general physicians as they form the benchmark of health system throughout the world. In this era of medical care, we should search better avenues for our clients rather discussing what is required or not required. Competing interests: None declared |
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Kunal Shah, SpR Stroke Medicine Wycombe General Hospital, HP11 2TT, Scott Grier
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Geriatric medicine is to look after the whole and not just one organ. Training in this specialty used to involve time spent with the '-ologies' to have a firm grounding in their spheres of expertise. This could then be applied to the older person who invariably has more than one system failure. The strength of the geriatrician is to use this knowledge, in collaboration with the patient and the MDT, to avoid the complications of over-investigation and polypharmacy. Should further management be desired (and indicated), this could be provided by prompt specialist input when requested. To qualify as a specialty, geriatric training has had to focus on more and more niche areas of frailty (dementia and delirium, falls, osteoporosis and stroke to name but a few). This move away from generalism has prompted your debate over the role of the geriatrician. I believe this is where we are going wrong. The geriatrician of the future must be able to provide ALL of the above to best serve the aging population. Competing interests: Trainee in Geriatric and General Internal Medicine |
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N.P. Viswanathan, Family physician sv clinic,gmpalya,Bagalore-560075, India
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Sir, In Bangalore India We donot have many geriatric Medicine Specialists.Ihave to search for such persons for getting an expert opinion.My elderly patients are also not aware of such speciality unless I tell them.With the increase longevityand more number of elderly persons they definitely require more attention.This care can be given by family physicians and general practitioners Who can be given periodic updates about geriatric medicine. Just as a baby is not a miniature adult, the elderly is not withered youth.His prescription should include a lot of wisdom. understanding and compassion and may be, some medication.company of friends,relatives, children,and grand children,TV,magazines and news papers,music and periodic outing will greatly help to improve the quality of life.But given the conditions of life many of these are not possible in practice. But it is the duty of the attending physician to advice the family.He too should set apart some time to make house call even if there is no obvious need.The doctor for the elderly is not just a healer but a friend of many years.It is only family physicians who can do this . It is easier to have vigour of youth at old age,than wisdom of old age at youth. Getting old is inevitable-Graying Gracefully is work of art. Competing interests: None declared |
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Kenneth Rockwood, Professor of Geriatric Medicine Dalhousie University, 1421-5955 Veterans' Memorial Lane, Halifax NS Canada, B3H 2E1
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I wonder how many other geriatricians shared my viscerally negative reaction to the idea of the BMJ considering whether geriatric medicine should continue as a specialty? (The editors might want to consider a Head to Head along the lines of “should the English be allowed to edit medical journals?” to get some comparable sense of it, and of how the “we merely raise the question” would seem a paltry riposte.) Denaro and Mudge turn to the “we are all geriatricians now” argument, so often used to try and strangle the growth of geriatric medicine.[1] They seem to have been encouraged in this by their success with running a multi-disciplinary team.[2] But there is more to geriatric medicine than team conferences. Geriatric medicine is the complex care of elderly people who are frail. As Prof. Flicker [3] and others [4] have pointed out our discipline has not been its own best advocate. We have relied too much on a simple set of utilitarian values: “we do these things because they seem to work”. Providing a scientific basis for the specialty of geriatric medicine is therefore essential to advancing the care of frail elderly patients. Where it is easy to agree with Denaro and Mudge is that the essence of the case for the special skills that geriatricians need is not age, but complexity. As people get older they are more likely to die. But they do not just drop dead from a state of excellent health – rather most die after the accumulation of the multiple, interacting medical and social problems that make them frail. The multiplicity of problems also makes these patients a poor fit for health care systems that largely have been designed for people who have only one thing wrong at a time. The medical and social problems inherent in being frail are susceptible to quantification. [5] As it turns out, the numbers that are produced by quantifying frailty and social vulnerability can themselves be the object of inquiry. These inquires allow for quantitative models to be built and for the complexity of patients to be understood mathematically – for complexity to be not just a synonym for ‘complicated’. One of the consequences is that clinico-mathematical correlation is now a pressing task in advancing our understanding of how to make care better for older adults who are frail, especially when they become ill. This effort can be shared by all who are willing to take it on, and the resulting knowledge can be shared with all who are willing to learn it. But the understanding of frailty will not happen on its own and the leadership, conceptualization and desire to do this chiefly comes from geriatricians. Fortunately, not all English medical editors gainsay this working with a glad heart in a difficult area,[4] so perhaps the English still should be allowed to edit medical journals. References 1. Denaro CP, Mudge A.Should geriatric medicine remain a specialty? No.BMJ. 2008 Jun 30;337:a515. doi: 10.1136/bmj.39533.696076.AD. 2. Mudge A, Laracy S, Richter K, Denaro C. Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: enhanced multidisciplinary care. Intern Med J 2006;36:558-63 3. Flicker L. Should geriatric medicine remain a specialty? Yes. BMJ. 2008 Jun 30;337:a516. doi: 10.1136/bmj.39538.481273 4. Anon. Who cares for the elderly? Lancet 2008;371:959. 5. Andrew MK, Mitnitski AB, Rockwood K.Social vulnerability, frailty and mortality in elderly people.PLoS ONE. 2008 May 21;3(5):e2232. Competing interests: I am a geriatrician all the time and only occasionally an editor. |
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Eduardo M. Curbeira Hernández MSc, MDD, Dentistry Department Gustavo Aldereguia Lima University Hospital. Cienfuegos. Cuba, Eduardo E. Castillo Betancourt MSc MDD, Bienvenido Mesa Reynaldo MSc MDD
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By the year 2000, 35 million Americans - more than one in six - will be 65 years of age or older,. In most general dental practices the proportion of older adults is even greater, and the elderly account for a higher percentage of practice income with each passing year.
Geriatric dentistry or gerodontics is the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age-related diseases as part of an interdisciplinary team with other health care professionals.
As we grow older, we often develop special dental needs. Some of these are naturally occurring, such as a dry mouth, and some are due to medications or specific surgical procedures and require specific understanding and diligence.
The dental needs of the elderly are changing and growing too.
The management of older patients requires not only an understanding of the medical and dental aspects of aging, but also of many other factors such as ambulation, independent living, socialization, and sensory function. Many barriers may interfere with providing older patients with dental care, including severe dental complexity, multiple medical conditions, diminished functional status, loss of independence, uninformed attitudes about dental care in old age, and limited finances.
The dental care to the third age at this time has taken supreme interest and it’s dedicating bigger time. For the attention to these patients, the odontologist should have a deep knowledge of the biological aspects, for the sensitive decrease of the mechanisms of adaptation and histic regeneration. The individuals of advanced age require a different focus, modified treatments and knowledge of how the histics changes dependent of the age affect the services of buccal sanity.
References
Flicker L. Should geriatric medicine remain a specialty? Yes. BMJ 2008;337:a516, doi: 10.1136/bmj.39538.481273.AD (Published 30 June 2008)
Brocklehurst J.C. Textbook of geriatric Medicine and gerontology. Churchill Livingstone. 2nd edition, 1980.
Competing interests: None declared |
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