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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