1. Geriatrics Workforce Policy Studies Center Geriatric Medicine in the United States 2012 Update (September 25, 2012) Elizabeth “Libbie” Bragg, PhD, RN Gregg A. Warshaw, MD

2. Methods Primary Data Collection 2001, 2005, 2007, 2008, & 2010 Surveys of Medical Schools GM Program Leaders (Allopathic & Osteopathic) 2001, 2004 & 2008 Surveys of FM Residency Program Directors 2002, 2005 & 2008 Surveys of IM Residency Program Directors 2001 & 2007 Surveys of GM and GP Fellowship Program Directors 2006 Survey of Psychiatry Residency Program Directors

3. Methods Secondary Data Sources AAMC AMA ABIM, ABFM, & ABPN ABMS VHA National Ambulatory Medical Care Survey (NAMCS) Medical Group Management Association (MGMA)

4. Results Practice of Geriatrics Academic Geriatric Medicine Fellowship Programs Graduate Medical Education Medical Student Education

5. Practice of Geriatric Medicine

6. Source: Lou Grosso, ABIM & Gary Jackson ABFM. Compiled by AGS/ADGAP Geriatrics Workforce Policy Studies Center April 2012 To maintain their certification in geriatric medicine, family medicine physicians must also maintain their primary certification in Family Medicine. Since July 2006 Internal Medicine recognized geriatric medicine as a subspecialty of Internal Medicine.

7. Certification and Re-certification in Geriatric Medicine by Year of Original Certification as of 4/12 Year Family MedicineInternal Medicine Certified First Recertification Second Recertification Certified First Recertification Second Recertification 1988752481 (64%)274 (36%)1,659817 (49%)280 (17%) 1990473317 (67%)190(40%)1,204550 (46%)227 (19%) 1992597372 (62%)1,254636 (51%) 1994771411 (53%)1,568764 (49%) 1996254123 (48%)291168 (58%) 199810349 (48%)337223 (66%) 19992816 (57%)183112 (61%) 20002721 (78%)200129 (65%) 20012117 (81%)193109 (56%) Source: Lou Grosso, ABIM, 2012 and Gary Jackson, ABFM, 2012. Recertification examinations are given twice a year, in the spring and fall. Certificates are valid for 10 years. Compiled by GWPS Center. Notes: Starting in 1996, fellowship training was required for certification. Starting in 1998 only one year of training was required for certification.

8. Specialty % of First Year Filled Positions 1 % USMDs 1 Private Practice Salary 2 Hematology/Oncology102.3%53.6%381,992 Physical Medicine & Rehabilitation102.2%55.0%241,182 Gastroenterology100.2%64.7%463,955 Emergency Medicine99.4%81.0%277,297 Psychiatry98.9%57.2%199,996 Family Medicine98.3%44.2%189,402 General Internal Medicine97.9%48.9%205,379 Dermatology97.6%94.9%392,885 Pediatrics97.2%66.5%192,423 Neurology96.3%55.3%249,867 Rheumatology96.1%50.6%225,521 Nephrology92.9%36.3%306,046 Infectious Disease91.6%51.9%219,556 Endocrinology91.5%48.5%211,400 Urology84.2%95.2%372,455 Hospice/Palliative Care*62.1%58.3%196,262 Geriatrics (FM+IM)57.2%24.4%183,523 Geriatric Psychiatry30.0%36.6%211,071 Sources: 1 AMA and AAMC data from the National Survey of GME programs, JAMA, September 2011. 2 Medical Group Management Association. Physician Compensation and Production Survey 2011 report based on 2010 data. Data compiled by Geriatrics Workforce Policy Studies Center. *Hospice and palliative medicine is a subspecialty of anesthesiology, emergency medicine, family medicine, internal medicine, neurology, obstetrics and gynecology, pediatrics, physical medicine and rehabilitation, psychiatry, radiology, or surgery. USMD = Graduates of US medical schools Comparison of Percent of Filled First Year Positions, Percent of USMDs, and Private Practice Salaries for Selected Specialties 2011

9. Current Geriatricians 4.3 Geriatricians/10,000 75+ –Range 0.9 to 7.1 1.1 Geriatric Psychiatrist/10,000 75+ –Range 0.1 to 2.3

12. Academic Geriatric Medicine

13. Academic Staff in U.S. Medical Schools (FTEs, Mean) Academic staff20012005200720082010 MDs7.59.6 10.211.3 First year fellows2.42.72.82.92.7 Second year fellows0.9 1.2 1.0 PhD Postdoctoral staff0.91.0 1.21.1 Research faculty2.53.04.23.7 Nurse Practitioners1.91.82.02.52.8 CNS0.70.60.70.60.5 PA0.3 0.5 0.6 Pharmacists0.30.50.6 Social Workers1.01.31.41.6 Geriatrics Workforce Policy Studies Center Survey of Geriatric Medicine Program Directors 2001, 2005, 2007, 2008 & 2010

14. Geriatrics Workforce Policy Studies Center Surveys of Academic Leaders in Geriatrics at US Medical Schools 2001, 2005, 2007, 2008, & 2010

15. Medical School Faculty Compensation median salary DepartmentInstructor Assistant Professor Associate Professor Chief Endocrinology106,000158,000171,000209,000233,000 Family Medicine 161,000155,000173,000190,000201,000 Gastroenterology146,000230,000275,000293,000374,000 Internal Medicine161,000159,000179,000221,000231,000 Geriatrics136,000144,000174,000211,000250,000 AAMC Report on Medical School Faculty Salaries, 2009-2010, April 2011

16. U.S. Medical School Geriatric Medicine Faculty and Staff Time Allocated by Program Mission (% effort, mean ) Category20012005200720082010 MS education13.613.111.411.512.1 Residency education12.611.611.911.010.8 Fellowship training10.79.98.69.09.7 Continuing education3.94.43.83.93.6 Clinical practice36.636.9 37.0 Research/scholarship18.215.318.617.016.2 AdministrationNA8.48.18.59.6 Other4.40.40.72.31.0 Geriatrics Workforce Policy Studies Center Survey of Academic Geriatric Medicine Program Directors 2001, 2005, 2007, 2008 & 2010

17. Source of Programs Revenues Mean Percent Category20012005200720082010 Clinical Practice26.827.129.828.328.7 College of Medicine 242018.419.322.4 Research Grants15.212.815.616.013.3 Hospital Support8.810.211.211.08.9 VHA11.310.39.69.710.7 Educational Grants8.49.76.87.87.6 Endowments4.45.15.35.46.7 Other0.34.93.42.71.6 Geriatrics Workforce Policy Studies Center Survey of Academic Leaders in Geriatrics at US Medical Schools 2001, 2005, 2007, 2008, & 2010

18. Annual Budgets In 2001, 26% had budgets < $250,000 By 2010 this ↓ to 14% In 2001, 42% had budgets > $1,000,000 By 2010 this ↑ to 65% Source: Geriatrics Workforce Policy Studies Center Surveys of Geriatric Academic Leaders in US Medical Schools in 2001 & 2008

19. Geriatrics Workforce Policy Studies Center Survey of Academic Leaders in Geriatrics at US Medical Schools 2001, 2005, 2008, & 2010

20. Fellowship Programs

21. Geriatric Medicine Fellowship Programs (Family Medicine and Internal Medicine) AYPrograms Fellows All Yrs Fellows Beyond Year 1 1 st Yr Positions Available % filled 1 st year Positions 92/9397215-- 95/969922310620657% 00/011193217433773% 06/071392873446854% 07/081402922846856% 08/091453202747062% 09/101482962348956% 10/111493012248857% Source: AMA and AAMC data from the National Survey of GME Programs compiled by Geriatrics Workforce Policy Studies Center

22. Geriatric Psychiatry Fellowship Programs AYPrograms Fellows All Yrs Fellows Beyond Year 1 1 st Yr Positions Available % filled 1 st year Positions 95/9638 3-- 00/016186712563% 05/066192513764% 06/075872414248% 07/0860 213643% 08/0957 113242% 09/105855112045% 10/115541213030% Source: AMA and AAMC data from the National Survey of GME Programs compiled by Geriatrics Workforce Policy Studies Center

23. Source: AMA and AAMC data from the National Survey of GME Programs compiled by Geriatrics Workforce Policy Studies Center. Does not include osteopathic programs.

24. IMGs in U.S. GME Programs Overall 27% of all Residents and Fellows are IMGs  Endocrinology -- 47%  Cardiology -- 37%  Ophthalmology -- 7%  Emergency medicine -- 7% Geriatric Medicine fellows – 69% Geriatric Psychiatry fellows –51% Source: AMA and AAMC data from the National Survey of GME Programs, 2010-2011. Note: IMGs= International Medical Graduates. IMGs do not include Canadians but do include U.S. citizen IMGs GME = Graduate Medical Education

25. Graduate Medical Education Primary Care Specialties

26. Geriatric Physician Workforce Pipeline 9,732 MDs graduated from FM & GIM residency programs in AY 2009/2010  3% entered a GM fellowship in Fall 2010 985 MDs graduated from Psychiatry residency programs in 2009/2010  4% entered a GP fellowship in Fall 2010 Source: AMA and AAMC data from the National Survey of GME Programs 2008/2009 & 2009/2010.

27. Required Time devoted to clinical instruction in Geriatric Medicine During 3 year Internal Medicine and Family Medicine Residency program –20 days (Median) Internal Medicine –12 days (Median) Family Medicine During 4 year Psychiatry Residency Program –23 days (Median) Geriatrics Workforce Policy Studies Center. Surveys of Program Directors in Internal Medicine (2008), Family Medicine Residency Programs (2008), and Psychiatry Residency Program(2006). Updated 10/10

28. Geriatric Medicine Training in FM, IM & Psychiatry Residency Programs as rated by Program Directors Curriculum conflicts #1 obstacle to implementing GM curriculum Geriatrics rated second most important curriculum area by IM and FM, third by psychiatry  ICU/CCU first for IM  Ambulatory Adult Medicine first for FM  Emergency Psychiatry first by Psychiatry Geriatrics Workforce Policy Studies Center. Surveys of Program Directors in Internal Medicine (2008), Family Medicine Residency Programs (2008), and Psychiatry Residency Program (2006).

29. MD Faculty Available to Teach Geriatric Medicine Mean and ± sd Full Time Equivalents Family Medicine (average 22 residents) 200820042001 1.3 (±1.6)1.3 (± 2.7)0.8 (± 1.1) Internal Medicine (average 53 residents) 200820052002 3.8 (± 4.5)3.5 (± 4.6)2.2 (± 2.8) Psychiatry (average 28 residents) 2006 N/A 2.8 (± 3.2) Geriatrics Workforce Policy Studies Center Surveys of Program Directors in Family Medicine Residency Programs in 2001, 2004, 2008; Surveys of Program Directors in Internal Medicine Residency Programs in 2002, 2005, 2008; and Survey of Program Directors in Psychiatry Residency Programs

30. Ambulatory Care Visits to Primary Care Generalist and Specialist Physicians, United States Patients Age 65 and over 1980199020062008 Specialist Primary Care Generalists Specialist Primary Care Generalists Specialist Primary Care Generalists Specialist Primary Care Generalists 38%62%47%53%59%41%56%44% Source: CDC, NCHS, National Ambulatory Medical Care Survey. Health 2010. Table 92: Visits to primary care generalist and specialist physicians, by selected characteristics and type of physician Note: This table presents data on visits to physician offices and excludes visits to other sites, such as hospital outpatient and emergency departments. Primary care generalists excludes geriatrics.

31. Percent of U.S. Medical Schools at which GM and GP Faculty Teach Geriatrics to Residents in Other Specialties 200787% 200575% Geriatrics Workforce Policy Studies Center Surveys of US Academic Medical Schools. 2007 response rate = 75%, 2005 response rate = 68%

32. Percent of Geriatric Medicine and Geriatric Psychiatry Programs that Teach Principles of Geriatric Care to other Selected Specialties SpecialtyPercent Psychiatry71% Gynecology62% Emergency Medicine50% 2007 Specialties taught/medical school: median 5.0 (range 1-14) Geriatrics Workforce Policy Studies Center 2007 Survey of Academic Medical Schools

33. Percent of Medical Schools Where Faculty from Other Selected Specialties Teach Principles of Geriatric Care to their Own Residents SpecialtyPercent Psychiatry71% Neurology44% PM & R42% 2007 Specialties teaching their own residents/medical school: median 4.0 (range 1-11) Geriatrics Workforce Policy Studies Center 2007 Survey of Academic Medical Schools

34. Medical Student Education

35. Medical student geriatrics curriculum 23% of medical schools require a geriatric clerkship in 2005 and in 2008 48% integrated geriatrics into a required clinical rotation in 2005 and this ↑ to 56% by 2008 Schools could report more than one type of experience Geriatrics Workforce Policy Studies Center Surveys of Geriatric Academic Leaders in US Medical Schools 2005 & 2008.

36. Medical student geriatrics curriculum 34% said curriculum experience depended on faculty interest in geriatrics in 2005 and this ↑ to 37% by 2008 17% had some exposure, but no objectives in 2005, but this ↓ to 12% by 2008 Schools could report more than one type of experience Geriatrics Workforce Policy Studies Center Survey of Geriatric Academic Leaders in US Medical Schools 2005 & 2008.

37. Percent of graduating medical students who thought adequate time was devoted to instruction in Long Term Care 1997 56% 2002 65% 2007 75% 2008 74% 2009 79% 2010 79% Source: AAMC, Medical School Graduation Questionnaire, All Schools Report

38. Percent of graduating medical students who thought adequate time was devoted to instruction in End of Life Care Source: AAMC, Medical School Graduation Questionnaire, All Schools Report 2001 64% 2004 76% 2007 78% 2008 79% 2009 78% 2010 80%

39. Percent of graduating medical students who believed that the time devoted to their instruction in Geriatrics was appropriate, inadequate, or excessive: 1990-2005 and 2010-2012 Source: AAMC, Medical School Graduation Questionnaire, All Schools Report

40. Percent of graduating medical students who agreed or strongly agreed with the following statements. Statement2009 I can identify situations where co-morbid conditions, life expectancy, and/or functional status should modify (or override) standard recommendations for screening tests in older adults 81% I can anticipate and identify hazards of hospitalization for older adults 86% I can identify those medications that should be avoided or used with caution in older adults 71% I can describe the differences in the presenting signs, symptoms, and laboratory findings of common conditions in older, as compared to younger adults 73% Source: AAMC, Medical School Graduation Questionnaire, All Schools Report

41. Percent of graduating medical students who agreed or strongly agreed with the following statements. Statement2009 I can differentiate the clinical presentations delirium, dementia, and depression in older adults 88% I can assess a patient’s self-care/functional capacity, e.g. ADLs and IADLs 77% I can assess on older patient’s fall risk, identify underlying causative factors, and make recommendations for further evaluation and initial management 72% Source: AAMC, Medical School Graduation Questionnaire, All Schools Report ADL = Activities of daily living; IADL = Instrumental activities of daily living

42. Contact Information http://www.americangeriatrics.org/advocac y_public_policy/gwps Libbie Bragg, PhD, RN The University of Cincinnati Elizabeth.Bragg@uc.edu 513-558-5241