Training of Specialized Geriatric Physicians to Meet the Needs of an Aging Population—A Unique Care of the Elderly Physician Program in Canada

To the Editor: In the United States, 21% (79.7 million) of the population will be aged 65 and older by 2040,1 with similar projections for Canada.2 These demographic changes will result in a greater number of older people needing complex care and a greater need for chronic disease management. There currently is a “dramatic shortage of all types of health care workers,” with the healthcare workforce overall “inadequately trained to care for older adults.”3 There were 7,356 certified geriatricians in the United States in 2012, with an estimated need for 30,000 by 2030.4 In Canada, there were 216 geriatricians in 2010,5 with an estimated need for at least twice that.6 Few physicians are joining this specialty in either country,5 and initiatives to bolster training in geriatrics for undergraduate medical students in North America have met limited success.7 As a result, there is a significant shortage of physicians caring for older adults.8 Primary care physicians can care for the vast majority of elderly adults, but recent evidence indicates that “higher quality of care for general medical (e.g., hypertension, diabetes) conditions and geriatric conditions is associated with improved survival among community dwelling older adults,”9 and evidence indicates that detection and care of geriatric syndromes by healthcare providers is less optimal than the care provided for general medical conditions.10 The objectives of this paper are to describe a unique Care of the Elderly (COE) physician training program in Canada and to report on the “preparedness for practice” of graduates of this program after graduation, and the program's contribution to capacity building within the healthcare system. COE programs are offered at 15 of the 17 universities with medical schools in Canada. Since its inception in 1993, the University of Alberta COE program has graduated 51 residents, which represents 43% of all COE graduates in Canada. In 2003, a formal Division of COE was established in the Department of Family Medicine. The director's visionary leadership, engagement and support from division colleagues, the presence of an “academic home,” and the support of department chairs have all been critical to the program's success. Dedicated funding for academic physician positions and three full-time research and support staff also have been critical. Collaboration between the divisions of COE and geriatric medicine and the availability of alternate funding for positions after graduation have further strengthened the program. Core COE program requirements include training in acute and rehabilitation inpatient and consultative care, geriatric psychiatry, ambulatory care, continuing care, outreach, and regular time in a longitudinal clinic (see http://www.familymed.med.ualberta.ca/Home/Education/ThirdYear/Elderly).11 Methodology and results related to “preparedness to practice” are provided below. The survey was administered online. Residents graduating from the program were invited to participate in a survey, with contact information obtained through various physician databases. Ethics approval was obtained from the University of Alberta Health Research Ethics Board. Thirty-nine of the 47 residents contacted responded (83% response rate). The mean age of the sample was 44 ± 8.92; 72% of respondents were female. Eighty percent of respondents were working as COE physicians on average 70 ± 27% of their working week. Most of the responding COE physicians were spending a majority of their time on direct care, with this care occurring in a variety of settings (e.g., consultation services on acute care and geriatric rehabilitation units, community-based adult day programs, continuing care and supportive living, home care). All respondents felt somewhat or very prepared in the approach to clinical problems, management of common clinical problems, and management of hospitalized individuals, with 97% of respondents somewhat or very prepared in terms of the referral and consultation process and management of psychosomatic and psychosocial problems (Table 1). A lower, but high, percentage of respondents felt somewhat (88%) or very (81%) prepared in terms of practicing evidence-based medicine, cost-effective use of diagnostic tests, continuity of care, and teaching health prevention/promotion. Historically, there has been a shortage of physicians trained in geriatrics, and that shortage continues, meaning that there is a need to increase the number of academic geriatric physicians. In Canada, COE training programs equip physicians with extra skills in care of elderly adults, including detection and care of geriatric syndromes. Graduates of the program are practicing outside of traditional practice settings, which has led to greater capacity in the care of medically complex seniors outside the traditional healthcare system settings. Abstract accepted at the North American Primary Care Research Group 2013 for a poster presentation. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Funded by the Northern Alberta Academic Family Physician Endowment Fund. Author Contributions: LC: conception and design, acquisition of data, interpretation of data, drafting the article, critical revision of the article for important intellectual content, final approval of the version to be published. BD: conception and design, analysis and interpretation of data, critical revision of the article for important intellectual content, final approval of the version to be published. RM: conception and design, analysis and interpretation of data, drafting the article, critical revision of the article for important intellectual content, final approval of the version to be published. OB: analysis and interpretation of data, critical revision of the article for important intellectual content; final approval of the version to be published. JT: conception, drafting the article, critical revision of the article for important intellectual content, final approval of the version to be published. Sponsor's Role: None.

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