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Educating the work force for geriatric care
Educating the Work Force for Geriatric Care JOHNA. BENSON,JR., M.D., Portland, Oregon
he Institute of Medicine (IOM) has convened T three studies of medical education related to aging. The first, held in 1978, resulted in the Beeson Report, which recommended that geriatrics be recognized as an academic discipline within the relevant medical subspecialties [1]. The second study, in 1986, concluded that the needed growth in academic training in geriatrics could best be conducted in "centers of excellence," which would focus on training physician faculty geriatricians [2]. The third study was charged in 1993 by the John A. Hartford Foundation to determine the current status of geriatric training in relevant medical disciplines and to provide recommendations on the most effective strategies for strengthening training of physicians in geriatrics. It was reported in a workshop held 2 weeks before the conference on which this supplement is based and included a review of future geriatrics work force requirements, given the progress made since 1986. It was published in late 1993 [3]. The IOM committee was interested in both academic and practice manpower; training in such specialties as emergency medicine, psychiatry, and the surgical subspecialties, as well as in the primary care specialties; and methods to make this "academic specialty," as characterized by the Beeson Report, more attractive. Its 1993 recommendations must be justified in the context of four important salients: (a) healthcare reform, including the expectation of little or no new resources, the development of basic benefits packages, competition among managed care organizations, and capitated payment systems; (b) recognition that geriatrics practice is inherently interdisciplinary; (c) the anticipated consortia of graduate medical education institutions; and (d) the rapidly increasing numbers of skilled geriatric nurse practitioners and medical social workers vital to a successful team effort in proper healthcare for the elderly. The IOM committee recognized that physicians must learn geriatrics along with colleagues in other professions and that increasing geriatric content only in physician-driven curricula and certification will not fulfill the larger
From the American Board of Internal Medicine, Portland, Oregon. {This publication does not necessarily reflect the opinions or policies of the American Board of Internal Medicine.) Requestsfor reprints should be addressed to John A. Benson,Jr., M.D., President Emeritus, the American Board of Internal Medicine, 200 SW Market Street, Suite 1950, Portland, Oregon 97201.
obligation of our respective professions to the elderly.
BARRIERS TO PHYSICIANS'PURSUINGGERIATRIC CAREERS Perceptions Young physicians may perceive geriatrics to be uninteresting or clinically unrewarding. They may define the work as managing chronic complex diseases, rehabilitation, and functional assessment, which may seem less compelling than curing acute illness. Some may avoid the field because they feel uncomfortable with the elderly or because nursing home patient care is not "high tech." More established specialties may seem more appealing: Geriatrics has received external recognition through certification only since 1988.
Economics Many expect a geriatric career to offer a lower income and burdensome paperwork.
Training A scarcity of role models, restricted and diminishing budgets for training, poorly supervised training at primary care sites, lack of funding for training by Medicare A, and the fact that department chair and deans rate geriatrics as low priority are also obstacles to pursuing geriatric careers.
AVAILABILITYOF GERIATRICSTEACHERS There is currently a shortage of geriatrics teachers. From 1988 to 1994, certified internists and family practitioners whose geriatric practice totaled ->25% of their total practice for ->4 years have been qualified to take the Certificate of Added Qualifications (CAQ) examination without formal training in an accredited geriatrics fellowship. Approximately 6,000 primary care physicians have been awarded a certificate of special competence in geriatric medicine since 1988 (Table I). (This is more than the number certified by the American Board of Internal Medicine in six other subspecialties for which examinations have been available for 20 years.) Approximately 90% have been certified via the practice, or "grandfathering," pathway. The shortage of geriatrics teachers exists because most geriatricians are in practice outside of academic medical centers. Relatively few geriatricians have received the kind of formal training desirable for substantial academic careers that those in more classic subspecialties have received.
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)
4A-3S
APM SYMPOSIUM ON GERIATRIC EDUCATION / BENSON
TABLE! Number of Medical Practitioners Certified in Geriatric Medicine/Psychiatry 1988-1993 Board
1988
1990
1991
1992
Total
ABIM ABFP ABP&N
1,654 753 -
1,204 473 -
490
597 359
4,112 1,823 849
ABIM.= AmericanBoard of InternalMedicine;ABFP= AmericanBoard of FamilyPractice;ABP&N American Board of Psychiatry and Neurologyl
TABLE II Hospital Geriatdc Services Grow Slowly Typeof Program
Hospitals .k
Adultdaycare
7.3% 10.2% 20.3% 31.5% 11.0% 8.1% 16.5% 19.4%
Alzheimer'sdiagnostic/assessmentservices Comprehensivegeriatricassessment Geriatricemergencyservices Geriatricacutecareunit Geriatricclinic Respiteclinic Seniormembershipprogram *Percentage of hospitals offering program. Source: American Hospital Association, 1993: Responsesfrom 6,044 hospitals.
TABLE III Community Hospitals Atrophy
Region
Numberof instit.tionsin " (1991)
Difference from1990
WestCoast Mountains No~ Central SouthCentral Midwest Mid-South Southeast Mi~tlautic NewEngland
633 353 726 758 819 461 801 563 228
- 11.6% -3.8% -8.9% -10.5% -9.4% -6.3% -2.7% -8.5% -9.5%
Source: American Hospital Association, 1993 .
Clinicians certified via the practice pathway represent a reservoir of expertise. They could serve as role models for students and residents if they were recruited into volunteer faculties and served as preceptors in extended care facilities, nursing homes, hospices~ and clinics. The shortage of geriatric faculty will be aggravated as the numbers of new certificants decline with closure of the practice pathway after the 199.4 examination, unless applications to geriatrics fellowships of >-2 years increase substantially. GERIATRICS SERVICE PROGRAMS Hospitals • Relatively few hospitals have set up programs aimed at-older patients (Table II) [4]. Geriatric ser4A-4S
October 17, 1994
The American Journal of Medicine
vices are poorly reimbursed through insurance. Indeed, hospitals themselves are not doing well (Table III) [5]. Community hospitals closed at the rate of approximately 10% per annum in 1990. Capital investment is lagging, and new training and geriatric service sites are not being developed to meet the needs of the population. However, the graying of the U.S. population has led to an increase in geriatrics programs in university hospitals [6]. Geriatrics programs identified at 41 medical centers, all major academic institutions, were rated on reputation, mortality rate, ratio of residents to beds, and ratio of board-certified physicians to beds. The team approach central to care of the elderly is part of the ethos of such institutions. Obviously, those in major educational enterprises believe geriatrics is important. ACADEMIA I hold that geriatrics is specialized primary care (i.e., more specialized than internal medicine) of the elderly and is the particular province of internal medicine, We must depend primarily on generalists to provide the bulk of care to the elderly. Therefore, this supplement should focus on the improvement of education, particularly the augmentation of geriatrics curricula in internal medicine and family practice residency programs. Training of >-6 months duration should be established under the supervision of qualified geriatricians. Published standards for geriatric medicine fellowships [7] can be used as the basis for qualifying the sites and content. Medical schools and professional societies qualifled by the Accreditation Council on Continuing Medical Education (CME) should mount selfsustaining CME exercises to retrain the estimated oversupply of 100,000 specialists and subspecialist physicians who are unlikely to have feasible roles in systems of capitated payment and managed care systems. An enormous need exists for more and better research in geriatric medicine. At present <15% of geriatric faculty time is devoted to research. Demand for clinical care of patients >65 years of age is high, and many faculty are also involved in the care of patients <65 years, often, without responsibility for teaching [8]. If this numerically few and muchin-demand faculty is to develop the investigative skills and achievement needed for promotion and tenure, department chairs need to organize a supportive environment for research. A contented, productive faculty advancing its science will attract new recruits. Deans and department chairs have a responsibility to society a n d our profession to strengthen training and research in geriatric medicine.
Volume 97 (suppl 4A)
APM SYMPOSIUM ON GERIATRICEDUCATION/ BENSON
TRAINING OF OTHER SPECIALISTS Although primary care physicians and nurses provide most geriatric medical care, surgeons, urologists, anesthesiologists, and others still require training in geriatrics. Physicians in many specialties will treat an increasing number of elderly patients. All residents should receive some training in the special problems of elderly patients related to their disciplines. Certainly, programs in psychiatry, neurology, emergency medicine, and physical medicine and rehabilitation should include particular training in geriatrics. But for the other specialists, geriatrics requires the team care model, and these other specialists can call in consultants as needed.
TABLEIV Levelsof GeriatricsExpertise Domain Geriatricnursepract~oner (graduatetraining) Clinicalnursespecialist (graduatetraining) Primarycarephysician Geriatricsclinician
Geriatricianor geriatrics specialist
STRUCTURE oF GERIATRICSWORKFORCE Because geriatrics practice is inherently interdisciplinary, collaboration of several professions in a team operation is necessary. Regrettably, primary care physicians have often been slow to delegate authority, to learn to be managers, and to overcome long-standing tensions with nurses and social workers involving decision making, acknowledgment of each others' skills, and sharing liability risks. The autonomous solo entrepreneur is giving way to medical acolytes more comfortable in group endeavors and shared responsibility. That attitudinal change is good and will enhance care of the elderly. Expertise in geriatrics may be considered according to the schema outlined in Table IV. According to this framework, policies to fulfill workforce goals can be implemented in a more logical, organized way. Planning, training, funding, and research toward such a collaborative organization of skills and functions has merit. This schema offers the educational advantage of interdisciplinary training, with physicians, nurses, and others learning side by side. Given the current and anticipated shortage Of generalists and the insufficient number of geriatric specialists being trained, What alternatives are available? One proposal is to leave primary care and health promotion for the elderly to general internists, family physicians, osteopathic physicians, and others with geriatric training. Physicians with academic training in geriatrics (the geriatrics specialists) could then be reserved for the more complex, high risk, and refractory cases. Those with sophisticated training in the care of the elderly Could also act as medical directors of nonhierarchical collabor a t i o n s - a s consultants and coordinators of nurse practitioners, nutritionists, rehabilitation and occupation therapists, pharmacists, audiologists, and medical social workers in planning the care for certain groups of elderly people. Certified geriatric
Practitioner " Nursinghomes,ECF Prevention Healthpromotion Practitioner Nursinghomes Practitioner Medicaldirector Clinicalfaculty ECF Hospice Consultation Full-timefacu~ Research Teamleader HCOmanager NIA VA
Certification StateBoardsof Nursing ANA ABFPor ABIMin primary specia~ ABFPorABIMinprimary specialtyplusspecial trainingand/orcertification in GeriatricMedicine ABFPor ABIMinGeriatric Medicine ABP&NinGeropsychia~
ABFP= AmericanBoardof FamilyPractice;ABIM= AmericanBoardOfInternalMedicine;ABP&NAmerican Board of Psychiatry and Neurology; ANA = American Nursing Association; ECFExtendedcare facility;HCO = Healthcare organization;NIA = Nationallnstituteof Aging;VA = U.S. Departmentof VeteransAffairs
nurse specialists can also occupy management positions in extended care facilities and hospices. For such a scenario to function, two important conditions must be fulfilled. First, new reimbursem e n t codes that reward cognitive skills and planning must be implemented: Second , such nonphysician professionals as nurse practitioners must be given more prescriptive authority, eligibility for reimbursement foi~services, and less restriction on their scope of practice. Interna.1 medicine has an unusually favorable opportunity to secure leadership of geriatrics and to improve geriatrics teaching and care. Or it can indulge itself with memories of its illustrious past and abdicate leadership to other specialties and other professions more interested in the care of the elderly. For m y part the latter course is unacceptable. Interi~al medicine simply cannot forfeit geriatric care to others.
REFERENCES 1. Institute of Medicine. Aging and medical education: Report of a study. National Academy of Sciences, Washington, DC, 1978. 2. Report of the Institute of Medicine: academic geriatrics for the year 2000. J Am Geriatr Soc 1987; 35: 773-91. 3. Strengthening training in geriatrics for physicians. Institute of Medicine, National Academy of Sciences, Washington, D.C., 1993. 4. Geriatric services grow slowly. AHA survey. Physician's Weekly, May 24, 1993. 5. Community hospitals atrophy. AHA survey. Physician's Weekly, May 31, 1993. 6. Geriatrics. U.S. News & World Report, July 12, 1993: 86. 7. Special requirements for programs in geriatric medicine (internal medicine). 1991-1992. Directory of Graduate Medical Education Programs. Chicago: AMA, 48-50. 8. Reuben DB, Bradley TB, Zwanziger J, Vivell S, Fink A, Hirsch SH, Beck JC. Geriatrics faculty in the United States: who are they and what are they doing? J Am Geriatr Soc 1991; 39: 799-805.
October 17, 1994
The American Journal of Medicine Volume 97 (suppl 4A)
4A-5S
he Institute of Medicine (IOM) has convened T three studies of medical education related to aging. The first, held in 1978, resulted in the Beeson Report, which recommended that geriatrics be recognized as an academic discipline within the relevant medical subspecialties [1]. The second study, in 1986, concluded that the needed growth in academic training in geriatrics could best be conducted in "centers of excellence," which would focus on training physician faculty geriatricians [2]. The third study was charged in 1993 by the John A. Hartford Foundation to determine the current status of geriatric training in relevant medical disciplines and to provide recommendations on the most effective strategies for strengthening training of physicians in geriatrics. It was reported in a workshop held 2 weeks before the conference on which this supplement is based and included a review of future geriatrics work force requirements, given the progress made since 1986. It was published in late 1993 [3]. The IOM committee was interested in both academic and practice manpower; training in such specialties as emergency medicine, psychiatry, and the surgical subspecialties, as well as in the primary care specialties; and methods to make this "academic specialty," as characterized by the Beeson Report, more attractive. Its 1993 recommendations must be justified in the context of four important salients: (a) healthcare reform, including the expectation of little or no new resources, the development of basic benefits packages, competition among managed care organizations, and capitated payment systems; (b) recognition that geriatrics practice is inherently interdisciplinary; (c) the anticipated consortia of graduate medical education institutions; and (d) the rapidly increasing numbers of skilled geriatric nurse practitioners and medical social workers vital to a successful team effort in proper healthcare for the elderly. The IOM committee recognized that physicians must learn geriatrics along with colleagues in other professions and that increasing geriatric content only in physician-driven curricula and certification will not fulfill the larger
From the American Board of Internal Medicine, Portland, Oregon. {This publication does not necessarily reflect the opinions or policies of the American Board of Internal Medicine.) Requestsfor reprints should be addressed to John A. Benson,Jr., M.D., President Emeritus, the American Board of Internal Medicine, 200 SW Market Street, Suite 1950, Portland, Oregon 97201.
obligation of our respective professions to the elderly.
BARRIERS TO PHYSICIANS'PURSUINGGERIATRIC CAREERS Perceptions Young physicians may perceive geriatrics to be uninteresting or clinically unrewarding. They may define the work as managing chronic complex diseases, rehabilitation, and functional assessment, which may seem less compelling than curing acute illness. Some may avoid the field because they feel uncomfortable with the elderly or because nursing home patient care is not "high tech." More established specialties may seem more appealing: Geriatrics has received external recognition through certification only since 1988.
Economics Many expect a geriatric career to offer a lower income and burdensome paperwork.
Training A scarcity of role models, restricted and diminishing budgets for training, poorly supervised training at primary care sites, lack of funding for training by Medicare A, and the fact that department chair and deans rate geriatrics as low priority are also obstacles to pursuing geriatric careers.
AVAILABILITYOF GERIATRICSTEACHERS There is currently a shortage of geriatrics teachers. From 1988 to 1994, certified internists and family practitioners whose geriatric practice totaled ->25% of their total practice for ->4 years have been qualified to take the Certificate of Added Qualifications (CAQ) examination without formal training in an accredited geriatrics fellowship. Approximately 6,000 primary care physicians have been awarded a certificate of special competence in geriatric medicine since 1988 (Table I). (This is more than the number certified by the American Board of Internal Medicine in six other subspecialties for which examinations have been available for 20 years.) Approximately 90% have been certified via the practice, or "grandfathering," pathway. The shortage of geriatrics teachers exists because most geriatricians are in practice outside of academic medical centers. Relatively few geriatricians have received the kind of formal training desirable for substantial academic careers that those in more classic subspecialties have received.
October 17, 1994 The American Journal of Medicine Volume 97 (suppl 4A)
4A-3S
APM SYMPOSIUM ON GERIATRIC EDUCATION / BENSON
TABLE! Number of Medical Practitioners Certified in Geriatric Medicine/Psychiatry 1988-1993 Board
1988
1990
1991
1992
Total
ABIM ABFP ABP&N
1,654 753 -
1,204 473 -
490
597 359
4,112 1,823 849
ABIM.= AmericanBoard of InternalMedicine;ABFP= AmericanBoard of FamilyPractice;ABP&N American Board of Psychiatry and Neurologyl
TABLE II Hospital Geriatdc Services Grow Slowly Typeof Program
Hospitals .k
Adultdaycare
7.3% 10.2% 20.3% 31.5% 11.0% 8.1% 16.5% 19.4%
Alzheimer'sdiagnostic/assessmentservices Comprehensivegeriatricassessment Geriatricemergencyservices Geriatricacutecareunit Geriatricclinic Respiteclinic Seniormembershipprogram *Percentage of hospitals offering program. Source: American Hospital Association, 1993: Responsesfrom 6,044 hospitals.
TABLE III Community Hospitals Atrophy
Region
Numberof instit.tionsin " (1991)
Difference from1990
WestCoast Mountains No~ Central SouthCentral Midwest Mid-South Southeast Mi~tlautic NewEngland
633 353 726 758 819 461 801 563 228
- 11.6% -3.8% -8.9% -10.5% -9.4% -6.3% -2.7% -8.5% -9.5%
Source: American Hospital Association, 1993 .
Clinicians certified via the practice pathway represent a reservoir of expertise. They could serve as role models for students and residents if they were recruited into volunteer faculties and served as preceptors in extended care facilities, nursing homes, hospices~ and clinics. The shortage of geriatric faculty will be aggravated as the numbers of new certificants decline with closure of the practice pathway after the 199.4 examination, unless applications to geriatrics fellowships of >-2 years increase substantially. GERIATRICS SERVICE PROGRAMS Hospitals • Relatively few hospitals have set up programs aimed at-older patients (Table II) [4]. Geriatric ser4A-4S
October 17, 1994
The American Journal of Medicine
vices are poorly reimbursed through insurance. Indeed, hospitals themselves are not doing well (Table III) [5]. Community hospitals closed at the rate of approximately 10% per annum in 1990. Capital investment is lagging, and new training and geriatric service sites are not being developed to meet the needs of the population. However, the graying of the U.S. population has led to an increase in geriatrics programs in university hospitals [6]. Geriatrics programs identified at 41 medical centers, all major academic institutions, were rated on reputation, mortality rate, ratio of residents to beds, and ratio of board-certified physicians to beds. The team approach central to care of the elderly is part of the ethos of such institutions. Obviously, those in major educational enterprises believe geriatrics is important. ACADEMIA I hold that geriatrics is specialized primary care (i.e., more specialized than internal medicine) of the elderly and is the particular province of internal medicine, We must depend primarily on generalists to provide the bulk of care to the elderly. Therefore, this supplement should focus on the improvement of education, particularly the augmentation of geriatrics curricula in internal medicine and family practice residency programs. Training of >-6 months duration should be established under the supervision of qualified geriatricians. Published standards for geriatric medicine fellowships [7] can be used as the basis for qualifying the sites and content. Medical schools and professional societies qualifled by the Accreditation Council on Continuing Medical Education (CME) should mount selfsustaining CME exercises to retrain the estimated oversupply of 100,000 specialists and subspecialist physicians who are unlikely to have feasible roles in systems of capitated payment and managed care systems. An enormous need exists for more and better research in geriatric medicine. At present <15% of geriatric faculty time is devoted to research. Demand for clinical care of patients >65 years of age is high, and many faculty are also involved in the care of patients <65 years, often, without responsibility for teaching [8]. If this numerically few and muchin-demand faculty is to develop the investigative skills and achievement needed for promotion and tenure, department chairs need to organize a supportive environment for research. A contented, productive faculty advancing its science will attract new recruits. Deans and department chairs have a responsibility to society a n d our profession to strengthen training and research in geriatric medicine.
Volume 97 (suppl 4A)
APM SYMPOSIUM ON GERIATRICEDUCATION/ BENSON
TRAINING OF OTHER SPECIALISTS Although primary care physicians and nurses provide most geriatric medical care, surgeons, urologists, anesthesiologists, and others still require training in geriatrics. Physicians in many specialties will treat an increasing number of elderly patients. All residents should receive some training in the special problems of elderly patients related to their disciplines. Certainly, programs in psychiatry, neurology, emergency medicine, and physical medicine and rehabilitation should include particular training in geriatrics. But for the other specialists, geriatrics requires the team care model, and these other specialists can call in consultants as needed.
TABLEIV Levelsof GeriatricsExpertise Domain Geriatricnursepract~oner (graduatetraining) Clinicalnursespecialist (graduatetraining) Primarycarephysician Geriatricsclinician
Geriatricianor geriatrics specialist
STRUCTURE oF GERIATRICSWORKFORCE Because geriatrics practice is inherently interdisciplinary, collaboration of several professions in a team operation is necessary. Regrettably, primary care physicians have often been slow to delegate authority, to learn to be managers, and to overcome long-standing tensions with nurses and social workers involving decision making, acknowledgment of each others' skills, and sharing liability risks. The autonomous solo entrepreneur is giving way to medical acolytes more comfortable in group endeavors and shared responsibility. That attitudinal change is good and will enhance care of the elderly. Expertise in geriatrics may be considered according to the schema outlined in Table IV. According to this framework, policies to fulfill workforce goals can be implemented in a more logical, organized way. Planning, training, funding, and research toward such a collaborative organization of skills and functions has merit. This schema offers the educational advantage of interdisciplinary training, with physicians, nurses, and others learning side by side. Given the current and anticipated shortage Of generalists and the insufficient number of geriatric specialists being trained, What alternatives are available? One proposal is to leave primary care and health promotion for the elderly to general internists, family physicians, osteopathic physicians, and others with geriatric training. Physicians with academic training in geriatrics (the geriatrics specialists) could then be reserved for the more complex, high risk, and refractory cases. Those with sophisticated training in the care of the elderly Could also act as medical directors of nonhierarchical collabor a t i o n s - a s consultants and coordinators of nurse practitioners, nutritionists, rehabilitation and occupation therapists, pharmacists, audiologists, and medical social workers in planning the care for certain groups of elderly people. Certified geriatric
Practitioner " Nursinghomes,ECF Prevention Healthpromotion Practitioner Nursinghomes Practitioner Medicaldirector Clinicalfaculty ECF Hospice Consultation Full-timefacu~ Research Teamleader HCOmanager NIA VA
Certification StateBoardsof Nursing ANA ABFPor ABIMin primary specia~ ABFPorABIMinprimary specialtyplusspecial trainingand/orcertification in GeriatricMedicine ABFPor ABIMinGeriatric Medicine ABP&NinGeropsychia~
ABFP= AmericanBoardof FamilyPractice;ABIM= AmericanBoardOfInternalMedicine;ABP&NAmerican Board of Psychiatry and Neurology; ANA = American Nursing Association; ECFExtendedcare facility;HCO = Healthcare organization;NIA = Nationallnstituteof Aging;VA = U.S. Departmentof VeteransAffairs
nurse specialists can also occupy management positions in extended care facilities and hospices. For such a scenario to function, two important conditions must be fulfilled. First, new reimbursem e n t codes that reward cognitive skills and planning must be implemented: Second , such nonphysician professionals as nurse practitioners must be given more prescriptive authority, eligibility for reimbursement foi~services, and less restriction on their scope of practice. Interna.1 medicine has an unusually favorable opportunity to secure leadership of geriatrics and to improve geriatrics teaching and care. Or it can indulge itself with memories of its illustrious past and abdicate leadership to other specialties and other professions more interested in the care of the elderly. For m y part the latter course is unacceptable. Interi~al medicine simply cannot forfeit geriatric care to others.
REFERENCES 1. Institute of Medicine. Aging and medical education: Report of a study. National Academy of Sciences, Washington, DC, 1978. 2. Report of the Institute of Medicine: academic geriatrics for the year 2000. J Am Geriatr Soc 1987; 35: 773-91. 3. Strengthening training in geriatrics for physicians. Institute of Medicine, National Academy of Sciences, Washington, D.C., 1993. 4. Geriatric services grow slowly. AHA survey. Physician's Weekly, May 24, 1993. 5. Community hospitals atrophy. AHA survey. Physician's Weekly, May 31, 1993. 6. Geriatrics. U.S. News & World Report, July 12, 1993: 86. 7. Special requirements for programs in geriatric medicine (internal medicine). 1991-1992. Directory of Graduate Medical Education Programs. Chicago: AMA, 48-50. 8. Reuben DB, Bradley TB, Zwanziger J, Vivell S, Fink A, Hirsch SH, Beck JC. Geriatrics faculty in the United States: who are they and what are they doing? J Am Geriatr Soc 1991; 39: 799-805.
October 17, 1994
The American Journal of Medicine Volume 97 (suppl 4A)
4A-5S