Family physician geriatricians do mostly geriatric care: is this a problem for our specialty?

In this issue, Peterson et al report that the majority of family physicians with Certificates of Added Qualifications (CAQs) in Geriatrics self-report practicing primarily geriatrics. Almost 40% of those surveyed reported spending 80% of their time devoted to geriatric patients. Another 20% reported spending 60% to 80% of their time with older patients. These figures raise many more questions than are answered by the data. Are these percentages different from the amount of time family physicians with other types of CAQs spend in their practices? Are family physician geriatricians a different “breed” than those who practice across a broader age spectrum? How is the “silver tsunami” affecting decisions of physicians with geriatric CAQs regarding the allocation of time within their practice? Could it be that many family physician geriatricians are simply getting older and seeing their practice age with them? Perhaps most controversial is whether this degree of “specialization” is inherently harmful to the discipline of family medicine. My analysis of these questions is strongly influenced by my personal journey in family medicine and geriatrics. I am an “early adopter.” I saw family practice (the term used in those days) as the natural counterpart to my 1960s-era nonconformity. I graduated high school in 1967, the same year Gayle Stephens was starting one of the first family practice residencies, and I read voraciously the writings of Dr. Stephens and Ian McWhinney. I was (and am) passionate about the family as a unit of care and the psychosocial approach. Later, in 1980, as a young residency faculty, my program director asked me to attend a Society of Teachers of Family Medicine meeting on integrating geriatrics into family medicine education. I jumped at the chance because it meant a free trip to Boston! Once there, however, I was bowled over by the presentations of David Kinney, Richard Ham, and other family physicians. The prospect of being able to help anyone to function better salved the wound that disease-based medical care inflicted on me. Over the next 3 years I transformed myself into a geriatrician, and by 1984 I too was practicing 80% geriatrics. When the American Board of Family Practice was considering joining the American Board of Internal Medicine in creating the first CAQ, a number of us met with the American Board of Family Practice to advocate in favor of the proposal. There was considerable opposition; however, we felt strongly that the care of older people should not be seen as the province of one specialty. In addition, we felt the fundamentals we learned in family practice training—continuity, the family as a unit of care, community-based thinking, and the psychosocial approach—would be important to this new, growing area of medicine. Over time, new CAQs have been added. Family medicine now has 6: geriatric medicine, adolescent medicine, hospice and palliative medicine, pain medicine, sleep medicine, and sports medicine. But many family physicians with other CAQs do not spend the majority of time doing that “subspecialty.” We have little information about how much time family physicians with other CAQs spend on that special area of interest, and more research into this question is needed. We do know that only about 6.7% of family physicians spend 80% of their time doing emergency or urgent care, but there is no From the Department of Geriatrics, Florida State University College of Medicine, Tallahassee. Funding: none. Conflict of interest: none declared. Corresponding author: Kenneth Brummel-Smith, MD, Department of Geriatrics, Florida State University College of Medicine, 1115 West Call St, Suite 4305, Tallahassee, FL 32306-4300 (E-mail: [email protected]).