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Geriatric Medicine and Geriatricians

HISTORICAL DEVELOPMENT AND CURRENT TRENDS IN HEALTH CARE DELIVERY TO OLDER PEOPLE

The evolution of geriatrics began in the late 1800s and early 1900s. The first American textbook on the diseases of old age was published in 1914 by Nascher, who is also credited with having coined the term geriatrics (Nascher, 1914). Interest in geriatrics waned during World War I and resurfaced only briefly in the late 1920s and early 1930s. It has been suggested that physicians were reluctant to enter the field of geriatrics because it was considered to be less interesting than other fields and because of the difficulty in developing an economically viable practice. Elderly people were perceived as having less money and more illnesses than the rest of the population.

In the early 1940s, there was an upsurge of public interest in the status of elderly people and the diseases of old age. This led to the formation of the American Geriatrics Society (1942) and the Gerontological Society of America (1945). The American Geriatrics Society is a professional organization and its members primarily comprise physicians, while the Gerontological Society of America was designed to serve a much broader constituency. The founding of the societies was coincidental with the recognition that almost 7 percent of the population was over age 65 in the 1940s as well as the realization that the care of elderly people was a multidisciplinary process. This reemergence of activity was short-lived, and not until the 1960s was there a reawakening of concern for elderly people. The passage of the Amendments to the Social Security Act in 1965, known as Medicare, resulted from this concern. It is curious that in the face of a massive infusion of funds via Medicare for the medical care of elderly



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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions 2 Geriatric Medicine and Geriatricians HISTORICAL DEVELOPMENT AND CURRENT TRENDS IN HEALTH CARE DELIVERY TO OLDER PEOPLE The evolution of geriatrics began in the late 1800s and early 1900s. The first American textbook on the diseases of old age was published in 1914 by Nascher, who is also credited with having coined the term geriatrics (Nascher, 1914). Interest in geriatrics waned during World War I and resurfaced only briefly in the late 1920s and early 1930s. It has been suggested that physicians were reluctant to enter the field of geriatrics because it was considered to be less interesting than other fields and because of the difficulty in developing an economically viable practice. Elderly people were perceived as having less money and more illnesses than the rest of the population. In the early 1940s, there was an upsurge of public interest in the status of elderly people and the diseases of old age. This led to the formation of the American Geriatrics Society (1942) and the Gerontological Society of America (1945). The American Geriatrics Society is a professional organization and its members primarily comprise physicians, while the Gerontological Society of America was designed to serve a much broader constituency. The founding of the societies was coincidental with the recognition that almost 7 percent of the population was over age 65 in the 1940s as well as the realization that the care of elderly people was a multidisciplinary process. This reemergence of activity was short-lived, and not until the 1960s was there a reawakening of concern for elderly people. The passage of the Amendments to the Social Security Act in 1965, known as Medicare, resulted from this concern. It is curious that in the face of a massive infusion of funds via Medicare for the medical care of elderly

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions people, there was no professional or academic response to the medical needs of this patient population. Data on the number and characteristics of physicians with an interest in geriatrics were initially derived by the University of California, Los Angeles, and the RAND Corporation from a 1977 American Medical Association (AMA) survey (Kane et al., 1980a). Only 0.2 percent of responding physicians listed geriatric care as one of three possible areas of emphasis in their practices. Some 629 respondents listed geriatrics as their specialty: as the primary specialty by 371, as the secondary specialty by 187, and as the tertiary specialty by 71. Adjusting for the 88 percent response rate reported by the AMA, this was equivalent to 715 of the then 363,619 physicians in the United States. Physicians who listed geriatrics as their primary specialty most commonly considered their secondary specialty to be general or family practice, internal medicine, psychiatry, general surgery, or orthopedic surgery. The 125 physicians who indicated that geriatrics was their sole interest were older than the other responding physicians, and they were less likely to have specialty certification or to be members of professional societies. The emerging system of care for older people must be perceived within a larger system of health and welfare services that need to be mobilized and coordinated to bring about an appropriate level of quality care to the elderly. The two extremes of this system are the acute tertiary-care hospital and the home. Between these extremes lie nursing homes, board and care facilities, physicians' offices and ambulatory care clinics, day hospitals, other partial hospitalization arrangements and day-care centers, geriatric evaluation units—both ambulatory and institution-based, geriatric rehabilitation facilities, a variety of congregate housing arrangements that are integrated with the provision of health care, and other alternatives that have yet to be developed. Several decades ago, discussions about the care of elderly people led to a striking dichotomy of views. The “social model” argued that aging was a social problem with primarily social solutions, such as improved housing, income, and social services. The “medical model” stressed that accurate diagnosis and problem identification with appropriate treatment would lead to improvements in the functional status of elderly people and lessen their dependency. The proponents of the social model clearly felt that the responsibility for the care of elderly people should not rest solely with physicians but, rather, should be directed by more socially oriented professionals who could call in physicians for technical assistance to address strictly medical problems. Clearly, at the time and perhaps even more strongly now, the distinction between the social and medical models might be useful conceptually in highlighting the complex interactions of the multiple problems that beset some elderly individuals. The dichotomy is a counterproductive one, however, and to facilitate the delivery of appropriate care to the elderly, a melding of both approaches is critical.

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions UTILIZING AND FINANCING HEALTH SERVICES With the greater prevalence of chronic conditions in older people, it is not surprising that they use medical personnel and facilities more frequently than the younger cohorts do (Aging America: Trends and Projections, 1991). On average, people over age 65 visit a physician nine times a year, whereas the average for the general population is five visits a year. They are hospitalized over three times as often as the younger population, their hospital stays are 50 percent longer, and they use twice as many prescription drugs. Health care utilization is greatest in the last year of life and among those who are over age 80. Those over age 85 have a threefold greater risk of losing their independence, seven times the chance of entering a nursing home, and two and a half times the risk of dying than people 65 to 74 years of age. The use of hospitals by older people, as measured by the number and rate of hospital discharges, rose steadily between 1965 and 1983 but has declined steadily since then. Average hospital length of stay has also been declining until recently. This indicator fell from 14.2 days per stay in 1968 to 8.5 days in 1986, but it then rose to 8.9 days in 1988. In 1987, people over age 65, then representing 12 percent of the population, accounted for 31 percent of all hospital discharges and 42 percent of all short-stay hospital days of care. The population age 75 and over (5 percent of the population in 1987) accounted for 16 percent of all hospital discharges and 23 percent of all hospital days. Most hospital admissions of older people are for acute episodes of chronic conditions. The demographic changes will create a greater demand for physician care. According to projections based on 1989 physician contact rates and projections for the noninstitutionalized elderly population, the demand for physician contacts will increase by 22 percent (from 259 million to 296 million contacts) by the year 2000 and by 115 percent (to 556 million visits) by 2030. In addition to physician and hospital services, older individuals use professional dental care, prescription drugs, vision aids, and medical equipment and supplies at higher rates than the rest of the population. Medicare's home health benefit expenditures are one of the fastest-growing components of the Medicare program. In 1989, Medicare's Hospital Insurance paid $2.1 billion for home health care for people over age 65, up from only $437 million in 1980. Acute-care services are primarily covered by Medicare; only 5.2 percent of acute-care services were not covered in 1989. In addition to Medicare coverage, many older people are also covered under private health insurance, which either is available from their current or former employers or is purchased independently (so-called Medigap insurance). The Medicaid program is directed at low-income people and so also covers low-income elderly people; among older people living in the community in 1989, 6 percent were enrolled in the Medicaid program as well as in Medicare. Medicaid is the primary source of public payment for nursing home care, and the vast majority of the elderly lack both public and

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions private insurance coverage for long-term care. In 1987, one third of the country's personal health care expenditures was for people over age 65, and per capita spending for health care for the elderly reached $5,360 in 1987. Of this total, the elderly paid more than one third of the cost directly through direct payments to providers or indirectly through premiums for insurance. The estimated cost of personal health care expenditures for the elderly in 1987 was $162 billion. Major portions of the health care system in the United States are oriented toward acute illness and the practice of specialty and subspecialty medicine. Although these elements are highly developed and meet some of the health care needs of the elderly, the basic approach does not respond to the regularly expected health care experiences of older people. Many elderly people do not have access to primary medical care services. Individuals requiring multiple types of health care services often find such services disarticulated and in separate sections of their community. Continuity of care for older people is difficult to achieve. Whereas younger patients with acute illnesses can find health care providers who are interested in their usually straightforward medical problems, elderly patients—with their complex medical, mental health, social, and economic problems—encounter substantial difficulties locating health care providers with the requisite attitudes, interest, knowledge, and skills in geriatric medicine. For most people over age 65, the Medicare experience has been, on the whole, a positive one. Coverage for acute care services in the hospital has been good; that for physician services has been fair. Major deficiencies relate to costs—both to the individual and to society—and the failure to cover preventive and long-term care. These omissions have an effect on health and contribute both to the ever-increasing fragmentation of services and to the unacceptable rise in costs. In the future every elderly person should have access to an identifiable source of primary care. Such care should emphasize responsible and continuing surveillance by a primary care practitioner, usually a family physician, general internist, or a nurse practitioner or physician 's assistant specially trained to deal with older people. The availability of periodic preventive services, referrals to specialized services, long-term and terminal care, and centralized comprehensive medical records is essential for such primary care. There appears to be consensus on the view that the care of the elderly population should primarily be the responsibility of appropriately trained primary care physicians. A 1978 Institute of Medicine (IOM) report initially recommended that geriatrics should be developed and recognized within various disciplines in order to advance research and education in geriatrics/gerontology and to train leaders in the field (Institute of Medicine, 1978). This view is still the predominant one. The various disciplines, however, have responded to this recommendation with different levels of enthusiasm (Beck and Vivell, 1984). It

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions is important to emphasize that since publication of the 1978 report there have been substantial changes: (1) there clearly has been a growing acceptance of geriatrics as a discrete area within medicine that requires special knowledge and skills; (2) there has been increasing financial support for faculty, program development, and research in geriatrics from both the public and private sectors; and (3) there is evidence of increasing interest in geriatric educational programs, although the quantity and quality of that training, especially at the undergraduate and graduate levels, are considered suboptimal. Reform in health care has focused primarily on cost, quality, and access. The Pew Health Professions Commission was the first to identify an essential element for reforming the health care system that was missing, namely, the education and reeducation of health care professionals (O'Neil, 1993). They emphasized that the skills, attitudes, and values of the nation's 10 million health care workers have a fundamental impact on health care. The kind of care that health professionals provide, how they provide it, what they value, how they interact with patients, how they define quality, and how efficiently they work determine to a great extent the quality, cost, and availability of health care. Thus, the reformation of the health education system is a major foundation of the long-term reform of health care. Although the future of health care is always perceived dimly, it is reasonably certain that it will be oriented more toward health —stressing injury and disease prevention, health promotion, and elimination of environmental hazards, as well as individual responsibility for health-related behaviors. At the same time, it seems reasonable to predict that the system will be population based and that much activity will be concerned with the community's needs as well as with the needs of the individual patient. Consumer participation in health care-related decision-making will clearly accelerate the availability of information on the outcomes of interventions and treatment effectiveness. It can also be reasonably predicted that care will be much more integrated and coordinated, with teams of providers carrying responsibilities quite different from those held by today's providers, who provide care largely on an individual provider-oriented basis. The revolution occurring in the information sciences will also play a prominent role. Thus, in considering reform of the health and medical education systems, geriatrics emerges as one of the templates for demonstrating many of these new attributes of the health care system. ROLES OF PHYSICIANS: GENERALISTS AND SPECIALISTS During the last one to two decades there has been a growing recognition that there is a need for physicians who are better trained to care for the elderly population. There has been less agreement on how this need should be met. In essence, four options have been considered:

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions The 1978 IOM report supported continuation of the heavy reliance on existing physician types—especially primary care providers in internal medicine and general and family practice (Institute of Medicine, 1978). It envisaged more intensive training in geriatrics during medical school and graduate medical education and remedial education in geriatrics through continuing medical education for those already in medical practice. This would require a cadre of academic geriatricians whose sphere of influence would be confined to the academic medical centers. However, it should be pointed out that the training of such a cadre of academicians would also produce a core of practicing geriatricians because experience from multiple fellowship training efforts would suggest a “spillover” rate of 40–50 percent into private practice. A second option was the development of trained geriatricians who would perform both the academic and the practice roles. It was envisaged that they would serve as consultant specialists in the management of complex geriatric problems and, possibly, would also maintain ongoing responsibilities for some subset of older patients. A third approach was an attempt to estimate the need for geriatricians by identifying the areas in which their activities would be focused. In this scenario, a strong emphasis was placed on nursing homes and teaching hospitals for the estimates. Finally, the option of producing a cadre of specialist physicians whose primary role was to look after the elderly just as pediatricians look after children was examined. Clearly, this option was ruled to be not feasible in the work force modeling studies that were done at the time (Kane et al., 1980b). From a variety of national data sets, it is clear that the bulk of medical care for the elderly age group in the United States is provided by primary care physicians. This was very apparent in an examination of practicing physicians by the University of Southern California 's Division of Research in Medical Education (Kane et al., 1980a). It indicated that approximately 80 percent of all visits to physicians by people age 65 or older were made to primary care physicians. Conversely, at that time elderly people made up 30–40 percent of these physicians ' practices. From the same data base, it was evident that family and general practitioners provide the largest proportion of non-hospital-based care and that general internists provide the largest fraction of hospital-based care. CERTIFICATION OF GERIATRICIANS Beginning in 1988, the American Boards of Internal Medicine and Family Practice jointly offered a certifying examination for a Certificate of Added Qualifications in Geriatric Medicine (CAQGM). Certification is intended to provide a means by which internists and family physicians can obtain formal recognition

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions of their expertise in geriatric medicine. Physicians have been admitted to the examination through one of four pathways: (1) the completion of 2 years of advanced training in geriatric medicine; (2) the completion of 2 years of advanced fellowship training in general internal medicine, including 1 year of acceptable training in geriatric medicine; (3) certification by the American Board of Internal Medicine in a subspecialty and the completion of advanced training in geriatric medicine; and (4) a clinical practice pathway (available only through the 1994 examination) that allows diplomates who can document at least 4 years of substantial practice experience involving elderly patients to sit for the examination (subspecialty certification has been accepted as the equivalent of 2 years of substantial practice experience) (Steel et al., 1989). During the first year it was offered, 4,282 diplomates sat for the examination and 56 percent passed. Performance on the examination was positively correlated with scores on the general certifying examinations and with training in geriatric medicine (Steel et al., 1989). Of those physicians who passed the examination, 11 percent of internists and 5 percent of family physicians had formal training in geriatrics. Reuben et al. (1990a) surveyed candidates for the first CAQGM examination as well as a comparison group of physicians who had not expressed interest in the examination. The vast majority of physicians who took the examination (92 percent of internists and 84 percent of family practitioners) reported that the care of older persons was a focus of their professional work. However, a substantial minority of those physicians without interest in the examination (39 percent of internists and 42 percent of family practitioners) also stated that the care of older people was a focus of their professional work (Reuben et al., 1990a). The CAQGM examination was offered subsequently in 1990 and 1992 to internists and family physicians and is being offered in 1994. The numbers certified and the number of these who have had formal training are presented in Table 1. In 1991 the American Board of Neurology and Psychiatry offered its first certifying examination in geriatric psychiatry. To be eligible, an applicant must have completed a minimum 1-year fellowship in geriatric psychiatry, or an applicant may be eligible through a clinical practice pathway (available during the first 5 years) by virtue of spending 25 percent of his or her practice time with geriatric patients. Four hundred ninety psychiatrists were certified in 1991, and an additional 359 were certified in 1992 (Table 1). REVIEW OF LAST DECADE OF INITIATIVES AND PROGRAMS IN EDUCATION AND TRAINING IN GERIATRIC MEDICINE During the period from 1981 through 1992,both Federal and private monies have been devoted to geriatrics training (Laura Robbins, The John A. Hartford Foundation, personal communication, 1993). The programs will be described in this section, and the outcomes of those programs will be described in Chapter 3.

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions TABLE 1 Numbers of Certified Geriatriciansa   No. Certified in:     1988 1990 1991 1992 Total Internal medicine 1,645 1,204   1,254 4,103 Formal training 183 178   123 484 Family medicine 753 473   597 1,823 Formal training 43 25   65 133 Psychiatry     490 359 849 Total 2,398 1,677 490 2,210 6,775 a The first examination was given in 1988, but none was administered in 1989 or 1993. No examination was given in internal medicine or family medicine in 1991. The first examination was given in psychiatry in 1991. Federal support has come from the National Institute on Aging (NIA), the National Institute of Mental Health (NIMH), the Bureau of Health Professions, and the U.S. Department of Veterans Affairs (DVA). NIA invested approximately $58.8 million in research training during that time period. NIMH has had two programs; the first supports pre-and postdoctoral research training on aging and has supported approximately 25 to 30 trainees per year, and the second is the Career Development Award mechanism for physicians. NIMH estimates that approximately $19 million has been spent on training since 1982. The Bureau of Health Professions has supported the training of 57 two-year fellows between 1989 and 1992 and the 1-year retraining of nine physicians in geriatric medicine during the same time period. The investment was approximately $14.6 million. DVA has supported training through the Geriatric Research Education and Clinical Centers (GRECCs) and by supporting non-GRECC fellows. Approximately 284 geriatric medicine fellows have been supported since 1982, and total estimated support has been $27.7 million. In 1991, DVA began training geriatric psychiatry fellows at nine sites, and 12 psychiatrists had graduated as of June 1993. In 1993, DVA began training geriatric neurology fellows at four sites; seven neurologists have enrolled, but none has yet graduated from these programs (W. F. Dube, DVA, personal communication, 1993). The John A. Hartford Foundation began its Aging and Health program in 1983, initially with a strategy to train midcareer faculty to become leaders in academic geriatrics. The program supported 29 scholars over 5 years. Following

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions the advice of an Institute of Medicine report in 1987, the next phase of the foundation's efforts in this program was the Academic Geriatrics Recruitment Initiative, which concentrated resources in Centers of Excellence in geriatrics. Initially, 10 centers were funded, and this number was expanded to 13 in 1991. The foundation has also supported the cross-training of five other specialists (in anesthesiology and gynecology) in geriatrics. Under the Aging and Health program, commitments to academic geriatrics since 1983 have totaled $10.1 million (Donna Regenstreif, The John A. Hartford Foundation, personal communication, 1993). Since 1985, the Brookdale Foundation has supported 28 fellows, providing support totaling $5.6 million. The Commonwealth Fund has provided $1.7 million for training in geriatric medicine, but funding was discontinued in 1992. The Dana Foundation no longer funds training in geriatric medicine, but between 1985 and 1991, 27 Dana Foundation fellows were supported at a cost of approximately $2.5 million. Since 1987, the Merck Foundation has supported two junior faculty per year for geropharmacology or geroepidemiology research. Merck 's estimated contribution to geriatric training has been $1.4 million. Each year, Pfizer has supported two 2-year postdoctoral scholarships for geriatric pharmacology research; since 1982, Pfizer has devoted an estimated $1.3 million to this training program. SmithKline awarded a one-time grant of $1.5 million to the University of Pennsylvania for training in geriatric medicine. The Travelers Insurance Companies have awarded a $1.0 million endowment to the University of Connecticut for the Travelers Center on Aging, whose mission includes training. Over the 10-year period, these governmental and private sources of funding for training in geriatric medicine have contributed a total of $145.2 million. PROFILES AND INVENTORY OF GERIATRICIANS A number of studies have attempted to characterize the practices of former geriatrics fellows and geriatrics faculty. According to recent figures provided by the National Study of Internal Medicine Manpower, a considerably higher percentage of graduates of geriatrics fellowship programs enter full-time academic positions compared with graduates of cardiology and pulmonary fellowship programs (Table 2). Siu et al. (1989) surveyed graduates of training programs in geriatric medicine and geropsychiatry who had completed training as of July 1, 1986. That study revealed that the typical alumnus of fellowship training in geriatric medicine is an internist who spends roughly half of his or her time on direct patient care and about one-half of a day a week each on research and on teaching, with most of the patients being seen in an ambulatory care setting or in a hospital. A substantial percentage of graduates in each specialty reported that they spent more than half of their time in direct patient care (44

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions percent of the geriatric medicine graduates and 39 percent of geropsychiatry graduates). Medical school appointments were held by 69 percent of geriatric medicine graduates and 83 percent of the geropsychiatry graduates. Only 6.7 percent of geriatric medicine graduates and 3.3 percent of geropsychiatry graduates spent more than 50 percent of their time in research. The limited number of publications by faculty geriatricians was similar to that by faculty in general internal medicine programs (who averaged 1.3 papers annually). The problems that confront faculty in these two specialty areas with respect to their progress in academe seem somewhat similar. The low publication rate among the graduates surveyed also suggests that scholarly research activities might not have been optimally pursued during their training. TABLE 2 Activities of 1991–1992 Graduates of Geriatrics, Cardiology, and Pulmonary Fellowship Programsa   Percentage Activity in the Next Year Geriatrics Fellows Cardiology Fellows Pulmonary Fellows Continued training 15 16 15 Full-time academic position 37 22 25 Full-time practice       Outside hospital 27 48 44 Hospital position 12 5 7 Other 10 8 8 a Data are based on National Study of Internal Medicine Manpower Study data (Kohrman et al., in press). Totals may not add up to 100 percent because of rounding. On the basis of the results of that survey, physicians who had completed fellowships in geriatrics appeared to be involved in providing interdisciplinary services (involving health professionals other than physicians) to patients older than those seen by other types of primary care physicians. Whereas patients over age 65 account for approximately one third of office visits to internists, the geriatricians in the survey reported that people over age 75 alone accounted for 45 percent of their patients. Not surprisingly, they also reported spending more

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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions time on each patient visit. Over half of the formally trained geriatricians reported that they spent more then 40 minutes on each new patient. This is in comparison with a reported 28 minutes for internists and 17 minutes for family physicians seeing new patients over age 65 (Radecki et al., 1988). Assuming that there are no differences in efficiency, this would suggest either that the geriatrician's patients are more complex or that the geriatrician is providing a different type of clinical service. Both of these possibilities are supported by the fact that geriatricians reported in the survey that they use interdisciplinary services extensively. Of those who responded to the survey, 93 percent were either satisfied or very satisfied with their decision to pursue a career in geriatrics. Greater satisfaction with geriatrics was reported by those physicians whose current activities most closely resembled the model advanced by the professional leaders in the field (i.e., an academic leadership role). Characteristics that were independently predictive of satisfaction included practices in which more than 50 percent of the patients were over age 75, practices in which more than 50 percent of the patients were prepaid, practices in which the geriatrician accepted patients through Medicare assignment, the geriatrician had a role as a clinician-researcher, and the geriatrician had a medical school appointment (Siu and Beck, 1990). They expressed the least satisfaction with resource-related issues. Their responses indicated that they were relatively dissatisfied with their work force and personnel resources and their abilities to meet the complex needs of elderly patients. Similarly, they reported low levels of satisfaction with their own salaries and incomes. The relationship between lower income (the rule among geriatricians) and professional satisfaction has been reported by others (Kravitz et al., 1990). These frustrations with resources were not surprising given the limited reimbursements available for cognitive evaluation and management services of elderly people. Barker and Podgorski (1991) reported somewhat different figures on the basis of a survey of physicians who completed geriatric fellowships from 1980 to 1988. More than 60 percent reported currently active participation in research, and 85 percent reported that they did some teaching in geriatric medicine. A nationwide survey of geriatrics faculty in five specialties (internal medicine, family practice, neurology, physical medicine and rehabilitation, and psychiatry) in 1989 indicated that a minority (46 percent of internist faculty and 38 percent of family practice faculty) had received formal training in geriatric medicine. These faculty in geriatric medicine spent their professional time teaching, primarily in association with patient care delivery (32 percent across all specialties), research (13 percent), and administration (8 percent). Of particular note, 30 percent of the time of geriatrician faculty was spent providing nonteaching patient care or care to people younger than age 65 (Reuben et al., 1991).