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related topics for a designated faculty leader, teaching aids, and related activities. RESEARCH GRANT SUPPORT Although the awards described above can provide a healthy environment for research and help start junior faculty on a research career, most research support as well as the long-term success of an academic research program depends on stable research grant support. Most research support from NIA is for biomedical research. However, two other federal funding sources pertinent to geriatrics are the NIA's Behavioral and Social Research Program and the Agency for Health Care Policy and Research. The best way to attract residents, fellows, and junior faculty with talent and interest in biomedical aging research is to have strong researchers as faculty in divisions of geriatrics. In addition, collaborating with other divisions or departments that have strong research programs can stimulate interest in aging research within and outside of geriatrics divisions. The potential contribution of basic scientists to academic geriatrics research programs remains largely untapped. In contrast, basic scientists in other specialties function as part of research teams, often holding appointments within the clinical department. These full-time researchers contribute

mightily to the success of research proposals and the productivity of funded projects. Development of such scientists can be supported by NIA fellowship programs, or departments of geriatrics can form liaisons with established researchers. One approach that uses liaisons with existing fellowship programs is the NIA Complementary Training Award for Research on Aging [4], which allows additional fellowship positions to be added to an ongoing fellowship training program. Although these and other NIA support mechanisms can be useful, departments may also need to invest other departmental revenues as seed money to support basic scientists in pilot studies. Funding for research projects may amply reward such investments.

From the Geriatrics Program, National Institute on Aging, Bethesda, Maryland. Requests for reprints should be addressed to Evan C. Hadley, M.D., Geriatrics Program, National Institute on Aging, Gateway Building, Suite 3E327, Bethesda, Maryland 20892.

REFERENCES 1. National Institutes of Health. The K Awards. 1993. (Available from the Grants Inquiries Office, Division of Research Grants, NIH, Bethesda, MD.) 2. National Institutes of Health. Guide to grants and contracts. September 17, 1993; 22. Bethesda, MD. 3. National Institutes of Health. Guide to grants and contracts. September 7, 1984; 13. Bethesda, MD. 4. National Institutes of Health. Guide to grants and contracts. January 15, 1988; 17: 8-11. Bethesda, MD.

Cycles, Clocks, and Power Plants ROBERT N. BUTLER, M.D., New York, New York

he title of this article should not seem too obscure to those in gerontology and longevity sciT ence, inasmuch as the life cycle is central to our work. A component of developmental biology, gerontology is concerned not only with aging, but also with longevity and death. Thus, it must explore not only how and why we age, but why we live as long as we do, as well as examine the nature of programmed death and disease-based necrosis. The content of academic gerontology covers cycles, such as the growth, development, and death of plants, animals, and humans. It should also include other cycles, such as past epidemics that have devastated populations. Such epidemics could conceivably change the age structure of populations in the future. The human species is still involved in a coevolutionary struggle, which we can lose to microspecies--viruses, bacteria, protozoa, prions, and so

on--some of which are powerful pathogens. From the point of view of such micro-species, the only function of a human is to provide them with nutrition, survival, and the opportunity for propagation. Clocks, too, are of great interest to academic gerontology. First is the great clock in the central nervous system, doubtless located in the hypothalamus; second, the sleep-wake cycle associated with melatonin production by the pineal gland; and third, the cellular clock that Leonard Hayflick and Paul Moorhead elucidated [1], bringing to an end the mythology of immortal cell replication created by Alexis Carrel [2]. And now there is exploration of telomeres, first hypothesized by Barbara McClintock [3], which may give us some further understanding of the pace of aging and its relation to cancer. What is it that has sustained life from its begin-

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APMSYMPOSIUMONGERIATRICEDUCATION/ BUTLER nings, perhaps 3.5 billion years ago? Then, certain blue-green algae "invented" photosynthesis and let loose free radicals. The sun is the source of all energy, which various life forms make use of. In mammalian and other life forms, mitochondria are the power plants, the sites of oxidative phosphorylation and adenosine triphosphate (ATP) generation. With the passage of time, energy fades. In humans, fatigue grows and reaction times prolong, independent of disease. It is clear why it is an important goal to understand celt energetics as they bear upon the vital questions of gerontology and longevity science. The great cycles of nature--its clocks, rhythms and timing, and the power and energy that propels all things--have fascinated people since the beginning of history.

HOW AND WHY WE AGE--AND HOW WE LEARN Theories of aging are determinant, stochastic, or a combination. All have made an appearance at one time or another in history, whenever there was reflection on aging and longevity. But how many of our contemporary students have even an inkling of this extraordinary terrain, the fascinating topics of aging and longevity? Biology textbooks in our secondary schools and even in our colleges and medical schools present little on these subjects to intrigue or even inform the student. Furthermore, there has been no major book on gerontology for the public that describes accurately what we know of how and why we age and live as long as we do. The exception is the now outdated but still interesting book by Alex Comfort on the biologic processes of aging [4]. We should soon have available a wonderful new book for the public by Leonard Hayflick called How and Why We Age, to be published by Ballantine Books. Medical students may only dimly recognize that the three great antecedents of all diseases are (a) genes ("bad" genes); (b) the environment, broadly defined to include the quality of our air and water, as well as what we eat and what we do; and (c) aging, The Gompertzian Curve holds that after age 30 the force of mortality increases exponentially, doubling every 7 years, yet we have devoted little conceptual, procedural, or financial energy to the understanding of the biology of aging and the increasing vulnerability to disease and dysfunction that comes with the processes of aging. Indeed, at the moment the National Institute on Aging's grant holdings are unbalanced. Perhaps no more than $50 million, if that, is devoted to the study of the basic biology of aging. Nearly 40-45% of the holding is devoted to Alzheimer's disease. As important as the disabilities of age--especially the 4A-36S

dementias--are, the intention was never to make the National Institute on Aging into the National Institute on Alzheimer's Disease. I favor every nickel that is being spent on Alzheimer's disease and would, indeed, encourage more. I am referring only to the imbalance within the institute, which must be rectified with more absolute funds devoted to academic geriatrics, basic biogerontology, and the relevant social and behavioral sciences. The images of clocks, cycles, and power plants are also relevant to education. We go through cycles of education, either pushing rote memory on the one hand, or on the other hand, encouraging students to engage in more active learning, such as that espoused by John Dewey. But the notion of a discipline implies the requirement of discipline. We spend too little time on deutero-learning, that is, helping students learn how to learn and to recognize that learning is a process as long as the life cycle itselfi The clock prescribes the amount of time given to any study and to continuing study (continuing medical education, in our case). The fuel--the power plant--for learning is acquired knowledge and its eventual application to the provision of services. Knowledge, therefore, is the power plant of learning. We have experienced a revolution in longevity in this century with nearly 28 years of added life expectancy in the United States, perhaps 20% of it from base age 65 and above. This is an extraordinary human accomplishment, which is not a function of biological evolution but of social evolution. That being the case, it is amazing that we have spent so little in the way of resources on the development of academic gerontology and geriatrics in U.S. medicine. How can we be so passive, given the fact that there are increasing demands being placed on geriatrics: first, the rising number of older persons, especially the frail old; second, the epidemiological relationship between aging and disease; third, rising health care costs; and finally, negative attitudes toward older people and aging in general, due perhaps to people's personal fears about growing old. We have yet another reason to promote development of gerontology and geriatrics--the very fact that there has been at least some increase in our understanding of aging in this century since 1906 when Eli Metchnikoff introduced the word gerontology and since Ignatz Nascher introduced the term geriatrics in 1909.

THE ROLE OF GERIATRICS Unlike U.S. medical schools, the medical schools of Great Britain all have departments of geriatrics. The Scandinavian countries have medical schools with departments of geriatrics, and Japan, never

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APMSYMPOSIUMONGERIATRICEDUCATION/ BUTLER one to be left behind, is following suit. Why do we have only one? Is it such a great idea to have geriatrics departments? If so, why don't we already have more? Is it because of the peculiarly U.S. preoccupation with youth? Is it due to the opposition of traditional medicine, especially academic internal medicine, which undoubtedly fears the further splintering of its field? I had to ask myself these questions during this, the tenth anniversary of the Department of Geriatrics at The Mount Sinai Medical Center. My own views are that we should not create a new practice specialty of geriatrics, but that we must have an academic and consultative specialty that would integrate and mainstream geriatrics within all primary and specialty care medicine, not only internal medicine. We also need geriatricians to be medical directors of nursing homes and available at continuing care retirement communities and naturally occurring retirement communities. I don't see how this can happen today if geriatrics is buried within another department or specialty, however well intentioned psychiatry, internal medicine, neurology, and some other departments are. I do recognize, of course, that there are outstanding divisions of geriatrics in departments of medicine in perhaps 15 or so schools, and there are important units of geriatric psychiatry within departments of psychiatry. I do not oppose divisions of geriatrics within psychiatry, medicine, neurology, and surgery; in fact, I favor them. I believe, however, that every medical school needs to have a strong geriatrics component that is autonomous and, therefore, central to the organization of the power plant. I see geriatrics as a perspective concerned with a stage of life, which calls for an interdisciplinary approach and interspecialty collaboration. The United States has a shortage of primary care physicians. Of the total number of U.S. physicians, 70% are specialists and 30% are primary care doctors, compared to the 50 : 50 ratio in most industrialized nations. There are outstanding general internists and family physicians who do practice primary care geriatrics. However, in general, academic internal medicine has become very fragmented and very devoted to organ-specific diseases. It is not as attentive as it should be to the complex, multicausal conditions found in older patients. Let me cite our department's outpatient services as an example of the kind of knowledge and skills that are needed. We are geared to patients with an average age of ->80, who have multiple, complex, interacting acute and chronic, as well as psychos0cial and physical pathologies. Half of our patients have psychiatric disabilities of one sort or another. Nearly as many have neurological signs and symp-

toms, and a substantial number require rehabilitative support. Our entire medical faculty is composed of board-certified internists with certificates of added qualifications in geriatrics. Because the goals of geriatrics are comprehensive assessment and individualized care and treatment with a view toward maintaining or restoring function, we use an interdisciplinary team model in our clinical services, which calls for physicians' collaborating extensively with nurses, social workers, and psychologists. We also have access on a consultative basis to such specialists as psychiatrists, cardiologists, orthopedists, gynecologists, physiatrists, physical therapists, neuropsychologists, and pharmacists. What are the obstacles to the development of academic geriatrics in the United States? First, there is the disease of academic stasis, somewhat endemic and difficult to prevent or treat. Second, there is a shortage of model programs and teachers, even though we now have perhaps 20 significant medical and psychiatric geriatrics programs at the 126 medical schools in the United States, compared to virtually none in 1975. Third, geriatrics is not a high-paying procedural specialty. The Physician Payment Review Commission, of which I was a member, has not yet succeeded in altering the balance of payment to physicians so that reimbursement for the primary care physician's work in evaluation and management is augmented while paymerits to procedural and surgical specialists and subspecialists are reduced. These days, of course, this must be done in a budget-neutral manner. Fourth, there has not been the kind of general federal support for geriatrics that there was for cardiology through the National Heart Institute, for example. During the Heart Institute's first 22 years of existence, it participated in the training of some 16,000 cardiologists. Had that not happened, I wonder if we would have the strong field of academic cardiology that exists today. Would we have had the dramatic reductions in deaths from heart disease and stroke that we have seen over the last two decades? Unfortunately, we have not had comparable development in academic geriatrics. Indeed, I had to negotiate with Senator David Durenberger (R., Minn.) and the late Senator John Heinz (D., Penn.) for an exemption from cut-backs in fellowship support in order to gain medical education funds for geriatrics fellowships through Medicare. NEEDED CHANGES IN MEDICAL SCHOOL EDUCATION AND ADMINISTRATION Medical schools go through educational cycles too. Most recently, they have been influenced by the MacMaster University medical school in Canada. As departments struggle over curriculum

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time, the curriculum clock does damage to the newest "kid" on the block, even when that kid relates to old folks. The locus of the educational power plant (the mitochondria, as it were) depends on the institution. It may be located in the dean's office or in the offices of the chairs of medicine and surgery. How can we change medical education and develop a framework in which academic geriatrics and gerontology can become respected and important parts of academic medicine in the United States? Money is a crucial factor. I recently testified before Senator Jay Rockefeller, (D., W. Vir.) Chairman of the U.S. Senate's Department of Veterans' Affairs Committee, and called for a federal geriatrics initiative, and I have made similar proposals to Senator David Pryor (D., Ark.), Chairman of the Aging Committee. What I have in mind is an effort to mobilize Medicare's Graduate Medical Education funding and the Department of Veterans Affairs funding to support and strengthen postgraduate programs. To do this means, in part, redirecting the power plant base from the hospital director, who controls the residency funds, to committees that would include the dean of the medical school as well as the hospital director, representation from longterm care (nursing home and home care program affiliates), and, where appropriate, an administrator from Veterans Affairs, since the majority of medical schools have affiliations with the Department of Veterans Affairs hospitals. It is time for the National Institute on Aging and the Department of Veterans Affairs to be gi~/en major responsibility and funding so that they may contribute to the building of academic geriatrics. I also believe that the private sector should contribute its share, as it has in other fields, by establishing endowed chairs, departments, and divisions. Here the goal is to ensure that every student graduates from medical school with a decent introduction to gerontology, and, of course, team-based functional diagnosis and clinical care of the elderly. Foundations and individuals can contribute on a proactive basis as well. Such foundations as the Brookdale, Commonwealth Fund, Hartford, and Dana have shown outstanding leadership in supporting geriatrics. With the assistance of the Alliance for Aging Research, the Commonwealth Fund is working to develop a physician-scientist program in aging. Philanthropists are generally older people and, therefore, more aware of the problems associated with aging in their own families. If they are given a sense that something positive can be done, philanthropists will, I believe, contribute to special endowments for research fellowships, research labs, and young faculty development, as well as clinical services funds and endowed chairs, depart4A-38S

ments, and divisions. A national campaign is in order. The American Board of Internal Medicine, the American Academy of Family Practice, and the American Board of Neurology and Psychiatry now offer examinations for certificates of added qualifications in geriatrics. However, we must be careful about counting the numbers of geriatricians in the United States. The 6,000 physicians who passed examinations to obtain certificates of competence in geriatrics do not constitute either a subspecialty group nor a cadre of academic geriatricians. Most gained their opportunity to take the examinations under the grandfather clause and, therefore, did not have fellowship training in geriatrics. Although it is required now that medical residencies provide a rotation in geriatrics in teaching hospitals, this does not mean that every medical intern and resident actually goes through such a rotation. This situation should be rectified. Another problem with residency or postgraduate education is the failure of programs to provide a longitudinal experience for medical interns and residents in order that they may better appreciate the nature of unfolding medical and social conditions of patients. There is also the failure to provide experience at a wide variety of sites, including long-term care institutions and home care programs and hospices, so that medical interns and residents can be exposed to the spectrum of care required as needs change over time. Moreover, we need to move medical schools beyond their limited hospital base and develop instead multi-site medical schools as well as multi-site residency training programs. It isclear that we are now at a point in the development cycle of gerontology and geriatrics where the gerontological knowledge we already have could be greatly expanded. The biological cycle is propelling the baby boomers, who now constitute 33% of our entire population, toward old age. The clock is running. The integration of the content of geriatrics in all primary care specialties is essential so that all students in the medical, nursing, and allied professions can be properly prepared to care for a growing older population. This must also include continuing education to update all providers. The power base of medicine must shift from preoccupation with organ-specific and procedurespecific medicine, the importance of which, nonetheless, should not be denied, toward a new balance of power shared with primary care, preventive care, and rehabilitative medicine. The energy or power plants that are centered in the dean's office and the offices of medicine and surgery chairs must be influenced by both the public and the private sectors, which should also play a large part in rais-

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ing endowment and operational funding for programs. Consumers--older persons and their famil i e s - a r e beginning to speak up, insisting on better integrated, gerontologically oriented care. I hope the baby boomers get the message and help lead the charge, for otherwise they will be a generation at risk when they grow old. A federal geriatrics initiative joined by individual philanthropists, foundations, and corporations must begin, with the goal of developing an outstanding cadre of academic and consultative geriatricians. In addition, general internal medicine and family practice should take leadership in the primary care of older patients. Rehabilitation medicine, psychiatry, and neurology should also play major roles in providing the best of care. Indeed, to respond effectively to the needs of older persons, all of primary care and specialty medicine must be involved. I

challenge academic medicine to take leadership and become the power plant that advances geriatrics in this country.

From the Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York, New York. Requests for reprints should be addressed to Robert N. Butler, M.D., Department of Geriatrics and Adult Development, Mount Sinai Medical Center, One Gustave Levy Place, Box 1070, New York, New York 10029.

REFERENCES 1. Hayflick L, MooreheadPS. The serial cultivation of human diploid cell strains. Exp Cell Res 1961; 25: 585-621. 2. Carrel A. Cited in reference 1. 3. McClintock B. Personal communication with Carol Greider. Cold Spring Harbor Laboratory, October 1992. 4. Comfort A. The biology of senescence. 3rd ed. Edinburgh, Churchill Livingstone, 1979.

The Merck Company Foundation and Geriatrics WILLIAM B. ABRAMS, M.D., West Point, Pennsylvania

of the Association of Professors of Medicine (APM) Geriatrics Curriculum DevelopSmentupport Conference by The Merck Company Foundation evolved from Merck's recognition early in the early 1980s that the aging of the population in this country and around the world represented a special concern, challenge, and responsibility for the drug development community. We at Merck recognized that the elderly were rapidly increasing in numbers, used medicines disproportionately, often exhibited differences in drug disposition and response, and were underrepresented in clinical drug trials. Furthermore, evidence was accumulating that prescribing for older patients was often suboptimal. Specifically, people >65 years of age represented approximately 12% of the U.S. population and were projected to rise to 20% by 2030. Numerically, this amounts to 30 million and >50 million persons, respectively. As a result of the frequency of illness associated with aging, this 12% of the population, then and now, use approximately 33% of all healthcare resources, including pharmaceuticals. Their healthcare resource use will reach almost 50% when this part of our population reaches 20% of the total.

Clearly, the pharmaceutical industry has an obligation to join the other elements of the healthcare enterprise in an effort to improve the well-being of our elders and to reduce total healthcare costs through the prevention, control, or cure of disease, disability, and dependency. Differences in drug disposition and response by older patients reside in reductions in organ function, particularly kidney, liver, heart, and brain; changes in body composition; alterations in the autonomic nervous system; and the presence of multiple diseases, and often multiple drugs. Underrepresentation in clinical drug trials in the early 1980s led to lack of information about prescribing for the elderly in official drug labeling, a prime source of information for prescribers--e.g., package inserts and the Physicians' Desk Reference. Recognizing these factors, the Food and Drug Administration, the pharmaceutical industry, the American Society for Clinical Pharmacology and Therapeutics, the Drug Information Association, and other organizations held a series of symposia and workshops. Merck was intimately involved in these programs. These collaborative efforts resulted in substantial changes in drug development

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