Re: Is it time for a new kind of hospital physician?
A focus on how we deliver of the most acute stages of hospital care (1) is important in a world where those presenting as acute medical admissions are most likely to be older and to suffer from multi-morbidity, frailty and polypharmacy. It is particularly timely as a recent Cochrane review demonstrates striking efficiency of the acute geriatric medicine model, with substantial reductions in death, disability and institutionalization compared to general medicine (2).
It is disappointing that the perspective of this editorial and accompanying paper (3) appear not only agnostic of this evidence but also to dismiss a leading role for geriatric medicine and universal training in geriatric medicine for doctors of all specialties in responding to this combination of complexity and acuity. Age-attuning the acute medical system is a critical success factor in responding to this challenge.
A wider perspective on developments in Europe affords us more encouragement in terms of enlightened approaches in a number of countries – Ireland, Belgium, Austria and Switzerland – which have formally incorporated significant geriatrician input as critical to the development of acute medical services, and other countries such as Finland are in the process of incorporating such measures. In addition, some hospitalists in the USA have recognized the value of a joint approach with geriatric medicine with promising results (4).
Barriers remain to ensuring expertise, particularly low rates of reimbursement in some countries with procedure-related payment (5), and the persistence of an unhappy and unscientific dilettantism among some physicians, the ‘we all look after older patients’ syndrome.
That there are low numbers of geriatricians in some countries should be a prompt for urgent development of the specialty rather than by-passing an important locus of gerontological and practical expertise in acute medical care. Not all older patients can, will, or need to be looked after by geriatricians: but the least they should expect is that those who provide their care have training and competence in geriatric medicine as a core element of their training (6), that geriatricians are involved in the design and delivery of their acute medical services, and that they have due access to consultation with specialists in geriatric medicine and old age psychiatry.
1. Temple RM, Kirthi V, Patterson LJ. Is it time for a new kind of hospital physician? BMJ 2012;344:e2240.
2. Ellis G, Whitehead MA, Robinson D, O'Neill D, Langhorne P. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011;343:d6553.
3. Wachter RM, Bell D. Renaissance of hospital generalists. BMJ. 2012;344:e652.
4. Merel SE, McCormick W. Geriatricians and hospitalists: opportunities for partnership. J Am Geriatr Soc 2010;58:1803-5.
5. American Geriatrics Society. Five Reasons Health Reform Helps Older Americans. New York: American Geriatrics Society, 2010.
6. Demanding dignity, and competence, in older people's care. Lancet 2012;379(9819):868.
Competing interests: No competing interests