Geriatrics Workforce Policy Studies Center

Geriatric Medicine in the United States2012 Update

(September 25, 2012)

Elizabeth “Libbie” Bragg, PhD, RN

Gregg A. Warshaw, MD

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

Methods Secondary Data Sources

• AAMC• AMA• ABIM, ABFM, & ABPN• ABMS• VHA• National Ambulatory Medical Care

Survey (NAMCS) • Medical Group Management Association

(MGMA)

Results

• Practice of Geriatrics

• Academic Geriatric Medicine

• Fellowship Programs

• Graduate Medical Education

• Medical Student Education

Practice of Geriatric Medicine

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.

Certification and Re-certification in Geriatric Medicine by Year of Original Certification as of 4/12

Year

Family Medicine Internal Medicine

CertifiedFirst

Recertification Second

Recertification Certified

First Recertification

Second Recertification

1988 752 481 (64%) 274 (36%) 1,659 817 (49%) 280 (17%)

1990 473 317 (67%) 190(40%) 1,204 550 (46%) 227 (19%)

1992 597 372 (62%) 1,254 636 (51%)

1994 771 411 (53%) 1,568 764 (49%)

1996 254 123 (48%) 291 168 (58%)

1998 103 49 (48%) 337 223 (66%)

1999 28 16 (57%) 183 112 (61%)

2000 27 21 (78%) 200 129 (65%)

2001 21 17 (81%) 193 109 (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.

Specialty% of First Year

Filled Positions1 % USMDs1 Private Practice Salary2

Hematology/Oncology 102.3% 53.6% 381,992Physical Medicine & Rehabilitation 102.2% 55.0% 241,182

Gastroenterology 100.2% 64.7% 463,955Emergency Medicine 99.4% 81.0% 277,297

Psychiatry 98.9% 57.2% 199,996Family Medicine 98.3% 44.2% 189,402

General Internal Medicine 97.9% 48.9% 205,379Dermatology 97.6% 94.9% 392,885

Pediatrics 97.2% 66.5% 192,423Neurology 96.3% 55.3% 249,867

Rheumatology 96.1% 50.6% 225,521Nephrology 92.9% 36.3% 306,046

Infectious Disease 91.6% 51.9% 219,556Endocrinology 91.5% 48.5% 211,400

Urology 84.2% 95.2% 372,455Hospice/Palliative Care* 62.1% 58.3% 196,262

Geriatrics (FM+IM) 57.2% 24.4% 183,523Geriatric Psychiatry 30.0% 36.6% 211,071

Sources: 1AMA and AAMC data from the National Survey of GME programs, JAMA, September 2011. 2Medical 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

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

Academic Geriatric Medicine

Academic Staff in U.S. Medical Schools (FTEs, Mean)

Academic staff 2001 2005 2007 2008 2010

MDs 7.5 9.6 9.6 10.2 11.3

First year fellows 2.4 2.7 2.8 2.9 2.7

Second year fellows 0.9 0.9 1.2 1.2 1.0

PhD Postdoctoral staff 0.9 1.0 1.0 1.2 1.1

Research faculty 2.5 3.0 4.2 3.7 3.7

Nurse Practitioners 1.9 1.8 2.0 2.5 2.8

CNS 0.7 0.6 0.7 0.6 0.5

PA 0.3 0.3 0.5 0.5 0.6

Pharmacists 0.3 0.5 0.6 0.6 0.6

Social Workers 1.0 1.3 1.4 1.6 1.6

Geriatrics Workforce Policy Studies Center Survey of Geriatric Medicine Program Directors 2001, 2005, 2007, 2008 & 2010

Geriatrics Workforce Policy Studies Center Surveys of Academic Leaders in Geriatrics at US Medical Schools 2001, 2005, 2007,

2008, & 2010

Medical School Faculty Compensation median salary

Department Instructor

Assistant

Professor

Associate

Professor Professor Chief

Endocrinology 106,000 158,000 171,000 209,000 233,000

Family

Medicine161,000 155,000 173,000 190,000 201,000

Gastroenterology 146,000 230,000 275,000 293,000 374,000

Internal Medicine 161,000 159,000 179,000 221,000 231,000

Geriatrics 136,000 144,000 174,000 211,000 250,000

AAMC Report on Medical School Faculty Salaries, 2009-2010, April 2011

U.S. Medical School Geriatric Medicine Faculty and Staff Time Allocated by Program Mission

(% effort, mean )

Category 2001 2005 2007 2008 2010

MS education 13.6 13.1 11.4 11.5 12.1

Residency education 12.6 11.6 11.9 11.0 10.8

Fellowship training 10.7 9.9 8.6 9.0 9.7

Continuing education 3.9 4.4 3.8 3.9 3.6

Clinical practice 36.6 36.9 36.9 36.9 37.0

Research/scholarship 18.2 15.3 18.6 17.0 16.2

Administration NA 8.4 8.1 8.5 9.6

Other 4.4 0.4 0.7 2.3 1.0

Geriatrics Workforce Policy Studies Center Survey of Academic Geriatric Medicine Program Directors 2001, 2005, 2007, 2008 & 2010

Source of Programs RevenuesMean Percent

Category 2001 2005 2007 2008 2010

Clinical Practice 26.8 27.1 29.8 28.3 28.7

College of Medicine

24 20 18.4 19.3 22.4

Research Grants 15.2 12.8 15.6 16.0 13.3

Hospital Support 8.8 10.2 11.2 11.0 8.9

VHA 11.3 10.3 9.6 9.7 10.7

Educational Grants 8.4 9.7 6.8 7.8 7.6

Endowments 4.4 5.1 5.3 5.4 6.7

Other 0.3 4.9 3.4 2.7 1.6

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

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

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

Fellowship Programs

Geriatric Medicine Fellowship Programs

(Family Medicine and Internal Medicine)

AY ProgramsFellows All Yrs

Fellows Beyond Year 1

1st Yr Positions

Available

% filled

1st year Positions

92/93 97 215 -- -- --

95/96 99 223 106 206 57%

00/01 119 321 74 337 73%

06/07 139 287 34 468 54%

07/08 140 292 28 468 56%

08/09 145 320 27 470 62%

09/10 148 296 23 489 56%

10/11 149 301 22 488 57%

Source: AMA and AAMC data from the National Survey of GME Programs compiled by Geriatrics Workforce Policy Studies Center

Geriatric Psychiatry Fellowship Programs

AY ProgramsFellows All Yrs

Fellows Beyond Year 1

1st Yr Positions

Available

% filled

1st year Positions

95/96 38 38 3 -- --

00/01 61 86 7 125 63%

05/06 61 92 5 137 64%

06/07 58 72 4 142 48%

07/08 60 60 2 136 43%

08/09 57 57 1 132 42%

09/10 58 55 1 120 45%

10/11 55 41 2 130 30%

Source: AMA and AAMC data from the National Survey of GME Programs compiled by Geriatrics Workforce Policy Studies Center

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

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 IMGsGME = Graduate Medical Education

Graduate Medical Education

Primary Care

Specialties

Geriatric Physician Workforce Pipeline

• 9,732 MDs graduated from FM & GIM residency programs in AY 2009/20103% entered a GM fellowship in Fall 2010

• 985 MDs graduated from Psychiatry residency programs in 2009/20104% entered a GP fellowship in Fall 2010

Source: AMA and AAMC data from the National Survey of GME Programs 2008/2009 & 2009/2010.

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

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 IMAmbulatory 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).

MD Faculty Available to Teach Geriatric Medicine Mean and ± sd Full Time Equivalents

Family

Medicine(average 22 residents)

2008 2004 2001

1.3 (±1.6) 1.3 (± 2.7) 0.8 (± 1.1)

Internal Medicine(average 53 residents)

2008 2005 2002

3.8 (± 4.5) 3.5 (± 4.6) 2.2 (± 2.8)

Psychiatry(average 28 residents)

2006N/A 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

Ambulatory Care Visits to Primary Care Generalist and Specialist Physicians, United States

Patients Age 65 and over

1980 1990 2006 2008

Specialist

Primary Care

GeneralistsSpecialist

Primary Care

GeneralistsSpecialist

Primary Care

GeneralistsSpecialist

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.

Percent of U.S. Medical Schools at which GM and GP Faculty Teach Geriatrics to Residents in Other

Specialties

2007 87%

2005 75%

Geriatrics Workforce Policy Studies Center Surveys of US Academic Medical Schools. 2007 response rate = 75%, 2005 response rate = 68%

Percent of Geriatric Medicine and Geriatric Psychiatry Programs that Teach Principles of Geriatric Care to

other Selected Specialties

Specialty Percent

Psychiatry 71%

Gynecology 62%

Emergency Medicine 50% 2007 Specialties taught/medical school: median 5.0

(range 1-14)

Geriatrics Workforce Policy Studies Center 2007 Survey of Academic Medical Schools

Percent of Medical Schools Where Faculty from Other Selected Specialties Teach Principles of Geriatric Care

to their Own Residents

Specialty Percent

Psychiatry 71%

Neurology 44%

PM & R 42% 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

Medical Student Education

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 experienceGeriatrics Workforce Policy Studies Center Surveys of Geriatric Academic Leaders in US Medical Schools 2005 & 2008.

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 experienceGeriatrics Workforce Policy Studies Center Survey of Geriatric Academic Leaders in US Medical Schools 2005 & 2008.

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

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%

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

Percent of graduating medical students who agreed or strongly agreed with the following statements.

Statement 2009

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

Percent of graduating medical students who agreed or strongly agreed with the following statements.

Statement 2009

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

Contact Informationhttp://

www.americangeriatrics.org/advocacy_public_policy/gwps

Libbie Bragg, PhD, RNThe University of CincinnatiElizabeth.Bragg@uc.edu513-558-5241