Geriatric Medicine Training For LTC Physicians

Doctors employed by nursing facilities are often internists by training. According to the American College of Physicians (ACP), internists “are recognized as experts in diagnosis, in treatment of chronic illness, and in health promotion and disease prevention…equipped to deal with whatever problem a patient brings—no matter how common or rare, or how simple or complex.” ACP also notes that internists “are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time.”¹

That seems to be a description of precisely the type of doctor who should be serving in facilities with large numbers of aging adults. According to ACP, “some internists choose to take additional training to ‘subspecialize’ in a more focused area of internal medicine. Subspecialty training (often called a “fellowship”) usually requires an additional one to three years beyond the basic three year internal medicine residency.” 

Geriatric medicine would seem to be the area of specialized training that would best prepare a doctor for working in a long-term care facilities (LTCFs), as geriatric medicine focuses on training and skills to treat older adults—the largest resident population in LTCFs. Internists who continue their education with advanced training in geriatric medicine “specialize in the diagnosis, treatment, and prevention of disease and disability in older adults.” Such doctors are concerned with “health problems that frequently affect older adults, such as pain, falls, memory loss, incontinence (involuntary loss of urine), and medication side effects. Another important aspect of geriatric medicine is evaluating an older individual’s ability to care for him- or herself (eg, prepare and eat meals, bathe, dress).”²

When my late wife, Clare, entered an assisted-living facility (ALF), she was in moderate stages of Alzheimer disease (AD) and placed in the ALF’s lockdown dementia unit. We were told that 2 internists came several days each week, and one would be assigned to serve as Clare’s primary care physician. I soon discovered, however, that these doctors had very little background or experience with AD patients.

If Clare’s ALF doctor had advance training in geriatric medicine, perhaps I would not have had to personally raise concerns so often with ALF administrators about Clare’s care. A doctor with geriatric care specialization would probably have observed that Clare needed greater assistance with such activities as eating, bathing, and dressing and, hopefully, would have directed ALF staff to give more attention to these areas of need.

When Clare eventually entered a nursing home (NH), her NH doctor was an internist with a specialization in cardiology. Whenever I wanted to discuss AD medication changes, I spoke with the visiting psychiatrist who then spoke with the NH internist on my behalf. Cardiopulmonary arrest was listed on Clare’s death certificate as the immediate cause of her death. In the section on her death certificate where doctors can list “other significant conditions contributing to death but not related to the cause of death,” the NH doctor made no mention of her 10-year battle with AD. A doctor with additional training in geriatric medicine likely would have noted that AD was a significant condition contributing to her death.

Internists definitely seem to be the type of doctor best suited for diagnosing and treating the aging population in LTC settings. However, internists with a specialization in geriatric medicine should be the gold standard, especially if the LTC’s aging population includes people with AD or other forms of dementia. 

References

1. American College of Physicians (ACP). About Internal Medicine. Acponline.org website. https://www.acponline.org/about-acp/about-internal-medicine. Accessed August 20, 2018.

2. HealthCommunities. What is a geriatric physician? HealthCommunities.com website. http://www.healthcommunities.com/health-care-providers/what-is-a-geriatrician.shtml. Published November 13, 2008. Updated September 18, 2015. Accessed August 20, 2018.

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This is Dr. Vann's last Commentary blog column for Annals of Long-Term Care. He has also written frequently for caregiver magazines, other medical journals, and major newspapers. After his late wife, Clare, was diagnosed with early onset Alzheimer’s disease, Dr Vann made it a point to increase public awareness of Alzheimer’s and to help fellow caregivers. You can read his many other articles about Alzheimer's at www.allansvann.blogspot.com. If you would like Dr Vann to respond to questions or comments about this article, please email him directly at acvann@optonline.net.

Published in Annals of Long-Term Care, online only, on 8/22/18.  Access at https://www.managedhealthcareconnect.com/blog/geriatric-medicine-training-ltc-physicians