a visit of high complexity with a new outpatient; a follow-up visit of moderate complexity (approximately 25 minutes) is reimbursed at a total rate of $55 for an established patient (Sheila Kopic, UCLA Medical Center, personal communication, 1993). Other insurance systems for younger patients (including capitated contracts) reimburse providers at far higher rates. Although there are no systematic data that support the view that the low levels of reimbursement for the care of the elderly patients may be an obstacle to adequate levels of recruitment into the field, there is a perception based on anecdotal evidence that the reimbursement issue is a major factor leading to the lack of attractiveness of geriatrics as a career track. This intensifies the shortage of faculty by two mechanisms: (1) inadequate recruitment into the field and (2) excessive use of faculty time to generate clinical income to bring faculty salaries to a level comparable to that of faculty in other disciplines.

Other obstacles in the academic environment that relate to the lack of attraction of geriatrics to faculty include the roles that academic geriatricians must assume. The rapid growth in numbers of programs in geriatric medicine must be tempered invariably by the fact that growth and quality may not be synonymous. There is evidence that many of the fellowship programs may not be of optimal quality; in a UCLA survey (1987), fewer than 15 percent of the programs at that time could be considered strong (Vivell et al., 1987). Weaker programs are less attractive to students at all levels, including the fellowship training level. Academic leaders in a field must have credibility in research, teaching, and clinical service or in a combination of these domains. In addition, those who have real credibility in research can only do the research if they are effective in acquiring extramural funding. However, in geriatric medicine other qualities of leadership have emerged. These include management and program development expertise and skills at relating with other academic departments and disciplines, and with community-based ambulatory care facilities, nursing homes, and other caregivers. These qualities, taken together with the complex medical needs of the elderly, may be more than one could expect to find in more than just a few extraordinary individuals. It suggests that the development of several types of leaders in geriatric medicine may be a more rational objective than what has been attempted to date.

Finally, the limited academic success of geriatricians as physician-scientists and clinical investigators has been an obstacle to the development of academic geriatrics. There is a convincing body of evidence that indicates that faculty must have been involved in extensive research training beyond that of the traditional 2-year fellowship for success in research. Data from several sources suggest that the median duration of research training lies between 3.5 and 4 or more years. Success in research is determined by a variety of criteria, including the ability to acquire independent funding through the investigator-initiated RO-1 award or comparable mechanisms (Oates, 1982).

Of note, other obstacles that were perceived to be major ones a decade ago—such as the lack of professional recognition in geriatrics—have now been solved and no longer appear to be major.



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