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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions 1 Introduction As the people born during the baby boom (about 76 million people born between 1946 and 1964) get older, rapid growth in the numbers of older people requiring a constellation of health care services will occur, but all health professionals are ill prepared to provide those services. Projections of the U.S. Bureau of the Census, using a middle level mortality assumption, estimate a more than doubling of the number of individuals age 65 or older by 2050 (30 million in 1989 to 68 million in 2050) (U.S. Bureau of the Census, 1989); and suggest an increase of from 1.3 million to 4.5 million in the number of institutionalized older adults over this same time period. The growth in the population age 85 and older, which represents the nation's most rapidly growing population segment (of which 58 percent were considered disabled in recent national health surveys), will have a dramatic effect on the need for acute-care, home-based care, and institutional long-term-care services. HEALTH CARE REFORM Although health care reform has intermittently surfaced on the national political agenda and then disappeared from the scene, its reemergence at this David B. Reuben and John C. Beck are Associate Professor of Medicine and Professor of Medicine, respectively, at the University of California at Los Angeles School of Medicine, Multicampus Program in Geriatric Medicine and Gerontology.
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Training Physicians to Care for Older Americans: Progress, Obstacles, and Future Directions time has gained a momentum that may be sustained. The call for reform has been fueled by increases in health care expenditures that are well beyond yearly increases in inflation, the large number of uninsured or underinsured individuals, the fact that Medicare recipients' out-of-pocket expenditures exceed their costs of medical care prior to the institution of Medicare, the prohibitive costs of long-term care, and finally, the fact that U.S. health care spending is far in excess of that of other industrialized nations. Although the plan that will eventually be implemented is not clear at this time, there appears to be consensus on issues such as the need for universal access to care, a meaningful basic benefits package, equity and fairness in the system, and a rational use of the nation's health care resources. MEDICAL EDUCATION There is a growing consensus that the medical education system is unable to meet the health care needs of the population in an appropriate way and that reform is overdue (Blendon et al., 1992; Council on Graduate Medical Education, 1992; Josiah Macy, Jr., Foundation, 1992; Levinsky, 1993; Petersdorf, 1993; Physician Payment Review Commission, 1993). The Pew and Josiah Macy, Jr., Foundations, the Council on Graduate Medical Education, the Physician Payment Review Commission, the Association of American Medical Colleges, and others have concluded that there is a major shortage of generalists (general internists, family physicians, and general pediatricians) and an excess number of specialists. This situation has contributed to rising health care costs and poses a major constraint on the provision of affordable and high-quality care to all Americans. In its most recent (fourth) report, the Council on Graduate Medical Education again recommended that funds be increased to improve the capacities of medical schools to train more generalist physicians in the care of elderly people (Council on Graduate Medical Education, 1994). It is upon this substrate that two needs have emerged: physicians with increased knowledge and skills of caring for elderly people and their special problems and an appropriate system of care that can be used to provide improved care for elderly people. This paper addresses the progress in geriatric and gerontological education that has been made throughout the educational continuum for physicians. It focuses sequentially on undergraduate education; graduate education in family practice, internal medicine, and psychiatry; as well as certain specialties whose primary focus is the elderly, such as orthopedic surgery. Since the bulk of care provided to elderly people today is provided by those already in practice, the paper also considers the more fragmentary data in the area of continuing medical education. The paper specifically addresses the present numbers of academic leaders in the area of geriatric medicine, including clinical geriatricians and those in selected specialties, and presents projections for work force needs over the next several decades.
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