Geriatric Psychiatry: Recruitment, Education, and Training

Abstract:

The growing need for trainees in geriatric mental health is well documented. This article explores the issue of how and why people enter this field, what educational qualifications they must attain, and what resources are available to help with their training needs, both financial and otherwise.

Introduction

The title of a report published by the Alliance for Aging Research in 1996, "Will You Still Treat Me When I'm 65?"[1] evokes the anxiety that accompanies aging in a society that often devalues older people and fails to appreciate their unique needs. The population of people who are qualified to ask that question is growing rapidly. While it is an accepted fact that older adults will eventually face declining physical health as they age, the high prevalence of mental health disorders in adults aged 65 and older is often overlooked. By 2030, older Americans will comprise more than 20% of the overall population, and 15 million of them will have to deal with some type of mental health disorder.[2] However, the American Association of Geriatric Psychiatrists (AAGP) projects that by 2030, there will be one geriatric psychiatrist for every 5,682 older adults.[3] Who will treat this population?

Influential Factors

Currently older adults are more likely to seek mental health care in the primary care setting, but these physicians often receive inadequate training in diagnosis and treatment of geriatric mental disorders.[2] For this reason, it is critical that future primary care practitioners receive specialized training in geriatric mental health.[2] Recruiting medical students into the field of geriatrics in general, and geriatric psychiatry in particular, is a daunting and well-documented challenge. However, while medical students' interest in the fields of primary care medicine -- traditionally the gateway to geriatric medicine -- and psychiatry has declined somewhat, there continues to be a group of medical students in each generation with the desire to treat older patients.[4] Based on feedback from a questionnaire fielded by the American Association of Medical Colleges, 13% of medical students who planned to enter internal medicine or general practice reported that they planned to become board-certified in geriatrics.[5]

The ability to recruit medical students into the field of geriatric psychiatry requires an understanding of how their attitudes are shaped during the medical educational process. Research shows that in general, first-year medical students harbor some negative attitudes towards psychiatry because of notions they have about the difficulty of dealing with psychiatric patients and the purported ineffectiveness of psychiatric interventions.[6] Nevertheless, research also proves that having a positive clinical training experience can guide medical students towards psychiatry as their career of choice. Although ageism exists among medical students, much like the population at large, their attitudes toward and understanding of geriatric medicine can be positively cultivated through a rigorous educational process.

The primary factors that drive an interest in geriatric psychiatry are excellent mentorship and supervision coupled with positive clinical exposure to geriatric psychiatric practice. Students look for quality learning experiences and rank competency, teaching ability, and a mentor's ability to support their learning as the key components of excellent mentorship.[7]

Exposure to geriatric psychiatry, especially through lectures and clinical experience, can stimulate students' interest, but the real challenge is to provide a context in which nascent interest is nurtured until it becomes full-fledged commitment. When students are exposed to geriatric psychiatry, they can gain an appreciation for its unique mission. In a series of AAGP surveys of residents, respondents were asked what drew them into the field. The majority of respondents indicated that they were positively stimulated by the neuropsychiatric, medical/psychiatric, and multifactorial nature of the problems associated with geriatric psychiatry as a discipline. Of those surveyed, 70% expressed a genuine interest in understanding their individual patients' lives and case histories and being able to help them. On a broader level, the majority of surveyed residents liked the idea of caring for an underserved population.[7]

When it comes to the career decision-making process, timing is critical. According to survey results from geriatric psychiatric fellows, 27% made their career decision before or during medical school. However, more than half (53%) made their decision during residency. Once again, mentoring and exposure play a significant role in how early students decide to pursue geriatric psychiatry. Among fellows already enrolled in a specialized geriatric psychiatry program, 48% cited having access to quality mentorship as crucial for their career development.[8]

The Educational Pathway: From Medical Student to Board-certified Geriatric Psychiatrist

The demand for qualified and dedicated geriatric psychiatrists is acute. Board-certified specialists in this field are educated to treat the burdens of mental illness in late life. They possess a unique knowledge base that allows them to address a wide range of age-related bio-psycho-social issues and concerns.[3,9] Ideally, recruitment of students who eventually become well-trained geriatric psychiatrists will result in both qualified clinical specialists and researchers who better understand the biological and psychological components of mental health disorders in late life. In addition, there must be a continual focus on growing the ranks of geriatric psychiatric clinician-educators in order to ensure the continuity and integrity of the field over time, particularly as the target treatment population expands.[9]

In response to these demands, established educational pathways are in place to provide aspiring geriatric psychiatrists a route to becoming well-rounded, board-certified members of the geriatric psychiatry community. Basic educational requirements include 4 years of medical school followed by 4 years of approved residency training in general psychiatry. After residency, the next stop is at least 1 year of specialty fellowship training in geriatric psychiatry in an Accreditation Council for Medical Education (ACGME)-approved program. During the geriatric psychiatric fellowship, psychiatrists acquire highly specialized knowledge about aging and mental health. At this time, foundational medical knowledge, including neurology and the entire spectrum of geriatric medicine, is supplemented with training designed to enhance interpersonal and communication skills. Fellows also focus on practice-based learning, professionalism, and mastering system-based practices.[3]

Geriatric psychiatrists are eligible to become board certified by sitting for the American Board of Psychiatry and Neurology (ABPN) certification exams, starting with the exam in general psychiatry. After becoming ABPN-board certified in psychiatry, the next step is board certification in the subspecialty of geriatric psychiatry, which was first introduced in 2001. The availability of subspecialty certification in geriatric psychiatry represented a significant step forward for geriatric psychiatry as a field and heralded the medical community's recognition that older adults have a unique set of mental health needs that deserve the attention of a well-trained cadre of specialists[10]

Although subspecialty certification is optional, it is highly encouraged. Pursuing subspecialty board certification shows a high level of commitment and conveys to employers, patients, and caretakers that the certified individual possesses a solid theoretical and practical knowledge base, as well as a foundation for excellence in the day-to-day practice of geriatric psychiatry. There is also a financial benefit: AAGP survey results suggest that AAGP members who have subspecialty certification have higher salary levels than their noncertified counterparts. As of 2002, there were roughly 2500 geriatric psychiatrists who were board certified in their subspecialty -- a number that falls far short of what is needed.[3]

Addressing the Issues That Make It Difficult to Develop a Sufficient Pool of Qualified Geriatric Psychiatrists

Since the 1970's, opinion leaders and governmental agencies have been attempting to address the problems associated with aging in the United States. Starting with the creation of the National Institute on Aging (NIA) in 1974 and the Center on Aging at the National Institute of Mental Health (NIMH) in 1975, there has been growing recognition that lifelong health includes having access to medical care and psychiatric care as needed. By 1980, there were 11 geropsychiatry training centers and that number rose to 17 by 1986. ABPN began offering subspecialty certification in 1991, and just 3 years later, the first accredited geriatric psychiatry program was established. Despite this progress, program growth was slow early on, and there were a limited number of qualified candidates.[4]

Initially, program directors favored the idea of 1-year fellowship programs so that fellows could maintain the flexibility to pursue various training tracks, including clinical, academic, and research tracks. Despite this optimistic perspective, 1-year programs have limitations. In general, in the field of geriatric medicine, fellows with only 1 year of training are less likely to participate in academic career development, research, or publishing. In fact, there is a distinct "2-year advantage." Having 2 or more years of fellowship training is strongly correlated with multidisciplinary participation in the field of geriatric medicine. Longer-trained fellows are more likely to conduct research, publish articles, and submit abstracts for presentation at scientific meetings.[7] In addition, they are more likely to be active members in professional societies.[4] Experts suggest that 1-year programs provide the minimum training necessary to gain expert training as a geriatrician, but that more than 1 year is needed to develop top-notch research and academic skills[11]

So why aren't there more geriatric specialists, and geriatric psychiatrists in particular, who have 2 or more years of fellowship training? It fits in with the larger pattern of what is happening in the field in general. Although first-year enrollment in geriatric psychiatric fellowship programs has remained relatively stable, overall growth in the field is weak. Between 2001/2002 and 2004/2005, the number of first-year fellows in training decreased slightly from 81 to 76, which translated into a lower fill-rate (56% from 61%). However, the steepest drop-off was in second-year enrollment. Between 2001/2002 and 2004/2005, the number of second-year enrollees decreased from 13 to 3. This decimation in second-year fellows mirrored the overall decline in the total number of geriatric psychiatry fellows in any year of training -- a figure that declined from 94 to 79 during the periods compared, a 16% decrease.[5]

Part of the problem is that training opportunities beyond the first year of fellowship are still relatively limited. Based on a recent survey, approximately 78% of geropsychiatry programs offer 1-year fellowships. The remaining 22% of programs (10 programs in all) offer 2 or more years of training. Two programs offer 3 years of training and one program offers a 4-year fellowship.[12]

Certainly, financial factors make it more difficult for psychiatric fellows, who are often burdened with a great deal of debt, to extend their training. With average medical graduate debt in the United States in the $100,000 to $150,000 range, additional years of fellowship at the expense of starting clinical practice can be too costly for many fellows to bear.[4] One of the major initiatives in the field of geriatric psychiatry is the provision of funding aimed at helping geriatric psychiatrists who want to gain additional experience in clinical research or academic career development. [9] There is funding available for second-year fellows from various sources, including the Veterans Health Administration (VHA), which provides generous support, as well as the NIMH and the Bureau of Health Professions (BHPr). Based on survey results from 2001, the VHA provided 63% of funding provided for fellows beyond the first year of training. NIMH provided 38% of funding, private hospitals provided 25%, and the BHPr provided 12.5%. In addition, departmental money or revenues from clinical service was also used to fund longer-term fellowship training.[11]]

More Than Money: Becoming a Member of a Respected Club

In addition to governmental and institutional funding, a variety of programs exist to encourage aspiring and/or actual geriatric psychiatrists to develop their careers and capabilities. For those beginning to consider a career in geriatric psychiatry, the NIMH funds the Summer Training on Aging Research Topics-Mental Health (START-MH) program and provides competitive scholarships to undergraduate, graduate, and medical students with an interest in aging and mental health research. Attendees are mentored and gain early experience by participating in rigorous research projects. In addition, the AAGP offers two programs designed to increase interest in and exposure to geriatric psychiatry. The AAGP Stepping Stones Program grants 1-year fellowships to up to 70 individuals. The grant covers AAGP membership, complimentary registration, travel, lodging for the annual meeting, a 1-day workshop, and networking sessions with geriatric psychiatrists. Further along the career path, the AAGP Fellows Program is a remarkable 2-year opportunity that provides 6 chosen fellows with AAGP membership, with special emphasis on structured mentoring and career development.[3]

Clinical research is currently an area of interest for recruiters, as opinion leaders continue to focus on developing a wider body of knowledge about mental health and aging. Experts contend that the transition from completion of a postdoctoral fellowship to receiving a career development award is a critical make-or-break turning point. A built-in funding mechanism for promising junior clinical investigators can help make it easier to pursue a research career.[13] For fellows willing to commit to a 2-year clinical research career, the National Institutes of Health (NIH) offers a loan-repayment program in which it will pay up to $35,000 per year of qualified educational debt, plus federal and state taxes.[3] Another short-term opportunity is the week-long Summer Research Institute at the University of California at San Diego, which prepares a group of 25 to 30 fellows or junior investigators for an academic career in geriatric psychiatry.[3]

Unfortunately, funding for clinician-educators is more limited, however, there is some money available. The Title VII Geriatrics Health Professions Programs of the Public Health Service Act (interdisciplinary, community-based linkages section), supports 3 important geriatrics initiatives: the Geriatric Academic Career awards, which support career development of geriatricians in junior faculty positions who are committed to academic careers teaching clinical geriatrics; Geriatric Training for Physicians, Dentists, and Behavioral/Mental Health Professionals, which funds training for health professionals who plan to teach geriatric medicine, geriatric dentistry, or geriatric behavioral or mental health; and the Geriatric Education Centers, which train health professions faculty, students, and practitioners in diagnosis, treatment, disease prevention, disability, and other health problems of this age group. Funding for these programs was eliminated in fiscal year (FY) 2006, but was restored for FY 2007. The American Geriatrics Society and the Association of Directors of Geriatric Academic Programs, among other organizations, consider continued funding for these programs to be a top priority.[14] The US Department of Veterans Affairs also offers a Special Fellowship Program in Advanced Geriatrics, which provides training to physicians in geriatric medicine, geriatric psychiatry, and family medicine who have completed their clinical fellowship programs.[15]

Career Satisfaction in Geriatric Medicine

Though geriatric psychiatry as a field is underpopulated, geriatric psychiatrists are among the most satisfied physicians in practice. According to results of research conducted at the University of California Davis School of Medicine, clinicians who treat elderly patients report a high level of satisfaction.[3] In a separate study published in the Archives of Internal Medicine in summer 2002, an analysis of career satisfaction among a group of more than 12000 physicians revealed that those in geriatric medicine are significantly more likely to have "very satisfying careers" than family physicians. It turns out that geriatric specialists are more than twice as likely to be significantly happier than their peers in family medicine. In fact, physicians who specialize in geriatric medicine top the list when it comes to career satisfaction.[16] Some reasons why this field may be so rewarding are found in one small qualitative study, in which academic geriatricians identified the "intellectual challenges" and the "desire to feel needed personally and societally" as among the most attractive aspects of a geriatrics career.[17]

There are many tools being used to recruit, educate, and train promising candidates for the field of geriatric psychiatry, and knowing how satisfying it is to address the needs of older individuals is one more reason for interested medical students to commit to a career in geriatric psychiatry.

References:

  1. Alliance for Aging Research. Will you still treat me when I’m 65? The national shortage of geriatricians. May 1996. Available at: http://www.agingresearch.org/brochures/treatme/treatme.html. Accessed December 2, 2006.
  2. Jeste DV, Alexopoulos GS, Bartels SJ, et al. Consensus statement on the upcoming crisis in geriatric mental health; research agenda for the next two decades. Arch Gen Psychiatry. 1999;56:848-83.
  3. American Association of Geriatric Psychiatrists. Health care professionals: careers in geriatric psychiatry. Available at: http://www.aagpgpa.org/prof/careers_gerpsych.asp. Accessed April 6, 2007.
  4. Mickus M, Colenda CC, Hogan AJ. Knowledge of mental health benefits and preferences for type of mental health providers among the general public. Psychiatr Serv. 2000;51(1):199-202.
  5. Bragg EJ, Warshaw GA. Evolution of geriatric medicine fellowship training in the United States. Am J Geriatr Psychiatry.2003;11:280-290.
  6. Association of Directors of Geriatric Academic Programs (ADGAP). Longitudinal study of training and practice in geriatric medicine: training & practice update. October 2005;3:1-6.
  7. Feifel D, Moutier CY, Swerdlow NR. Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry. 1999;159:1397-1402.
  8. Lieff SJ, Tolomiczenko GS, Dunn LB. Effect of training and other influences on the development of career interest in geriatric psychiatry. Am J Geriatr Psychiatry. 2003;11:300-308.
  9. Medina-Walpole A, Barker WH, Katz PR, et al. The current state of geriatric medicine: a national survey of fellowship-trained geriatricians, 1990-98. J Am Geriatr Soc. 2002;50:949-955.
  10. Dunn LB, Blake L. The challenge and promise of geriatric mental health training. Am J Geriatr Psychiatry. 2003;11:264-266.
  11. Juul D, Scheiber SC. Subspecialty certification in geriatric psychiatry. Am J Geriatric Psychiatry. 2003;11:351-355.
  12. Lieff SJ, Warshaw GA, Bragg EJ, et al. Geriatric psychiatry fellowship programs in the United States: findings from the Association of Directors of geriatric academic programs longitudinal study of training and practice. Am J Geriatr Psychiatry. 2003;11:291-299.
  13. Detweiler MB. Do we need more creative solutions to increase the number of second-year and beyond geropsychiatry fellows?: a postfellowship viewpoint. Acad Psychiatry. 2004;28:157-158.
  14. Kupfer DJ, Hyman SE, Schatzberg AF, Pincus HA, Reynolds CF III. Recruiting and retaining future generation of physician scientists in mental health. Arch Gen Psychiatry. 2002;59:657-660.
  15. Health in Aging Advocacy Center. Code Blue issue: Restoring geriatric health professions Title VII funding. Available at: http://www.americangeriatrics.org/advocacy/TitleVIIPrimer.asp. Accessed on: April 6, 2007.
  16. United States Department of Veterans Affairs. VA Special Fellowship Program in Advanced Geriatrics. Available at: http://www.va.gov/oaa/specialfellows/programs/SF_AdvGeriatric.asp. Accessed on: April 6, 2007.
  17. Leigh JP, Kravitz RL, Schembri M, Samuels SJ, Mobley S. Physician career satisfaction across specialties. Arch Intern Med. 2002;162:1577-1584.
  18. Cravens DD, Campbell JD, Mehr DR. Why geriatrics? Academic geriatricians' perceptions of the positive, attractive aspects of geriatrics. Fam Med. 2000;32:34-41.

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