University of Southern California Dissertations and Theses

Educational status and trends in gerontology and medicine

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Educational status and trends in gerontology and medicine

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Content EDUCATIONAL STATUS AND TRENDS IN GERONTOLOGY AND MEDICINE by Bernice Fisher and Norman Davidson A Thesis Presented to the FACULTY OF THE LEONARD DAVIS SCHOOL OF GERONTOLOGY UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirement for the Degree MASTER OF SCIENCE IN GERONTOLOGY January 1978 ÜMI Number: EP58857 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Oisawtatton Ruoiismng UMI EP58857 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106 -1346 UHIVERSnV OF SOUTHEm CALIFORNIA LEONARD DAVIS SCHOOL OF GERONTOLOGV UNIVEP3ITV PARK LOS ANGELES, CALIFORNIA 90007 C - x - e V o '18 FS33 ^ S 3 J T) ^=>1/ lhÂ3 tk£AÂJ>, (A)/uJXe.n by Bernice Fisher and Norman Davidson__________ a n d v i th u dJjiacJion, o ^ tk eir ZomnijttzQ,, and appAoved by aZZ mQ,mboA3, kcu> bac.n p ^ e - 6zyitzd to and accep-ted by tk z Vzan Tkz Le,onaxd Vavt6 School. o£ GcAO'At.oloay, tn p o Ju tla l ^uZilZlm ayvt o£ th z ^e.qiUA.etmnt6 {^oK tk z d e g / i e e o^ d , j c? ^ _______ 0 ( i c i n Vato, ^ ' P ^ THESIS COMMITTEE C - c ’- * CkaOiman ACKNOWLEDMENTS We wish to recognize the students in the first class of the Leonard Davis School of Gerontology for their con cern about the professional future of gerontology which provided the impetus for the origination of the project, of which this is a part. Our sincere appreciation is expressed to the Andrus Foundation of the Retired Teachers Association and the American Association of Retired Persons for the financial backing which made this project possible. Special recognition is given to the other members of the research project for their contributions in the follow ing areas: Beverly Little and Debby Secord, Chapter I; Rick Matros and Eldon Teper, Chapter II; Dagney Cooke, Bernice Fisher and Monique Waller, Chapter V; Cheryl McCamish and Steve Epstein, Chapter VI. These students also participated in the development of the data collection forms. Our sincere gratitude and appreciation is extended to Drs. William Albert and Robert Wiswell, and Mr. Dan Tiberi for their knowledge, advice, guidance, and especially patience and understanding afforded us in the completion of this study.. 11 TABLE OF CONTENTS ACKNOWLEDGMENTS ................ ii LIST OF TABLES ..................................... CHAPTER I STATEMENT OF THE PROBLEM ............. 1 Introduction .... ............... 1 The Study of Medicine ............. 2 Background . 6 Research Problem .......... 8 II PROFESSIONALISM ....... .. ... 13 Introduction .................... 13 Defining Profession ............... 14 Criteria of a Profession............19 Process of Professionalization . . . 36 Conclusion . . . . . . . .......... 4 3 III MEDICINE AS A PROFESSION...............46 Introduction ................ 46 Early American Medical Education. . 48 Pre-Flexner Medical Education . . . 50 The Flexner Y e a r s .................. 58 New Medicine................ ...62 The Professional Status of Medicine. 64 Summary . . . . . . ...............83 IV MEDICINE AND GERONTOLOGY ............ 84 Introduction ....................... 84 Projected Needs . . . . 85 Medicine and Gerontology ...... 88 Educational Programming ...... 90 The Team Approach ..........93 111 CHAPTER V THE PROFESSIONAL STATUS OF GERONTOLOGY ........... 96 „ Introduction.......... 96 Trends of Gerontology F . ; 97 Documentation of Needs . . . * , 100 Gerontology on the Continuum of Professionalism . . . . , 104 Conclusion . . . . . . . . , . .120 VI METHODOLOGY......................122 Introduction............ .. 122 Procedures for Entire Project . .123 Specific Procedures for Medicine. 126 Selection of Colleges and Universities for Study .... 127 Description of Survey Questionnaire ............... 128 Treatment of the Data ...... 131 VII RESULTS AND DISCUSSION........... 132 Introduction .............. 132 Summary . . . . . . ............. 159 VIII SUMMARY ............. 162 Introduction ................... 162 Curriculum Development ........ 164 Limitations of the Study . . . .166 Recommendations for Future Action 170 Conclusion.............. 173 BIBLIOGRAPHY ................. 176 APPENDIX A ............. ....... ................ 187 APPENDIX B . 192 APPENDIX C ............. ........................ 200 APPENDIX D ........................................202 APPENDIX E ............ . 204 APPENDIX F ......................... .............206 APPENDIX G ........................................208 APPENDIX H ........................................210 IV LIST OF TABLES TABLE Description of Medical Schools Surveyed 134 Responses to Questions 3, 9/ 10 and 11 , 141 Responses to the Attitudinal Questions (5, 6 and 12) From the Interview Questionnaire ,. ^ , . . 146 Association of the Number of Courses with Aging Content Offered by Each School and the Number of Full-time Medical Students using Pearson r , . , 150 Association of the Number of Courses with Aging Content and the Total Number of Students at the Institution Using Pearson r . . . . . . . , , . , 151 Association of the Number of Courses with Aging Content at Each School and the Number of Full-time Faculty at the School Using Pearson r . . . . . , . . 152 Library Journals Subscribed to by the Medical Schools . . . . . . . . . 154 Full-time Faculty and Full-time Medical Student Ratio . . . . . . , . 156 Attitudinal Questions 5, 6 and 12 and Ranks ............... ...... 158 V CHAPTER I STATEMENT OF THE PROBLEM Introduction This report is based upon an exploratory study of the educational trends and status of eight selected disciplines in their relationships to gerontology. The professional and technical schools studied include; adult education, counselor education, dentistry, law, medicine, nursing, public administration, and social work. Course curricula, attitudes toward the relevance of gerontology for each dis cipline and prospects for the future development of courses in aging within each discipline were examined. Credentials and licensing procedures were explored for those disci plines which have such procedures. A better understanding of how gerontological content is integrated into educa tional curricula and how/if licensing bodies are testing for this knowledge are two goals of this study. The project was conducted by faculty and staff from the Ethel Percy Andrus Gerontology Center and by students from the Leonard Davis School of Gerontology at the Uni versity of Southern California. Eleven out of the 13 Leonard Davis School students were involved in this study to partially fulfill the requirements for a Masters degree. One student used the project for undergraduate research credit, and one student used the project for graduate re search credit. An outcome of this research will be a re port detailing the individual disciplines, synthesizing the overall findings and making inferences about the prepara tion in professional and technical schools studied and possible unmet needs in the area of gerontology. The Study of Medicine Each discipline was investigated by one or more stu dents. This particular section of the project is concerned with medicine as a profession, and as part of an important service provided to the aged community. For the purposes of this study, a distinction between gerontology and geriatrics is presented. Gerontology is defined as the scientific study of aging and encompasses the special problems of the aged persons, using a develop mental approach from birth to death. Included would be the study of biological, psychological, and sociological fac tors. In examining course offerings, gerontology courses would be those which scientifically study the older adults. Geriatrics is a branch of gerontology, and medically is concerned with the health of the elderly in all aspects: preventative, clinical, remedial, rehabilitative, and con tinuous surveillance (World Health Organization, 1974; Hodkinson, 1975; Isaacs, 1965). According to Isaacs (1965), geriatrics evolved from general medicine to meet the spe cific health needs of the elderly and infirm. Shock (1957) states that many middle-aged and elderly people need spe cialized medical services and that establishing geriatrics as a branch of medicine may best provide these needs. Shock also states that the arguments for and against the establishment of geriatrics as a specialty are similar to those made during the early days of pediatrics. One may conclude that since pediatrics has since been recognized as a specialty, that geriatrics will become a specialty, per haps in the near future. In geriatric practice today, "The most important task is still the need to alter the atti tudes which people have about old age" (Anderson, 1974, p. 102)-. Geriatrics is recognized as a part of medicine. However, it has not yet been recognized as a separate spe cialty which would include examination, regulation and licensure of geriatric physicians. The World Health Organization recommended in 1974 that geriatrics should be a specialty and that medical schools curricula should include the study of adult human develop ment and aging. According to Lee (1968), "all medical schools should have courses in gerontology and geriatrics" (p. 20) and all internists, general practitioners and sur geons should be exposed to the problems of aging. For the purposes of this study, all forms of gerontology, including geriatric aspects are examined. It would seem that there is a lack of interest in the number of physicians trained in geriatric medicine or even interested in geriatric care (McGlone & Schultz, 1973). In 1962 Robert Butler (1975) surveyed by mail the deans of all medical schools and all chairmen of departments of psychia try. The 90 percent plus response that he received at that time indicated that there was little interest in establish ing special courses related to geriatric medicine or the principles of gerontology. That study provided a base for this project; to determine whether or not there was been any progress. There is increasing concern in medicine that the teach ing of geriatrics is inadequate and that the appropriate development of geriatrics as a specialty in the medical profession is necessary and has been too long in coming (Goldman, 1974). It seems that innovations in the delivery of geriatric health care have not kept pace with medical knowledge and the techniques of other areas of medicine. Thus far, geriatrics has been unattractive to the medical profession (Goldman, 1974). Perhaps one reason is the stereotype of the unattractive aged person, their decreas ing capabilities, and the nearness of death. Treatments given an aged person do not always act as effectively as they might in a younger person, and progress is less rapid. Butler (1975) states that the medical profession and other health personnel share a negative attitude toward the aged. These attitudes are further complicated by bureaucratic and financial considerations. A growing problem is the quant ity of paperwork involved in Medicare and like subsidies, all of them used by the older indigent person. This has led many doctors to refuse or set limits on the number of these patients they will care for (Butler, 1975). There has been an increase in the older population and an increase in the ability to pay for health services that has turned the need for health care into a demand for health care. However, there has not been the same kind of increase in the number of physicians trained in geriatric medicine or even interested in geriatric care (McGlone & Schultz, 1973). If we are to improve services to the elderly then we must begin at least to introduce knowledge about aging to physicians that deal with that population. For example, continuing medical education has recently become required in order to remain licensed. These Continuing Medical Education programs provide the opportunity for physicians to update medical education in topical areas, such as gerontology. In medical schools there are already major problems related to medical education. One of the major problems is the amount of material to be covered, leaving little time for the student to learn new subjects and material. In questioning medical school students (Freeman, 1962), on their opinion whether the medical school curricula should contain specific geriatric coverage, 90 percent replied affirmatively and only 10 percent gave negative answers. More recently, a survey of American physicians reported in the September 27, 1976 issue of Impact, an American Medical Association news periodical, that 75 percent of all prac ticing physicians now believe that MDs do need special training in geriatrics. Butler (1976) states that the first argument in favor of the inclusion of geriatric medi cine in medical schools is that the specialized "body of knowledge" already exists. Though it is not complete, it is substantial. Background This project was initiated by students of the Leonard Davis School who were concerned about the future develop ment of the field of gerontology and its professional status. These students, who were members of the first class of the Leonard Davis School in 1975, were concerned about whether their training would be accepted by profes sionals in other fields and whether gerontologists would be considered professionals. In response to this concern, the faculty and admini stration of the Leonard Davis School identified various professions that are likely to be serving the elderly. A proposal to explore relationships between these disciplines and gerontology was submitted to the Andrus Foundation for funding and was approved. The students selected the dis ciplines in which they were most interested and collabor ated with the entire group in preparing and refining this research design. The immediate goals of the study were to determine the current gerontology courses offered (both courses in aging and courses with aging content), in selected colleges and universities in California; the field work experience available through these schools ; the attitude of faculty and staff within the selected disciplines toward the in clusion of aging content in their curricula; and the extent to which the licensing and/or credentialing boards screen candidates for expertise in aging. This project is an initial step toward a long range goal to assist in the im provement of the quality of services offered to the retired and aged by upgrading professional and technical education, relevant licensing procedures and the accountability of educators in the fields of adult education, counselor edu cation, dentistry, law, medicine, nursing, public admini stration, and social work. Research Problem The researchers have identified several variables that require investigation, have devised instruments to quantify each variable, and have made relevant assumptions regarding the associations between the variables. Some of the more important variables taken into consideration were: (1) the number of students in the department/school; (2) the number and types of degrees within each department/school; (3) the number of full-time faculty within the department/school; (4) the number of doctorates held by faculty teaching courses with gerontological content; (5) the number of faculty belonging to the Gerontological and the Western Gerontological Societies; (6) attitudes of faculty and ad ministration toward the importance of gerontology to their discipline; and, (7) the number of journals related to gerontology which are subscribed to by the library of each department in the school. The researchers recognized that, in an exploratory study of this nature, it would be difficult to establish cause and effect relationships. More basic data needs to be collected through this and other studies before such cause and effect relationships can be established. How ever, associations between variables were observed and these were analyzed and reported. One association investi gated was the respondents * attitudes toward the importance of gerontological curricula and issues and whether these attitudes were reflected in the educational institutions' course offerings. It was assumed that a rating of "impor tant " or "very important" regarding overall gerontological issues and curricula by the respondents indicated an in creased emphasis on courses in which aging content is offered. If the respondent rated the gerontological issues and curricula "not very important" or "of no importance," then a decreased emphasis was assumed. The organizations* plans to provide curricula related to aging in the future and to provide continuing education classes in aging were also analyzed according to the attitudes of the respondents, Another area which required examination was the number of course offerings having gerontological content in re lationship to the number of opportunities for field prac- ticum, especially in agencies which work with or on behalf of the older adult. As previously stated, a cause and effect relationship was difficult to establish— did classes in aging proliferate due to the demand by the students working in the agencies which were related to the older adult or did the classes with gerontological content create a demand for field practicums where this knowledge could be employed? In the same manner, the number of gerontological courses offered and the number of students attending each institution were compared and evaluated. Did the course material on gerontology provide impetus for theses and dis sertations relating to aging? Did the department offer gerontology courses in response to student interest? Did courses with gerontological content stimulate student in terest in the field of aging? Did the faculty, who were interested in gerontology, spark this interest in their students? Was the availability of aging related journals in the school/department library a significant factor in developing student interest in gerontology? Of course, these questions cannot be resolved through one study, but such relationships can provide a basis for new hypotheses which may eventually contribute to a better understanding of the causal relationship. The number of students and faculty in each department/ school were also correlated to course offerings in geron tology. Did a larger student population exist at those in stitutions with more specialization in gerontology (e.g., more minors, dual degrees, or emphasis being offered)? Another parameter investigated was whether the size of the 10 faculty of the department/school was related to the availa bility of aging related courses. Did the number of teachers holding doctorates correlate in any way with the number of aging related courses? The status of a department/school is often determined by the number or proportion of faculty holding doctorates. Is a school/department with high status more likely to offer specialized courses in aging? The statement of the problem, as presented, has spe cifically reviewed the basic purpose and the course of this research effort. The remaining chapters present detailed information about the issues which were of particular con cern to the participants in this study. The literature re view will provide an in-depth analysis of the following topics : The criteria a discipline must meet to be con sidered a profession will be discussed in Chapter II. Med icine as a profession will be the topic of Chapter III. The advancement of gerontology along the continuum of profes sionalism will be examined in Chapter IV. The professional status of gerontology will be discussed in Chapter V. Chapter VI will discuss methodology or the process of oper ationalizing the research. Chapter VII will provide the results of the research effort described in the methodology chapter. The researchers will offer interpretations of those results. The concluding chapter. Chapter VIII, will provide a summary of the literature review, the methodology 11 and the findings. Implications of the research findings, the limitations of the study, and recommendations for future research will also be addressed in the final chapter. 12 CHAPTER II PROFESSIONALISM Introduction Examining the concept of professionalism is difficult because the term is used to define a variety of traits, characteristics, and ideals of occupational status. Review ing the sociological literature on professionalism reveals the amorphous, and oftentimes ambiguous explanations which have developed in attempts to delineate the limits of pro fessional standing. It is the intent of this paper to can vas the extant literature on professionalism and formulate a reasonable clarification of the major constituents of pro fessional standing, as well as the processes that can trans form an occupation into a profession. Three specific ques tions are answered in attempting to provide a succinct picture of the nature of professionalism. 1. What is a valid definition of a profession? 13 2. What are the requisite criteria needed for achieving professional status? 3. What are the processes intrinsic to the development of a profession? Defining Profession The problem of developing a specific definition of profession is complex because of the term's generalized utilization. Barber (1965) states that there is no abso lute difference between professional and other types of occupational behavior, but only relative differences with respect to certain attributes common to all occupational behavior. There are different degrees of professionalism and not all professions display the same characteristics. In fact, some business organizations may encompass criteria of professionalism without ever achieving professional status. Therefore, while precise verbal definition about the term profession persists, we should think of occupa tions as falling somewhere along a continuum of profession alism, the continuum being made up of common definitional traits (Goode, 1960)^ , A profession is usually defined as an occupation which requires training in the liberal arts or the sciences and graduate study in a particular field. Manual labor is not considered to be one of the areas of professionalism. At the professional level of employment, individuals often are 14 assigned a large amount of responsibility based solely on their past experiences within the setting and direct client contact is most extensive. Professional status is not gained by claiming it, but must be created as a result of behavior. A professional works in an occupation that pri marily serves people by contributing to and enhancing their potentials as humans. Profit motives are secondary to the concern for people (Stone & Shertzer, 1969). Cogan (1955) states that there is an almost insurmount able controversy in trying to define profession. He ex amines the development of a definition of professions at three different levels : (1) historical and lexicological, (2) persuasive, and (3) operational. In the historical and lexicological interpretation, a profession is a vocation whose practice is founded upon the understanding of a theoretical structure of some department of learning or science, and upon the abilities accompanying such an under standing. This understanding and these abilities are ap plied to the vital practical affairs of man. The practices of the profession are modified by knowledge of a general ized nature and by the accumulated wisdom and experience of mankind, which serve to correct the errors of specialism. The profession, serving the vital needs of man, considers its first ethical imperative to be altruistic service to the client (Cogan, 1953). The persuasive definition of 15 profession has justified the existence of professional oc cupations in society. These justifications keep the pro fession desirable by directing societal attitudes to the value of the services the profession offers. Operational definitions are designed to furnish the basis upon which individuals and associations may make specific decisions as to the behavioral concommitants of a profession. They are guidelines for the practitioner in his day-to-day work, and are the rules for professional conduct. They mediate the practitioner's relation to the client, to his colleagues, to the public, and to the professional association. They set forth the specific criteria of general and specific education for the professional, the requirements for admis sion to practice, and the standards for competent service. Cogan summarizes his discussion of the definitional aspect of profession by stating that the promulgation of a satis factory definition has progressed little beyond the six elements proposed by Abraham Flexner (1915): (1) intellec tual operations coupled with large individual responsibil ity; (2) raw materials drawn from science and learning; (3) practical application; (4) educationally communicable techniques; (5) a tendency towards self-orientation; and, (6) an increasing altruistic motivation. Cogan (1953) also states that an important, though im plicit, criterion of profession is revealed through the 16 study of dictionary definitions. The first point to be noted is that the professions are described as dealing with the practical affairs of men. Also, the profession is traditionally applied specifically to the three learned professions of divinity, law, and medicine. Cogan con cludes from an analysis of dictionary definitions that it may be observed that the traditional professions mediate man's relation to God, man's relation to man and state, and man's relation to his biological environment. Smith (1958) discusses the diversity of professions and infers that they are complex social institutions which select people of varied skills, often from several social strata, and organ ize them into different levels of operation and diverse interest groups. Some authors have tried to define profession in a con cise and explicit manner. Greenwood (1972) adapts Hall's (1949) definition and sees a profession as an organized group which is constantly interacting with the society that forms its matrix, which performs its social functions through a network of formal and informal relationships, and which creates its own subculture requiring adjustments to it as a prerequisite for career success. Any occupation wishing to exercise professional authority may find a technical basis for it, assert an exclusive jurisdiction, and convince the public that its services are uniquely 17 trustworthy, and while there is a general tendency for oc cupations to seek professional status, remarkably few of the thousands of occupations in modern society attain it (Wilensky, 1964). Hughes (1963) states that a profession delivers esoteric services— advice or action— to individual organizations, or government; to whole classes of people ; or to the public at large. The action may be manual, but the service still includes advice. The person for or upon whom the esoteric service is performed, or the one who is thought to have the right or duty to act for him/her, is advised that the professional's action is necessary. Pro fessionalism might be defined as a process by which an or ganized occupation, usually, but not always, by virtue of making a claim to a specific esoteric competence and a con cern for the quality of its work, controls training for and access to it, and controls the rights of determining and evaluating the way the work is performed (Vollmer & Mills, 1966). It is clear that the concept of professionalism does not lend itself to precise definition; however, certain oc cupational attributes are generally characteristic of pro fessional status. The next section will examine in detail those criteria, revealed in a review of sociological liter ature, which have been consistently ascribed to the estab lished professions. 18 Criteria of a Profession Defining specific criteria of professional status is also a precarious task. Different authors list varying numbers of attributes which they consider essential to the establishment of a profession, but it is evident that some long standing professions do not comply with all of these requisites. Also, many occupations do possess some ele ments of professionalism without having professional status. This section will closely examine seven attributes which most authors generally regard as constituents of profes sional status. These criteria are as follows: body of knowledge; university education; professional ideology; professional associations; codes of ethics; self-regulation; and, public sanction. Body of Knowledge All mature professions rest on a common body of know ledge that can be utilized flexibly by practitioners in various types of interventive activities (National Associa tion of Social Workers, 1964). Others supporting the need for a body of knowledge are Engel (1970); Halmos (1970); Schott (1976); Lewis and Maude (1952); Wickenden (1950); Boehm (1959); Turner and Hodge (197 0); Harries-Jenkins (1970); Schein (1972); Pavalko (1974); Bearing (1972); and. Stone & Shertzer (1969). The nature of this knowledge, whether substantive or theoretical, on which advice and 19 action are based is not always clear; it is often a mixture of several kinds of practical and theoretical knowledge. But, it is part of a professional complex, and the profes sional claim, that the practice should rest upon some branches of knowledge to which the professionals are privy by virtue of long study and initiation and apprenticeship under masters already members of the profession (Hughes, 1963). Greenwood (1972) states that the characteristic skills of a profession are derived from a source of know ledge which has been systematically organized into a body of theory. This body is made up of abstract propositions which describe in general terms the focus of the profes sion's interest. Preparing for professional status is, therefore, an intellectual, as well as a practical experi ence . Wilensky (1964) refers to a technical base on which professional knowledge is supported. He differentiates "technical" from "scientific" in that both scientific and non-scientific systems of thought can serve as a technical base for professionalism, but the success of the claim is greatest where the society evidences strong, widespread consensus regarding the knowledge or doctrine to be applied Goode (1961) reports that a prolonged specialized training in a body of knowledge is paramount to the success ful development of a profession. The principles of this 20 knowledge must be applicable to concrete problems. Profes sionals must not only use, but help create this knowledge; the profession itself must be the final arbiter as to what is valid knowledge. Therefore, the profession controls access to knowledge and hence, access to the profession. Society should believe that the knowledge can actually solve existing problems and should also accept as proper that these problems be given over to some occupational group for effective solution (Goode, 1969)) University Education Education clearly emerges as an important factor in determining whether or not a discipline is a profession (Lewis & Maude, 1952; Wickenden, 1950; Harries-Jenkins, 1970; Stone & Shertzer, 1969). The problem is that every one has a different idea as to how much education really is necessary. Moore (1970) regards it as extremely improbable that technically trained individuals with less than a bachelor of arts or science degree could manage to attain the relatively higher positions on any scale of profession alism. Goode's (1957) criterion of lengthy training in a body of specialized abstract knowledge infers formal educa tion at the graduate level. The training involves inquiry into an abstract body of knowledge, not the acquisition of technical skills. Jackson (1970) believes the existence of professionalism itself depends on the notion of the uni- 21 versity as the institution of the intellectual. Further more, he sees the rise of the professions as positively correlated with the rise of the universities. Traditionally, professions have been affiliated with organized educational institutions> and this has developed into the concept of professional schools within the uni versity. Barber (1965) cites four major roles of the uni versity professional school. They are as follows : 1. Transmission to its students of the generalized and systematic knowledge that is the basis for professional performance; 2. Creation of new and better know ledge on which professional practice can be based; 3. Ethical training of students, explicit (codes) and implicit (behavioral aspects); and 4. Improvement of existing codes. Barber concludes that the better the university professional school, the more likely it is to use resources from the other professional schools in the university and from all the other departments of basic knowledge insofar as they are relevant. The university professional schools are the leading, though not the sole, innovators and systematizers 22 of ideas for their professions. The emerging or marginal professions seek to locate in universities. Harries-Jenkins (1970) infers that professional educa tion is dependent upon training and knowledge acquired out side the employment setting while generalists receive their occupational preparation from within the employing organi zation. Carr-Saunders and Wilson (1964) state that a sound general education in theoretical and practical knowledge and then specialized education in the specific discipline, as in the professions, increases efficiency. Professiona1 Ideology Every profession has a professional ideology, which is the basis for offering the best possible service in the public interest (Ritzer, 1973; Boehm, 1959; Harries-Jenkins, 1970; Pavalko, 1974 ; Bearing, 1972; Stone & Shertzer, 1969). Elliot (1972) states that a professional ideal has three important aspects: 1. The notion of service; 2. An emphasis on professional judgment based upon professional knowledge; 3. Belief in professional freedom and autonomy in the work situation, (p. 23) The service ideal may be defined as the norm that the technical solutions which the professional arrives at should be based on the client's needs, not necessarily the best material interest or needs of the professional himself or 23 those of society. Further specifications of the service ideal is inherent in its four subdimensions: 1. The practitioner decides upon the client's needs, and the occupation will be classified as less professional if the client imposes his own judgment. 2. The society actually believes that the profession not only accepts these ideals, but also follows them to some extent. 3. The profession demands real sacrifice from its practitioners as an ideal, and occasionally, in fact. 4. The professional community sets up a system of rewards such that 'virtue pays off . (Goode, 1960,* p. 23) Wilensky (1964) reports that the success of the claim to professional status is governed also by the degree to which the practitioners conform to a set of moral norms that characterize the established professions. These norms dictate not only that the practitioner do technically, high- quality work, but that he adhere to a service ideal— devo tion to the client's interest more than personal or commer cial profit should guide decisions when the two are in con flict. In short, a major determinant of professional status is the degree of adherence to the service ideal and its supportive norms of professional conduct. Beatman (.1952) feels that basic to professional matur ity are the knowledge essential to practice and the appro- 24 priate use of that knowledge. He goes on to say that. The hope of every profession is to have its practitioners embody the best of its knowledge, experience, skill, and ethics; that they will practice with dignity, confidence and success ; and that the nature and con tribution of the practitioner that its perpetuation and continuing progress are assured. (p. 383) The nature of professional practice is such that the practitioner must make many unique and special decisions on the singularity of any particular client-practitioner transaction (Ritzer, 1973). Quality of services rendered is of deepest concern to the client. He places his health and his fortune in the hands of his professional advisor, and he entrusts him with confidences of an intimate and personal kind. He is interested in the moral quality of service (Carr-Saunders & Wilson, 1964). Therefore, this problem is particularly complicated by the fact that the professional service is said to require not only special skills from the practitioner, but also a particular kind of relationship between the professional and the client Ritzer, 1973). Lewis and Maude (1952) state that the re lationship of the client and the practitioner is the basis of professional morality. This relationship is between in dividuals and it is fiduciary. The practitioner gives the best possible advice, which the client is not competent to criticize, and the practitioner acts according to his 25 client's needs. Schein (1972) stresses this point even further saying the very essence of professionalism is the delivery of a service in response to the need of a client. There must also be a clear identification as to exactly whose needs are being met. Moore (1970) maintains that an important professional qualification is commitment to a particular calling. It is this commitment that lends cre dence and stability to the profession's code of ethics. The profession and all its requirements are treated as a lasting set of norms and behavioral expectations. The pro fessional accepts these standards, identifies with his col leagues and sees the profession as a whole entity. These standards should come across in the professional's dealings with his client. Professional Associations Professional associations are necessary for the de velopment and continued growth of a profession (Goode', 1960; Wickenden, 1950; Boehm, 1959; Harries-Jenkins, 1970; Schein, 1972; Stone & Shertzer, 1969). The professional organization provides a framework and sanctions for this complex of obligation and responsibility delegated to the established profession. In essence, it is disciplinary in all its functions, especially the educational. It is con cerned with keeping its members accountable to the implied contract with society. The organization also insures the 26 provision of the best possible advice and service within existing knowledge, while protecting the public from the unqualified practitioner. The professional organization is the profession's ultimate measure of professional independ ence . It is the association that defines the educational requirements, entry standards, and code of ethics of the profession (.Lewis & Maude, 1952) . Greenwood (1972 ) pro poses that professional associations exert control over the profession's training centers and granting or denying ac creditation by one of the associations, within a profession is the prime way the caliber of curriculum and instruction and the location of professional schools is regulated. Carr-Saunders and Wilson (1964) propose that generally speaking, each profession is organized on a craft basis, and though within a profession it is usual to find a number of independent associations, relations between them are generally friendly and there is a clear tendency towards a dominating association or a closely cooperating group. Part of the constitution of a profession is the spontaneous coming together of the practitioners in associations. The reasons for associations are protection and the desire to hallmark the competent and to foster the study of the tech nique and give this technique such an importance that boundaries are clearly defined and stable. Ritzer (1973) lists three characteristics of profes- 27 sions which are basic to the justification for professional control over members. They are as follows : 1. Assume power of ethical codes. 2. The consequences of control over recruitment and certification. 3. The professional review boards and their assumed control over practitioners. Code of Ethics Professional ethics arise from the codes of the most ancient professions: The Hippocratic oath; the inviolabil ity of the confessional; and the devotion of the lawyer to his client's interest (Lewis & Maude, 19 52). The codes of ethics of specific disciplines are an integral component in the establishment of a profession (Goode, I960;. Harries- Jenkins, 1970; Schein, 1972; Pavalko, 19 74; Bearing, 19 72; Stone & Shertzer, 1969). Ethical conduct, proposed or values in the codes of ethics of the human services, per- . tain to four major aspects of professional relationships (Levy, 1974) : 1. The practitioner, where codes insure competence, integrity, independence, impartiality, and propriety. 2. The client, involving values of de votion, loyalty, objectivity, honesty, candor, confidentiality, autonomy. 28 respect, punctuality, exeditious- ness, and personal attention. 3. The professional colleagues, regard ing etiquette, fairness, and pro fessional orientation. 4. The society, insuring care in the use of personal status, care of one's personal associations, regard for others, justice, obligation to be con cerned about social problems, and social orientation. Codes of ethics are at once the highest and the lowest standards of practice expected of the practitioner; the awesome statement of rigid requirements; and the promo tional material issued primarily for public relations pur poses, They embody the gradually evolved essence of moral expectations, as well as the arbitrarily prepared short cut to professional prestige and status. At the same time, they are handy guidelines for the legal enforcement of ethical conduct (Levy, 1974) . Greenwood (1972) states that the profession's ethical code is part formal and part informal. The formal is the written code to which the professional usually swears upon when being admitted to practice. The informal is the un written code, which nonetheless carries the weight of formal prescriptions. As a written document, the code of 29 ethics serves as a guideline of expected levels of service. Not only does it describe expected levels of quality and competency, it also may remind members to refrain from com mercialism (direct competition with colleagues), as well as state the professional's responsibility to the interests of society (Marshall, 1939) . Contained within the code is a strong altruistic commitment to the betterment of the larger society through the use of the professional's spe cialized abilities (Cogan, 1953). Self-régulâtion Self-regulation refers to the monitoring of profes sional behavior by colleagues. In other words, the peer group holds its members accountable and will invoke disci plinary action when deviation from acceptable standards has occurred (Posz, 1973). This type of monitoring system is distinguished from one in which the principal monitoring tasks fall on a hierarchial organization, the consumer of the service, or an external governmental regulatory agency. Under true professionalism, monitoring and corrective ac tion is performed by the peer group. In theory, the pro fessional group itself is held accountable for the actions of its members (Wichenden, 1950; Lewis & Maude, 1952; Harries-Jenkins, 1970; Schein, 1972; Pavalko, 1974; Bear ing, 1972 ; Stone & Shertzer, 1969) . One aspect of self regulation is the level of autonomy attained by the profes sion. 30 Ritzer (1973) states that the professional organiza tion rather than the society or the client defines the nature of the expected service and the manner of its trans mittal because the profession claims to be the only legiti mate arbiter of improper performance. In practice, auton omy exists when the leaders of a profession define or regu late the nature of the services offered in two ways: (1) control over recruitment and certification of members; and, (2) setting standards of adequate practice (Ritzer, 1973). In discussing the idea of recruiting. Caplow (1954) states that in the independent professions the entire re cruiting process, from the initial choice of candidates for training to the bestowal of honors at retirement, is under the close control of the professional group. Although the right to practice is generally conferred by a governmental board, this agency normally represents the profession and has usually been kept free from political interference. Goode (1960) states that professional autonomy means having one's behavior judged by colleague peers, not out siders. He adds that this is a derivative trait and is based on both the mastery of a field of knowledge and com mitment to the service idea. Because of this mastery, based on specialized training and the complicated nature of the problems being dealt with, the professional person has the authority to dictate what a client should do. The 31 rationale behind this authority is that the client lacks the needed theoretical background to diagnose his need or prescribe any of the possible cures. This authority does not carry over to any other professions. One only has authority when one has knowledge of a certain specific area (Greenwood, 1972) . An effective method of self-regulation is through the creation of what Goode (1961) calls the community profes sional. Although the profession cannot produce the next generation biologically, it can do so socially. A profes sion should and can control the selective process of its professional trainees. After these trainees are selected they are sent through the profession's adult socialization process. The profession is determining who will be market ing the services of the profession and, to an extent, the way in which those services are marketed. The profession can better preserve its standard in this way. Public Sanctioning and Licensing Greenwood (1972) discusses the importance of community sanction in the achievement of professional status. Other authors recognize this contention (Goode, 1960; Engle, 1970. Schott, 1976; Lewis & Maude, 1952; Wichenden, 1950; Turner & Hodges, 1970; Schein, 1972; Bearing, 1972; Stone & Shertzer, 1969). Public sanction refers to the community's formal and informal acceptance of a disciplines' ability to 32 best deliver necessary services in its area of expertise. A profession may gain sanction from the community by formal or informal means. Formal approval constitutes reinforce ment of professional standards by police power. By formally sanctioning a profession, the community gives a profession a monopoly on performing a certain service. The profession employs its association to convince the community that it will greatly benefit from the monopoly. Professions must be convincing on three factors : 1. Specialized education is necessary to perform the specific skill. 2. Those who have completed this educa tion have capability to deliver ser vice superior to those who have not. 3. The target population of service is of sufficient significance in the community to warrant the superior per formance. Greenwood notes that formal aspects of public sanctions take the form of approving of professional- client confidentiality and acceptance of a system of licensure. Licensure is the process by which permission to practice a profession is granted once the requirements of legality are recognized. 33 The degree to which a profession is subject to state supervision depends upon the external constitution or legal status it has in society (Carr-Saunders & Wilson, 1964). Licensing systems for screening applicants assures legal status. Thereby, the professional controls admission into the field (Greenwood^ 1973), operational De f ini t ions From the preceding literature review and for the pur pose of this study, operational definitions of the seven criteria required for professional standing have been de veloped. They are as follows : 1. Body of knowledge - an identifiable and distinct set of theories, method ologies, and principles which form the technical base for professional practice. 2. University Education - the formal process within an educational insti tution in which the professional body of knowledge is transmitted, usually at the graduate level. 3. Professional Ideology - the notion of service that is the basis for the pro fessional's commitment to the field and which establishes the practitioner 34 as the most appropriate individual to offer this particular type of service because of his training and knowledge of the discipline. 4. Professional Association - estab lished organizations of professionals that set criteria for membership in the field, keep members accountable for their actions, insure the pro vision of the best possible services, exert control over the profession's training centers, and keep abreast of current legislative and political activity affecting the field. 5. Code of Ethics - written and formalized standards of professional conduct that establish the commitment of the profes sional as well as insuring the compe tence of the practitioner and the quality of his services. 6. Self-régulâtion - the professional mechanism which maintains the ability of the discipline to autonomously govern and regulate its members, estab lish standards of service, enforce the 35 code of ethics, assume responsibil ity for any disciplinary action and be publicly accountable for the action of its constituency. 7. Public Sanction - the formal and in formal approval which a community grants a discipline acknowledging the profession's ability to best deliver offered services and to be self-regulating. Conclusion This discussion has delineated the criteria that have been found to be relatively universal in regard to profes sional characteristics. It should be noted that in addi tion to our defined criteria, the concept of autonomy is also associated with professional standing. The authors of this study feel there are inherent problems in defining and measuring this concept. Therefore, we have integrated the notion of autonomy in the examination of self-regula tion, and will utilize these seven criteria in analyzing the professional status of our individual discipline. Process of Professionalization While there are definite criteria requirements for eligibility to professional status, the process by which an occupation achieves this distinction is varied in the de 36 velopment of each specific discipline. Certain steps are common for professionalization in general, but the sequence of events and the intensity of their implementation dif fers. This section will examine the processes that precede professional standing. Professions with a more substantial and more theoreti cal body of knowledge behind them are better able to con vince society of the need for their particular services and perhaps to persuade society of their right to take respons ibility for them. Reference must be made to a theoretical body of knowledge for decisions made by the practitioners of the profession. The professional's responsibility for interpreting the body of knowledge and for considering, even deciding, the client’s needs and solutions to them is an important aspect of the autonomous development of the individual profession. One way in which a profession may first develop as a separate occupational group is when some individuals recognize a social need and become committed to providing for it. These initial pioneers, entering the field from a variety of routes, will be united by this com mon concern. The development of a new occupational group may open up new career possibilities for others in rela tively marginal or terminal career positions. As time goes by and the process of professionalization continues, quali fications will be laid down for entering into the occupa- 37 ——^ ^ ^ --- 1 tion and entry routes institutionalized. An occupation with! pretentions to professional status cannot afford to serve as a refuge for the unqualified (Elliot, 1972). The emerging profession claims to be offering a unique service not available elsewhere. It does not rely on open competition with those occupations closest to its field, but is likely to proclaim openly that its rivals are either im properly trained or illegal competitors. The economic suc cess of a new profession is based on the normative accept ance it achieves— or how much right to a legal enforceable monopoly it can successfully claim. Professional services usually cannot be adequately evaluated by laymen. Pro fessionals admit that they need their client's cooperation for a good performance; for survival, they also need their client's faith (Goode, I960).) Those taking the lead in striving for the advancement of professionalism within the occupational group and in claiming public recognition of its new status become the elite of that profession. They implement the following procedures according to Barber (1965): 1. Acknowledge the inadequacies of their group but compare them to ones that formerly existed in established pro fessions— express hope for progress. 2. Construct and publish a code of ethics. 38 3. Establish a professional association which will perform the following functions : a. self control; b. socialization; c. education; d. communication with public ; e. defense of professional interest against infringement by the public or other occupational groups. 4. Leaders establish measures and titles of more or less professional behavior, hoping, of course, to use such prestigious titles as "fellow" as an incentive for the less professional to become more so. 5. Seek licensure from the state. 6. Seek to strengthen university professional schools. 7. Information program for the general public. 8. Conflict resolution— with those in the group who are less qualified and with other professionals who may be charging them with encroachment. As previously stated, there are differences of opinion 39 about the subsequent processes of professionalization. Wilensky (1964) enumerates five procedural elements of pro fessionalization. They are as follows: 1. Start doing full time the thing that needs doing. 2. Establish a training school within a university. 3. Combine to form a professional associa tion with: a. further self-conscious defini tion of core tasks; b. the contest between the home- guard who learned the hard way and are committed to the local establishment, on the one hand; and the newcomers who took the prescribed courses and are com mitted to practicing the work wherever it takes them; c. the hard competition with neigh boring occupations. 4. Political agitation to win support of law for the protection of the job territory and its sustaining code of ethics : a. licensing; b. certification. 40 5. Establishment of rules to eliminate the unqualified and unscrupulous, and rules to protect clients and emphasize the service ideal in a formal code of ethics. Caplow (1954) lists the following processes as inher ent to the achievement of professional status: 1. Establishment of a professional associa tion with definite membership criteria designed to exclude the unqualified. 2. Change of occupational name, which serves the multiple function of reducing identification with the previous occupa tional status asserting a technological monopoly. 3. Development and promulgation of a code of ethics which asserts the social utility of the occupation, sets up public welfare rationale, and develops rules which serve as a further criteria to eliminate the unqualified and unscrupulous; this imposes a real and permanent limita tion on internal competition. 4. Prolonged political agitation, whose object is to obtain the support of the public power 41 for the maintenance of the new occupa tional barriers, and also development of training facilities directly or in directly controlled by the professional society, particularly with respect to admission and to final qualification; the establishment through legal action of certain privileges of confidence and in violability, the elaboration of rules of decorum found in the code, and the estab lishment— after conflict— of working re lations with related professional groups. Goode (1961) lists seven steps of professionalization which occur simultaneously: 1. Formulating a code of ethics. 2. Founding of a professional association. 3. Promulgating favorable legislation. 4. Establishing curricula for professional training (preferably in a university). 5. Making appeals to foundations for funds with which to develop new professional knowledge. 6. Writing articles to explain the unique contribution of the occupation. 7. Making protests against inaccurate stereotypes of the occupation. 42 Conclusion It is evident, from the preceding analysis, that pro fessionalism is not an easily defined characteristic. While one can observe a well-established profession, such as law or medicine, and describe its component and deriva tive traits, it is much more difficult to specifically de lineate those elements which are mandatorily required for achievement of professional status. Varying professions may or may not possess all the aforementioned criteria, and the degree to which a criterion is integrated into a pro fession also differs. Therefore, it must be concluded that professionalism is a continuum of occupational status, with no definite demarcation between the profession and the non profession. While some occupations are distinctively re cognized in the professional and non-professional loci, others seem to arbitrarily fall between the two classifica tions . Generally, there are seven criteria that are frequently observed in professions. They are: 1. A specific body of knowledge. 2. Training and education within a university. 3. A professional ideology. 4. An organized professional association. 5. A professional code of ethics. 6. Self-regulation through occupational authority and autonomy. 43 7. Public approval, sanction, and licensure. These seven criteria are often used as indicators of pro fessional standing, but are not always present in all pro fessions . The evolutional process which ultimately confers pro fessional status is also not a specific, well-defined para digm. Some events that usually occur are: 1. recognition of need; 2. recruitment of full-time workers to meet the need; 3. establishment of a body of knowledge that is transmittable through a uni versity. 4. organizing a professional association with the development of a code of ethics and a professional ideology; 5. winning legal sanction through licensing and certification. In conclusion, it must be mentioned that these pro cesses often occur simultaneously rather than in a pre scribed sequence. Nevertheless, a general paradigm does exist. This paradigm implicates a basic framework of events that occur in the evolution of a profession. The evaluation of our specific discipline will utilize the seven profes sional criteria and related processes examined in this 44 discussion for an assessment of the fields locus on the professional continuum. The next chapter in this review is the evolution of medicine as a profession according to the seven criteria suggested in this chapter. 45 CHAPTER III MEDICINE AS A PROFESSION Introduction The purpose of this chapter is to document medicine as a profession in accordance with the previous literature re view on professionalism. The chapter is divided into two sections. The first covers a history of the field of medi cine in America which includes discussion about some of the seven criteria established by the study as necessary for professions. The historical review is intended to provide information about medicine to the reader which may simplify the understanding of this report. The second part of the chapter includes a detailed examination of the seven cri teria from the literature review on professionalism. These seven criteria will be discussed in the same order as be fore: body of knowledge, university education, professional ideology, code of ethics, professional association, public 46 sanctioning and licensing, self-regulation. Freidson (1968) states that the field of medicine considers medical educa tion to be the single most important factor in determining the performance of the practicing professional and accord ingly, a large part of these sections is concerned with medical education. The physician is the most prominent among members of the generally re cognized professions. He is seen by the public as possessing a higher standard than any other professional, and by the sociologist as the virtual prototype of his kind. (Friedson, 1968, p. 122.) Medicine is recognized historically as one of the first groups to attain professional recognition in the sense that the term profession is used today. The previous chapter on Professionalism has examined criteria that constitutes a discipline becoming a profession. Bulloch (1966) contends that medicine meets many of these criteria of profession alism. These criteria and their relevance are listed below: Body of knowledge - medical knowledge is developed and, for the most part, unaccessible to the layman. University education - medical knowledge is institu tionalized and transmitted efficiently. Public sanction and licensure - medical practitioners claim exclusive rights to practice. Code of ethics - a code of ethics exists ahdlis\en forced . 47 Self-regulation - medical practitioners have control over fellow practitioners and auxiliary practitioners. As there has always been sickness, accidents, and ail ments of man, there too has always been the practice of alleviating these discomforts (Hughes, 1968). All socie ties have beliefs about the origin and treatment of dis eases whether they are spiritual or scientific in nature. Medical care can be defined as "the application of scien tific knowledge and technique to solving the physical and emotional problems of man" (Glaser, 1968, p. 197;).. For the physician, medical care denotes the "body of diagnostic and therapeutic theory and procedure developed to understand, cure, and prevent disease" (Glaser, 1968, p. 198). Early American Medical Education In the early days of American history there were no medical schools to educate and train personnel for the practice of medicine. Consequently, most physicians (those with formal training) were educated in Europe. The earli est of these physicians were often the clergy (Beck, 1966). This association of clergy and medicine has been common place throughout history as physical and moral evils have long been associated. Many clergy turned to the study of medicine before leaving Europe for the Colonies. European medical schools had been operating for many years, and for the most part were associated with universities (Bulloch, 1966) . 48 In America during the 17th and 18th centuries, little attention was paid to medical education. The first train ing programs were limited to personal instruction in ap prenticeship fashion. The most distinguished physicians of the day continued to be educated in Europe. Circa 1730, there were 3,500 people calling themselves physicians in the Colonies. No more than 175 held degrees and no more than 400 had any sort of formal training in medical subject matters (Hughes, 1973). By 1730, medical education had be come an issue and informal classes and lectures began with Philadelphia as the center of medical interest. These lectures covered mostly anatomy and patient care. Prompted by this interest and concern for medical education, the College of Philadelphia in 1765 created a professorship in, "The Theory and Practice of Medicine." In that same year, the first American medical school granting a degree in medicine, the University of Pennsylvania, was established. Four more medical schools were founded before havoc in medicine began: University of Columbia, 1797; University of Harvard, 1783; University of Dartmouth, 1797; and. University of Maryland, 1807. These pioneer medical schools were conceived as part of an institution of higher learning and connected with a hospital. Apprenticeship became sup plemental rather than a substitute for academia. In the years to come, medical education would dramatically change in both quantity and quality. 49 Pre-Flexner Medical Education This section is appropriately titled after the man who reported on the proceedings of the medical profession during this period of history, Abraham Flexner. This section is concerned primarily with the events leading up to the Flexner report on medical education. The single best word to describe this niche of Ameri can medical education is "uncontrolled." The Jeffersonian philosophy that government governed best when governed least was an understatement in regards to medical educa tion. This laissez faire type of philosophy dominated the medical profession by the end of the 19th century and re sulted in the takeover of medical education by the pro prietary school. Many factors were responsible for this uncontrolled growth in numbers of both medical schools and medical prac titioners. At a time when medical education was just be ginning, careers in law and theology were preferred to medicine (Hughes, 1973). Consequently, top notch students were not often enrolled in medical schools. As time passed, the demand for physicians became greater than the legitimate medical schools could supply. Economically, when demand exceeds supply, one of two things, or a combination thereof can happen: Either cost increases until demand is lessened due to high prices, or supply is increased. The latter is 50 an economic explanation of the series of events leading to the establishment of the proprietary schools. In the early 19th century, proprietary schools were established, almost none of which were associated with uni versities . Often, these schools were no more than a group of physicians banding together for* the purpose of establish ing such a school. More emphasis was placed on monetary gains rather than quality education. Though referred to as proprietary schools, they were a "school" in name only. Nothing seemed essential for proprietary schools other than professors (Flexner, 1910). No quality control or stand ards of medical school curriculums were required by states and as a result the proprietary school curriculums were usually very simple (Hauser, 1974). Lectures, when offered, were not mandatory to attend as attendance requirements were very vague. Patient contact usually was not available until after graduation. Students lucky enough to catch the attention of the instructors were allowed to observe the instructor in his private practice. Admission requirements were unreasonably low and vague. The legitimate medical schools required two or more years of college education prior to admission. Proprietary schools required a "common school" education which could be, and was interpreted in any way to gain admission (Hauser, 1974). In these proprietary schools, tuition was 51 usually proportional to the admissions requirements. The lower the admissions standards, the higher the tuition and vice versa. Usually, payment of the tuition satisfied all the necessary requirements for graduation. Legal control over medical practice was virtually non existent. Medical licensure existed as far back as the Colonial period, but as the number of medical students in creased it became easier to license all those who graduated rather than to individually examine each one. The earliest form of licensure of medical practice dates back to the Colonial period. The first medical licensing examination was given in New York in 1760, at which time a certificate to practice physic or surgery was granted by a board of medical examiners that included penal ties for practice without a license (Beck, 1966; Derbyshire, 1969). In 1762, a similar law was passed in New Jersey. In 1773 in Connecticut a different approach to licensing was undertaken that granted the right to practice medicine to all, but only allowed licensed physicians to collect fees. State medical boards functioned in many states by the 1830 * s that included principle duties of examining and licensing physicians. Licensing by or through medical schools became an issue in the early 19th century, and at that time many states permitted licensure through examina tion at the medical school or before the state board of 52 medical examiners. During this time, the medical degree became superior to state licensing. As the number of medi cal schools increased, mostly proprietary schools, state medical boards were abandoned in favor of licensing all those who graduated. As a result, many unqualified physi cians were granted degrees by medical schools that often required no more than the payment of fees for satisfaction of the requirements. After the Civil War, state boards of medical examiners were reestablished and in 1891 the National Confederation of State Medical and Licensing Boards (later to become the Federation of State Medical Boards (FSMB) in 1912), was founded to deal with state licensure. The National Board of Medical Examiners (NBME), a voluntary organization formed in 1915, developed an examination and awarded a certificate to practice medicine that was approved by the FSMB to be used in lieu of individual state examinations. Qualifying requirements of the "board" were : a high school diploma,, a satisfactory course of college study in natural science, graduation from a grade A medical school (as rated by the American Medical Association), and one year internship in a "board" approved hospital. The three part examination used then is similar to the one still being used today, covering three areas : basic medical science, clinical medicine, and practical medicine (bedside examination). 53 Four university medical schools (legitimate schools) were operating by 1800. By 1820, there were 17 medical schools, in 1839 there were 30, and by 1865, 65, This in crease in number was due mainly to the proliferation of the second class proprietary school. By the mid-20th century^ the original medical schools were in competition with pro-' prietary schools that "sprang up all over the country" (Shyrock, 1966, p. 112). The graduates of the university medical schools carried much prestige, but by no means did they monopolize the medical marketplace. Without regulc^- tion by either the state or by the profession, medicine was flourishing in the high profit market of medical education. Behavior within the profession was also disrupted. A practical code of ethics was virtually non-existent and un controlled competition between physicians resulted in pub lic displays of condemnations of fellow physicians. These public medical quarrels were injurious to the credibility and reputation of the profession. Percival's medical eth ics, originally adopted in London, were later adopted by the American Medical Association. These ethics expressed general ideas about behavior toward patients, colleagues, and the public at large. The idea of uncontrolled competi tion had been attended to earlier and was the principal motive behind the founding of a pionner medical society in 1766 in which the standardization of fees was discussed. 54 The decline of quality medical education, and as a result a related decline in the competence of the practitioner, had become apparent by the mid-19th century. Steadfast physicians and medical educators were alarmed at the present status of the situation and attempted to in itiate medical education reforms. This partially inspired the founding of the American Medical Association. In 1846, there was no national association of medicine in America. Members of state medical societies invited colleagues and representatives of medical schools to meet and discuss the formation of a national medical association. Due to an initial lack of interest no action was undertaken, however, the following year a similar meeting was held and on May 5, 1847, the American Medical Association (AMA) was born. The primary reason for the formation was to raise medical education standards. Among the objectives of the AMA was to "cultivate and advance medical knowledge" at a time when medical knowledge was at a low level of sophisti cation . Quickly the AMA sought to homogenize the profession by opposing sectarian groups, such as homeopaths and eclec tics. The association condemned the mixing of homeopathy with standard medical education to further emphasize this point. The AMA did sanction the state medical societies, but, at the same time, feared the rise of interstate bodies 55 that might draw portions of the discipline out of the AMA sphere of influence. The sanctioning of specialties and specialty examination boards took place as knowledge and technology dictated the need for them. On the issue of medical education, the AMA was very active. In 1867, the Council of Education was formed withir the AMA and in the first year reported that medical educa tion should be "materially, if not completely reformed." Data on this subject was collected as early as 1901. In 1904, the official journal of the AMA, the Journal of the American Medical Association (JAMA) reported on medical education standards. The AMA went through a reorganization in the early 1900's. Additional duties of the Council on Education included the evaluation and rating of medical schools and the reporting of the findings to the House of Delegates of the AMA. The Council of Education reported on medical education in 1907 and rated the 161 medical schools; 82 acceptable, 47 doubtful, and 32 unsatisfactory. The AMA also assisted Abraham Flexner in his classical study on medical education. The official journal of the AMA is the Journal of the American Medical Association (JAMA). The first publication of the AMA, entitled "Transactions," an annual report of the association, began in 1848. Thirty-five years later, in 1883, JAMA began circulation on a weekly basis to "serve 56 and elevate journalism and educate the profession,” "JAMA enhanced the prestige of the profession more than any other action during the 19th century"" (Burrow, 1963, p. 67). Under the initial organization of the AMA, the methods of membership, representation, and voting were very com plicated, so much that in 1882 memberships were extended to attract more members. Reorganization procedures began in the early 1900's and during this time great enthusiasm was generated. Action was rapidly undertaken on ethical, polit ical, and educational reforms. The medical education matter was acted on with most enthusiasm, the feeling being that this was the area that needed reform the most. Aside from the addition of councils of different areas, the basic structure and operation is the same now, The AMA proved to be an influential factor in the re form of medical education; however, the AMA, physicians, and medical educators encountered many difficulties in these reform attempts beca,use many influential practitioners were also presiding officers of the proprietary schools at which the reforms were aimed. Instituting the reforms would severely affect the profitable business operation. In the 1870.7s, reform attempts moved forward. Uni versity medical school professors appealed again to the AMA to upgrade educational programs of the second rate medical schools. The AMA had, at this time, the power to 57 license physicians. These medical reformers also convinced the states to reestablish medical examination and licensing boards that had earlier been abandoned. As a result, the quality of medical education was somewhat upgraded and by 1901 medical education had become a national and political issue. In 1904, the AMA reorganized by consolidating state medical societies and established the Council on Education with duties that included the careful examination and grading of the medical schools. An association known as the American College of Surgeons undertook the task of factually grading hospitals for the purpose of undergradu ate teaching and post-graduate research. In 1890, the Association of American Medical Colleges (AAMC) was founded in which one of the objectives was the advancement of medical education. The issue of medical education and the reports on the ratings by the Council on Education prompted the single most important study on medical education by Abraham Flexner. The Flexner Years In 1908 Abraham Flexner was commissioned by the Carnegie Foundation for the Advancement of Teaching to factually survey and rate medical education in America and Canada. Two years later the report was published as Medical Education in the United States and Canada, a docu ment that completely reorganized and upgraded medical edu- 58 tion. Flexner reported on the 155 medical schools that had survived the 457 that had existed in fact or intent in little over a century (Hauser, 1974). Flexner visited each school and reported on, among other things : entrance re quirements, attendance, faculty, students, finances, facil ities, and curricula. The report revealed that a substan tial number of medical schools primary objective was to make money, medical educators successfully confused the public in distinguishing between qualified and unqualified physicians, low admissions standards prevailed, curricula generally consisted of little, if any, dissection, oppor tunities to attend clinics were rare, attendance require ments usually were non-existent, and the faculty were generally not qualified to teach medicine. Of the 155 schools reported, 16 required two or more years of college before admission, 50 required high school education, and 80 or more required no more than a "common school" education. To say the Flexner report affected medical education was an understatement. During the course of his study, 20 schools closed their doors. By 1910 there were 131 medical schools operating and by 1929 there were 76. This reduc tion occurred in proprietary schools in three ways; clos ing doors completely, merging with other medical schools, or most often merging with universities. By 1920 the "blatant offenders had closed shop" (p. 127) as state 59 legislators and universities began to reorganize medical education (Lippord, 1974). In 1905 the AMA Council on Medical Education suggested that one year of pre-medical education be completed prior to admission. In 1926, 76 of 83 medical schools required a minimum of two years of college before admission and most schools required three years. Some required as much as a bachelors degree. A basic knowledge of biology, chemistry, and physics was con sidered essential before beginning medical school. A semi standardized curriculum replaced the series of lectures and the length of education became four years, two years medi cal sciences and two years clinical study. The Flexner report was a major turning point in the organization and quality of medical education that in the course of time would make similar improvements in the qual ity of medical care itself. Among the report, recommenda tions were that medical education should be based more on the biomedical sciences than it had in the past. A second major change was a proposal to relate medical education to hospital clinical experience. Association with the uni versity system was seen as beneficial in making these changes, especially with that of biomedical research. Flexner was greatly impressed with the current curricula at Johns Hopkins Medical School, Baltimore, Maryland. "Here the decisive benefits of emphasis upon the biomedical 60 sciences and the university base, the close integration with the teaching hospital and the implementation of the concept of full-time faculty, could be seen as essential for future progress in medical education (Sheps & Seipp, 1972, p. 87). After the initial shock and resentment of the report, reorganization and attention to the recommenda tions began. The following improvements were made after the report; two years of college was required prior to ad mission, basic medical sciences were taught by a signifi cantly larger number of full-time faculty, clinical facili ties were utilized for instruction and the clinical clerk ship was introduced as a learning technique, the program was expanded to four years, the medical school was inte grated into the university system, and endowment was from other than students. The Rockefeller Foundation, for ex ample, distributed over $78 million among medical schools of 24 universities between 1910 and 1928 (Sheps & Seipp, 1972). In less than 20 years after the Flexner report, medi cal education progressed from an unresponsible, unregulated, and unorganized state of existence into an organized system of state and self-regulatory guidelines and procedures for medical education and licensure. Medical Schools previously unattached to universities became associated with these in stitutions after the Flexner report, or closed their doors. 61 The evil reign of second-rate proprietary medical education came to an end. New Medicine In 189 3 the Johns Hopkins School of Medicine had been established, using the European university system as a model. The new educational methods incorporated at Johns Hopkins were utilized by most "university" medical schools for the next 30 years. The new medical curriculum con sisted of; basic medical sciences taught in research labs in order to continually update the scientific discoveries, a university teaching hospital associated with the medical school, clinical clerkships, full-time faculty, bachelors degree requirements for admission, and the course of study lengthened to four years. In 1938 the AMA Council on Educa tion recommended that no medical students be admitted with out at least three years preparatory college study. Internship (supervised clinical practice after complet ing academic study requirements) was required by most states for obtaining the Doctor of Medicine degree immediately following the Flexner report. Residency programs (post graduate period of hospital education and training which qualified the physician as a specialist) were under the control of the AMA. In the earlier days of medicine, there was not enough medical knowledge to justify specialization. At that time, diseases were thought of in terms of either 62 impurities in the blood, or excessive tension or laxity of the nervous and vascular system. Most often bleeding was the treatment for these "diseases." As medical knowledge and techniques became more sophisticated, treatment cor respondingly became more precise. Specializations emerged some time after the Civil War. Specific diseases were cor related with specific lesions and symptoms. Treatment was the removal of the lesions. By 1940, 15 specialty boards were operating, each recognized by the AMA and each with educational and licensing requirements. The Council of Education published lists of approved residency programs. Presently, there are 22 approved specialties, each with specific academic, residency, and licensure requirements that are under the jurisdiction of the AMA. By 1955, 70 percent of medical students had received bachelors degrees. The pre-medical education reflected a heavy science background that many felt too stringent and not covering enough of the humanities and social sciences (Hauser, 1974). It was argued that heavy science education did not prepare the students adequately to deal with so ciety and that a broader pre-medical and medical education was needed. Medical programs had been very structured: two years medical science, two years clinical study, and one year internship. The student had very few electives to choose from. The 1960's brought opposition by students to 63 these rigid schedules. Subsequently, alternative medical programs appeared in order to accommodate the individuality and the different career goals of students. In 1965, Duke University Medical School incorporated these ideas into a new approach to medical education, a three phase approach. Phase I covers the basic medical sciences, with the empha sis on principles rather than details. Phase II consisted of clinical clerkships: Medicine, surgery, pediatrics, obstetrics, gynecology, and psychiatry. The third phase was a course of study tailored to the specific interests of the student. Within five years most medical schools adopted this as a similar program, variations mainly in the length of medical sciences and elective courses. Currently, in the United States there is variation in the medical education plans, yet standardization is main tained. Strict regulation of medical subject matter is maintained by the AMA and by the individual states licens ing boards. Individual medical programs may vary as long as they meet the requirements for subject matter and clerk ships set forth by the state and federal regulatory agencies. The Professional Status of Medicine The previous chapter on professionalism reports on seven criteria that this study considers essential for a discipline becoming a profession. This next section ex- 64J amines each of these criteria in relation to the field of medicine in the following order; body of knowledge, uni versity education, professional ideology, code of ethics, professional associations, public sanctioning and licensing, and self-regulation. Body of Knowledge The practice of medicine is based on certain biologi cal, chemical, physical, and other scientific principles which cumulatively may be called a body of knowledge. The amount of medical knowledge is so vast that Freidson (1968) claims that one of the medical students most difficult task is to "select from the enormous mass of facts presented to him, the information he is really to learn." (p. 122) This information is readily available to medical students in theoretical and practical form, to physicians in con tinuing education programs, but is rather inaccessible to the layman. Once theoretical and practical medical skills have been demonstrated by the medical student in examina tion form, the license to practice medicine is granted, all other requirements being met. However, medical specialties all have specific "bodies of knowledge" and regulations that govern the pursuit of these specialties. It can be stated that one body of knowledge is common to all physi cians, the medical knowledge acquired in the basic medical education program. There are also other bodies of know 65 ledge, more precise and more intensive for each of the re cognized medical specialties. The concept of body of knowledge is directly related as the basic medical education process. The instruction of this knowledge is done almost entirely by members of the profession at a university. The medical material included in the educational process is also partly regulated by the California Board of Medical Examiners. Certain medical skills and facts are required by this "board" to be in cluded in the medical curricula. Manual skills are neces sary for medical practice, but for the most part practice is based on intellectual skills of the physician. It is interesting to note that geriatrics is not a re cognized specialty as such. No specific study of knowledge is required in order to practice this unofficial specialty, and under these circumstances, any physician can become a geriatrician. University Education All medical schools in the nation are: part of a uni versity, on the graduate level (except for a special pro gram that accepts students directly out of high school), affiliated with one or more teaching hospitals. The medi cal education includes inquiry into the body of medical knowledge as well as the acquisition of practical skills. The first two years reflect a high degree of medical 66 science classroom instruction. The third and fourth years cover mostly the various clerkships. The clerkship (also known as the preceptorship) is the practical learning ex perience in which the student accompanies the instructor on patient visits in the hospital. Clerkships usually included are: Neurology, Obstetrics/Gynecology, Surgery, Medicine, Ambulatory and Community Medicine, and Pediatrics. Addi tional clerkships are usually required by the school but are often selected by the student in accordance with his goals. One year of internship takes place at an accredited hospital after the student graduates from medical school. The internship is required by law before the license to practice is issued. The intern is under supervision of a medical school, but is not required to intern from the hos pital that granted the degree. All medical schools in California must meet specific entrance and curricular requirements outlined by the Cali fornia "board." California medical schools are legally chartered and approved by this board. Candidates for the Doctor of Medicine degree must complete four academic years in an approved school in the United States or Canada with at least 4,000 hours of course work. One year internship in general practice medicine is also required. California medical school graduates receive the license to practice upon completion of the above requirements and under condi- 67 tions outlined by the board. The subject of continuing medical education has, until recently, been optional for physicians in California. Once formal education had been completed, there was no more formal direct guidance. Relicensure of physicians required no more than payment of the license fee, "Licensure for life" was wrong and continuing education must be regarded as a matter of course, not a matter of choice (Van der Koot, 1973). In response to this concern, the AMA established the Physicians Recognition Award (PRA) for continuing education, Application for this award was voluntary and was "presented to physicians who earned it by completing the educational requirements" set forth by the AMA (JAMA, 1976, p. 141). A total of 150 credit hours of continuing medical education of "AMA acceptable" work was required over a three year period. All of the California medical schools were ac credited by the AMA for continuing education courses. Other accredited courses were offered through clinics, hospitals, and other "AMA approved" institutions. This had been the major thrust exerted by any professional medical associa tion regarding continuing education. As of August 1, 1976, a California statute required that continuing medical education be completed prior to re licensure. The physician is required to submit a report of 68 continuing education courses before the license can be re issued. Regulations concerning the acceptability of these courses are explained in detail in the statutes. Accept able courses range from accredited formal courses to inde pendent study hours. Specific hour requirements for the various categories that make up the application are also outlined in the statute. This program is similar in design to the AMA PRA program with the major exception that it is mandatory. A supplement to JAMA (August, 1976) lists courses sponsored or co-sponsored by the AMA. In Califor nia there are five such courses listed under Geriatrics (see Appendix F). This list of courses is not exclusive for continuing education requirements for Geriatrics be cause other non-AMA supported courses offered at other locations may meet the requirements set forth by the pro gram. Profes s ional Ideology The basic principle of professional ideology (as stated in the chapter on professionalism) is that the phy sician is the best qualified to decide the needs of the client, the best qualified to decide the solution to the problem, and practices an inherent notion of service based on client interest and need rather than personal or com mercial gain. The degree of adherence to these and other service ideals is regarded as a degree of professionalism. Also stated is the acceptance by the client and the public that the physician is the best qualified to offer the needed services. The medical profession offers a set of services that no other profession can morally or legally duplicate. Through years of medical education, internship, and pos sibly residency, and most recently, a required program of continuing medical education, the physician has acquired information regarding the best possible treatment of clients; for various problems. The states have accepted this to be valid and have subsequently passed legislation granting the practice of medicine only to those meeting rigid require ments set forth by the "state board of medical examiners." The power to revoke licensure is retained in the event dis ciplinary action is needed. The public generally accepts the physician's position as the best provider of needed medical services due to the continued patronage of physi cians. Many would argue that the service ideal-devotion is less than the desire for personal or commercial profit. This can be easily demonstrated by some physician's refusal of services to those who cannot pay or those on Medicare or Medicaid. Hospitals often refuse admittance without demon- I ! stration of the ability to pay. The personnel involved in I these cases do not accordingly reflect a high degree of i professionalism based on the idea of service rather than ' 70 personal gain. On the contrary, there are clinics, hospi tals, and private physicians who offer services knowing they will not be paid. There is also a part of profession alism which supports the payment of fees for services rendered, that services of professionals should not be free. This ideological ambivalence begins early in the life of a pre-medical student, the inclination to assume service orientation and help people, and the desire to seek prestige and money (Freidson, 19 70). The notion of service is suggested by such documents as the code of ethics (The Principles of Medical Practice) and the Hippocratic oath which suggest that inherently all men are good and know what is right. These documents offer guidelines of behavior in achieving the sense of righteous ness . On professional judgment, the physician has almost complete autonomy in making decisions. The physician's judgment is based on his medical knowledge, the right to administer and prescribe drugs, to perform surgery, the right to hospitalize, and the right to order laboratory procedures that are otherwise inaccessible to the layman. The client is expected to accept the advice on the basis that he is not competent to criticize the physician's j udgment. The belief in professional freedom and autonomy in the 71 work situation is upheld in the field of medicine. Except ing national health for the aged and medically indigent, physicians are free to practice with few formal constraints (Freidson, 1970). According to Friedson (1968), this pro fessional freedom and autonomy is joined by the responsi bility of self-regulation, differing in the various methods of medical practice. Schein (1972) stressed that the essence of profession alism is the delivery of services in response to the client needs. This is the basic method of medical practice. The patient approaches the physician with a complaint, the physician uses his professional judgment and makes use of the wide variety of clinical testing to provide the best possible treatment. The client is expected to accept the physician's advice and the necessary treatment. Code of Ethics According to Sperry (1956), "medical ethics are more codified than any of the kindred professions" (p. 110). "The Principles Of Medical Ethics" is the definitive and authoritative code of ethics adopted by the AMA for medical practice. The various medical associations are very rigid in upholding these standards. For example, physicians are not supposed to advertise and there are examples of viola tors being expelled from the AMA and state medical socie ties for violating this ethics. The state medical socie 72 ties often publish their own codes of ethics, but usually these ethics are no more than footnotes to the "Principles." The "Principles" express the general account of physicians and the profession's duties to the patient and public, and duties to the patient and public, and duties of physicians to each other, and to the public at large. The earliest written code of ethics for medicine was noted in Babylonia about 2500 B.C., and was essentially a definitive code of conduct. The Oath of Hippocrates is a brief statement of principles that has been passed down through the centuries. The Hippocratic writings state that "medicine is an art, a difficult art, and one inseparable from the highest morality and the love of humanity." It was written by Hippocrates some time during the period of Grecian greatness. It has remained in Western Civilization as an expression of ideal conduct of the physician. The Hippocratic Oath, still spoken at graduation of some medi cal schools, states the physician will not divulge confi dential information. Thomas Percival, an English physi cian, published "Percival*s Code of Medical Ethics" in 1803 that expressed codes of conduct relative to hospitals and charitable organizations. One of the first orders of busi ness of the newly formed AMA in 1847 was the adoption of a codie of ethics. The code of ethics adopted was based on Percival's "code." Revisions have since been made, but the 73 Council on Constitution and Bylaws has assured the AMA House of Delegates that "every basic principle has been preserved." The basis of the ethics is that inherently every man knows what is right and what is wrong, and the "Principles" are, in essence, guides to good conduct to attain what each person knows is true. Professional Associations Professional associations have been discussed pre viously as one of the criteria of a profession. The medi cal field has many such organizations. The American Medi cal Association (AMA), a voluntary national organization "to promote the science and art of medicine and the better ment of public health," (p.174) is by far the largest and most powerful (DeGroot, 1966). The AMA is a physician's organization existing to serve the public and the physician members and their interest. A president is elected each year to office without pay by members of the House of Delegates. This body consists mainly of members of the state medical societies. The number of delegates per state is proportional to the number of members of the state medi cal society. The delegates meet two times per year, mainly to determine operational policies. The Journal of the American Medical Association (JAMA) is the official publi cation of the AMA. Other publications include Quarterly Cumulative Index Medicus, Today's Health, and numerous 74 others relating to drugs, illnesses, operations, and other special interest subjects. Although the AMA has no legal power, the association is very powerful. Moral persuasion has been witnessed to be very effective. The AMA is the most powerful and active, yet other professional associations exist. Specialty societies exist for every specialty and almost all local geographic inter ests (e.g., American Geriatrics Society, American Urologi cal Association, California Public Health Association, Los Angeles Radiological Association, etc.). These societies inform members Of ongoing developments in the specialty through seminars, society meetings, and society publica tions. There are 22 officially recognized specialties (e.g., surgery, psychiatry, internal medicine, medicine, etc.), each with a specialty/^ society and regulations. Voluntary health organization (e.g., American Cancer So ciety, American Heart Association, etc.) work in the medi cal field and inform physicians through publications of their own or other publications of medical advances. State medical associations (e.g., California Medical Association, Hawaii Medical Association, Academy of Medicine in New Jersey, etc.), exist mainly for the benefit of physicians in those states. Other health related associations do re search in the medical field and have information provident systems for physicians (Center for Disease Control, Na 75 tional Institute for Health, Kidney Foundation of Northern California, etc.), also represent various medical interest groups. Of these associations, the most influential for physicians are the specialty societies because of their regulatory and licensing power of physicians. Although geriatrics is not an Officially recognized specialty, a special interest society. The American Geri atrics Society exists for the benefit of physicians inter ested in this area of medicine. The society holds annual meetings, supports research in the aging field, and pub lishes a journal, the Journal of the American Geriatrics Society. The power of the AMA is not to be underestimated. Some claim it to be the most powerful union in the country. At any rate, many issues and platforms have been supported or opposed. For example, the AMA was called essential in the passage of the Pure Food and Drug Act. Physicians were encouraged by the AMA to enlist in the World Wars. The AMA has also enforced medical ethics and exposed wrongdoings, such as medical fakery. According to Rayack (1967), the AMA pressured medical schools, with the assistance of the American Association of Medical Colleges (AAMC), in the 1930's to restrict the number of admissions. Rayack con tends the purpose was to increase the demand for physician's services and subsequently elevate the income. The admis 76 sions were down 18 percent between 1933-1939 and resulted in a shortage in physicians. The AMA and the AAMC claimed that an oversupply of physicians was present previously, partially as a result of the large number of second-rate medical students. During the second World War, accelerated programs of medical education graduated 7,000 physicians. After the war, the AMA tried to again reduce the number of admissions by opposing federal aid to medical schools and students. The AMA claimed again that there was a surplus of physicians, but Rayack (1967) claims that this opposi tion was made in order to maintain the high economic posi tion of physicians. Despite the opposition by the AMA bills passed that granted student and construction funds. The most recent crisis involving the AMA was that of Health Insurance bills. Skeptics again argue that AMA opposition was only in the interest of maintaining high physician in comes . The AMA supported private health plans rather than national health plans initially, but submitted a health in surance plan of their own, "eldercare," a plan that covered medical services, administered by the states, and priced according to income. Needless to say, it failed. It is evident from the above proceedings that the AMA i has been involved in many issues, supported and opposed by j ! the public and government. As large and as influential is j the AMA, enemies and opposition, as well as friends and sup-}- 77 porters are found on many different issues. As long as the AMA exists there will always be those to criticize, and always those to support it. Public Sanctioning and Licensing As explained in the previous chapter on professional ism, the idea of public sanctioning and licensing is con cerned with the public acceptance that physicians are the best qualified to deliver medical services. It was also mentioned that formal and informal means of sanctioning by the community are possible. In medicine, the formal sanc tion is provided by the state in the form of licensure and monoply of medical services: the privilege to hospitalize, to use and prescribe drugs, to perform surgery, and to order laboratory procedures otherwise inaccessible to the laymen. The specialized education and training of medical students, the examination and licensing of those students, and a significant need for medical services by the commun ity that are not available by other means constitute the claim by medicine to the monopoly of these services. The issue of state or federal licensure has been de bated to a great extent. The philosophy of state examina tion maintains a sense of individuality accordant to state needs, but as evidences resulted in great diversity of standards, including problems of recognizing other state licensed physicians. Federal control would maintain higher 7 ^ uniformity and control, but the concept of individuality is lessened. The main concern to the AMA and the medical field at large was that federal control may put a damper on the progress of medical science and technology. Today's medical examinations are issued by the state, but incor porate both aspects of federal and state administration. The physician is licensed according to the state's require ments in which he is applying, but tests such as the Na tional Board of Medical Examiners (NBME) and the Federation Licensing Examination (FLEX) are used on a national scale. The legal practice and licensure of medicine is regu lated by the California Board of Medical Examiners. All physicians practicing in the state must be licensed by this board. Those physicians licensed by other states may usually obtain a license under reciprocity guidelines under conditions outlined by the "board." All California medical schools must have specific entrance and curricular require ments outlined by the "board." The "board" grants two licenses: the Physicians and Surgeons Certificate, and the Certificate to Practice Podiatry. "The Physicians and Surgeons Certificate authorizes the holder to use drugs or what are known as medical preparations in or upon human beings and to sever or penetrate the tissues of human beings and to use any and all methods in the treatment of diseases, injuries, deformities, or other physical or 79 mental conditions" (West's California Codes, 1969, p. 85). The members of the "board" are physicians and must have lived in the state for at least five years. Candidates for the Doctor of Medicine degree must complete four academic years in an approved medical school in the United States or Canada with at least 4,000 hours of course work. One year of supervised clinical internship in an approved school by the board in general practice medicine is also required. Graduates of the California medical schools receive the license to practice upon com pletion of the above requirements and under conditions out lined by the code. Each of the 24 medical specialties is regulated by individual specialty "boards" that outline curricular, residency, and examination requirements. Self-regulation The basic principle behind self-regulation is that professional behavior is monitored by colleagues, that they are as a result of specialized education and training the best qualified to account for professional behavior, and that medicine likewise is the best qualified to set stand ards for practice. The medical field theoretically is re sponsible for the behavior of its members. Self-regulation| of the medical field is evident in many ways, both formal | I and informal. j The purpose of peer review is to apply the collective ; 8 0 j professional judgment to individual or group medical prac tice. Peer review is the only acceptable means of mandated review of medical practice (Decker & Bonner, 1973). The control over practice often depends on the type of organi zation in which the service is provided. There are three general methods of peer review based on the complexity of the medical service organization. Simplest is the solo practice in which the physician acts as an entrepreneur, free to do what his conscience and knowledge dictate. "As surance of adequate performance on the part of the solo practitioner seems to require exceedingly effective educa tional procedures" (Freidson, 1968, p. 125). Control rests solely on the individual. The "colleague network" is a much more common organization, that of physicians loosely organized to refer cases to one another. The referral pro vides the Opportunity to observe the work of fellow col leagues and thus influence to some extent performance and number of referrals in the future. The last practice or ganization is referred to by Freidson (1968) as a profes sional bureaucracy, a large group practice, university clinic, or hospital. All have countless sets of administra tive rules and guidelines and as a result provide the best | opportunity for professional regulation. The most common ' I system of action in regards to the above mentioned controls| I in the United States is what is known in Britain as the ! "boycott," refusal to enter collaborative relationships with those whom they do not approve. Insofar as formal review procedures are concerned, only medical societies are supposed to review patient and colleague charges against physicians. Review committees in hospitals systematically review credentials, medical re cords, laboratory analyses, and medical performances. For mal review procedures are not common, most often they are found in hospital settings. In the early 1970*s, the Bennett Amendment established the Professional Standards Review Organization (PSRO), a modification of the AMA proposal for regional peer review. Regional peer review voluntary organizations were estab lished to review mostly matters of national health insur ance claims, particularly Medicare and Medicaid, Included were standards for necessities of service, proper practice procedures, and reasonable fee rates. The aspect of controlling those who will perform medical services in the future and, to some extent, the way the services are performed by those persons is almost ex clusively under the control of the medical field. The AMA, to a large degree, controls the admissions of medical stu- : dents, the curriculum, and the teaching hospitals. Acered- i itation of medical schools and teaching hospitals is also 1 under control of the state "boards." Physicians make up I 82 the membership of both the AMA and most state "boards and, therefore, regulate themselves. It can be concluded that self-regulation is an active component of professionalism in the field of medicine, that physicians judge themselves both formally and informally, and that autonomy is achieved greatly through the high degree of self-regulation. Summary For the purpose of this study, seven criteria have been documented to be essential for a discipline to legiti mately call themselves a profession. Insofar as the last chapter has related these criteria to the field of medicine, and that medicine has been shown to comply with these seven criteria, we conclude that medicine, therefore, is a pro fession . 83_j CHAPTER IV MEDICINE AND GERONTOLOGY Introduction This chapter will deal briefly with the projected needs of gerontology, the relationship between medicine and gerontology, educational programming, and the team approach. Advancing age increases the complexity of relation ships between individuals and the world. In a nation that has always valued a high standard of well-being for its population, it is disheartening to discover that the medical profession is slow to recognize that the elderly need spe cial attention for their "well being" and that this requires special training that must begin early in the career of a physician. Perhaps the new discipline of gerontology has something to say to medical educators about those needs, and the re searchers of this report hope that these findings might be of value. 84 Proj ected Needs The tremendous increase in the number of older persons over the past few decades has placed in our society liter ally millions of people not anticipated by demographic pro jections made earlier in the century. Persons 65 and above constituted 4 percent of the American population in 19Ô0, 10 percent by the Second White House Conference on Aging in 1971; it will, perhaps, con stitute 12 percent by the turn of the century and so on. By the time the year 2020 rolls around, one out of every five Americans will be over 65 years old (Butler, 1976). With such great technological and organizational changes (such as the present century has witnessed), new techniques and new ways of solving problems are needed. At the present, medical schools teaching Family Medi cine, or Community Medicine, provide the best opportunity for the inclusion of gerontology into the curriculum. There are more and more qualified persons able to teach and develop curriculum for medical schools. Butler (1976) states, "There are no home grown geriatricians in the United States, therefore, we need to develop faculty - (p. 3). Currently, there are less than 15 percent out of an esti mated 25,000 faculty members in medical schools that have any real training in geriatric medicine (Butler, 1976)., Many of the problems the aged face are also sociologic. 85 ; psychologie or economic, as well as medical. Thus, medi cine must look to the behavioral sciences, as well as to medical science, in seeking a solution (McGlone & Schultz, 1973), and it is here also that gerontology could play an important role. Certainly, those persons now graduating from recognized universities, with advanced degrees in gerontology, might be used to fill these gaps. There are suggested remedies to help the current lack of interest by medical schools. Bayne (1974) says there must be admonition and persuasion to increase the time allowed for presentation of information on changes due to aging. Students need to be indoctrinated to the importance of such material and negative attitudes must be changed. Perhaps here in the United States we need to follow the example of Great Britain which has established several pro fessional chairs in Geriatrics and where post-graduate study in the subject is well established. Weiss and Spence (1973) stated that "the potential for bringing better health to more people lies less in medicine than in public health" (p. 7).) Perhaps then, this points to a need of other kinds of health professional, as geron tologists. The medical field is only one facet which might use the services of trained gerontologists. Recently, Dr. Robert N. Butler, Director of the National Institute on Aging, stated: It is NIA's responsibility as charged by Congress, to construct, promote, conduct and support research in biology, medicine and social sciences, including the economics and behavioral sciences of aging, and to support research training, so that we have adequately trained people to conduct important, practical, useful research that will benefit older people. (Senior Citizen News, June, 1977, p. 7) Butler (1976) states that perhaps the root of failure to provide adequately for the older population is an atti- tudinal problem that Americans suffer from. It is an in stitutionalized and personal prejudice against older people. Yet, this is a cultural sensibility that could be changed through study and education. When the medical student or the doctor shares in that negative attitude, it is all the more concerning. Hopefully, there are some signs of change. The Na tional Institute on Aging was planning, in 1976, to co sponsor conferences related to geriatric medicine and re search with the American Geriatrics Society, there is sup port for post-doctoral training in geriatric medicine, and research is being sponsored. The researchers realize that medicine and geriatrics and gerontology, as they relate to each other, is a complex and important subject, but feel that progress is taking place on many levels. 87 Medicine and Gerontology The question may be posed whether or not the profes sion of medicine encompasses sufficiently the concepts of gerontology, and if not, what can be done about it. With out a specially sensitized group of physicians and person nel who are trained, the problems of aging, health care systems may fail in their duty. In other professional dis ciplines as well, it can be said that there has often been a reluctance to recognize the importance of the problems experienced by older persons. Systematic planning on be half of the aged is just beginning to emerge in the fields of education, economics, housing, to name a few. Solutions will not be reached quickly, but programs must be under taken to correct the deficiencies. The last hundred years of medicine has been success ful beyond anyone's imagining. First, there has been a system of preventive medicine, second there are new methods of diagnosis, and third, there has been in medicine a vast increase of knowledge based upon experimental work. Lloyd (1968), stated that As the horizon of knowledge spreads slowly in every direction from the center, one individual can hope to master only an increasingly narrow sector of the whole. Specialism be comes inevitable and unity in medi cine can, therefore, be achieved only by increasingly large teams of workers, backed by machines, (p. 184) 88 As early as 19 36, Lloyd prophesized that one of the most serious difficulties the world would face would be that of the aging population. The net result of life sav ing measures and the conquering of diseases will cause the average age of the population to increase. He saw this as detrimental, stating It is only too plain that if the pres ent progress over the control of dis ease goes on; the developed countries will gradually become nations composed largely of old men and women in their dotage, being kept alive by large numbers of doctors, nurses and techni cians and machines, all of which could be better employed in attending to the needs of the younger and healthier members of the community. This, the logical conclusion of the successful pursuit of medicine, is the doctor's dilemma of the immediate future. Is the object of medicine to keep people alive as long as possible? If not, at what point do we deliberately decide to let them die? (p. 336) Fortunately, the importance of the quality of life for the aged has become a concern to the medical profession of the present. Currently, there is an upsurge in students planning careers in "community health" (Time, 1971, p. 61) and now some professors are trying to make training more appropriate to community medicine also. Community medicine tends to pay more attention to the specialized needs of the elderly. Freidson (1970) states that a "consulting profession is called into existence by some need or desire felt by a 89 lay public— a need which laymen define as a need, a problem to be dealt with" (p. 147). Medicine did not become a pro fession until it answered the needs of the public. It ap pears that gerontology is just beginning to be felt as a public need. To determine what the needs of the population are, the state turns to professionals for guidance. Freid son (1970) further states that "when service to the commun ity is defined by the profession rather than the community, the community is not truly served" (p. 280) . It would seem then, that medicine without a concentrated study of geron tology is not serving the best interests of the community as it is needed. There seems to be increasing recognition of the fact that medical students require particular train ing in the basic and clinical aspects of aging (Freeman, 1962). Gerontology and the field of geriatrics as a part of medicine are definitely under growing consideration in the medical field. Geriatric curriculum in medicine is slowly increasing, and medical students are more interested. There are some signs that the medical profession is begin ning to give more attention to the medical problems of the elderly. Educ a t iona1 Programming "Medical schools could still play a large role in the movement for change than they do now, but most are firmly controlled by the professions" (Time, 1971, p. 62). 90 S in c e 1970 th e s i t u a t i o n has n o t much im p ro v e d . Bullock and Bauman (1974) found that a Review of the catalogues for the academic year, 1969-1970, from 99 medical schools revealed that in struction in gerontological subjects was fragmentary or non-existent; only 48 schools cited curriculum material pertaining to the aging process (gerontology, geriatrics, senescence, senility) by explicit designation. This same study showed that of the 20,000-25,000 [circa] faculty members associated with these 99 institutions, only 15 had primary assignments in the field of aging. This marginal atten tion from medical institutions probably stems in large part from the negative attitude of medical students and prac titioners, as far as gerontological subjects are concerned. Indeed, some clinicians tend to doubt the medical specialty in geriatrics. Others tend to view the aging population as a small medically unresponsive fraction requir ing a disproportionately large share of health care. (p. 319) A further examination of the literature reveals the pattern of a major debate in medical education is beginning to stand out from much of the material. Whether the clini cal features of aging warrant special consideration in American medical schools, and in forms of medical practice, is on trial. Recognition that medical students need spe cial training in geriatrics appears to be increasing (Butler, 1976). Gerontology and the field of geriatrics as a part of clinical medicine are corollaries to changes underway in both medical and social scenes (Freeman, 196 2) . 91 As Krauss (1963) remarked. It is becoming more and more evident that the needs of the aged and aging require a specialized knowledge in modern society. For this reason, it is important that, through proper in doctrination, the medical student with his genuine enthusiasm, becomes more sensitive to the problems which he will be dealing with throughout his curriculum and later on entering medical practice. (p. 155) The American Geriatrics Society, which began with only 352 members in 1950, now numbers more than 7,000 physicians (Newsweek, 1977) and the Student American Medical Associa tion (SAMA) has called for the incorporation of geriatric medicine into the medical school curriculum (Butler, 1976). Recently, the Committee on Undergraduate and Continuing Medical Education of the Clinical Medical Section of the Gerontological Society has designed a 3-week (105) hour in- depth elective course in gerontology (Bullock & Bauman, 1974) . In spite of this promising outlook, geriatric medicine is still seen as a relatively unpopular field and so it is offered on an elective basis in many medical schools. The introducing of gerontology courses into a medical curricu lum is the beginning of the development of training prog ress in this specialty. Perhaps with time, this specialty will become a required, rather than an elective, subject for all medical students. 9 ^ The Team Approach Gerontologists could be an integral part of the health team concept that is beginning to be seen. Hospitals are beginning to show more interest in starting residency training programs in geriatrics, however, the only hospital residency program that is in existence at the present is that of Libow's Institute, which is part of New York's Long Island Jewish Hillside Medical Center. All of the litera ture points to the need of indoctrination of medical stu dents in geriatrics because of the complexity of the many medical problems faced by the aged. The addition of the gerontologist to the medical team would prove to be valu able. In the medical setting the gerontologist would be part of a team that would work with the physician on the needed treatment. He could evaluate the effectiveness of theprogram for the patient and communicate this to the physician. The gerontologist could be expected to give time and personal commitment to the patient. In the same setting he might do in-depth interviewing and whole person evaluation (not medically). He could be aware of family relationships, and assess needs. He could be knowledgeable about the functions of "paramedical" professionals and would work with the entire team. The gerontology specialist would know about institu tional care and be able to make the proper recommendation. 93 He could work with the patient and family in cases of ter minal illness, and give time that the busy doctor does not have. He would have knowledge of community resources and what benefits are available to the elderly. At the 1972 meeting, the American Association of Med ical Colleges, a recurring theme for better delivery of health care was the emphasis of the treating team (Linn & Carmichael, 1974). Team approaches must begin early in educational training, before rigid roles have been de veloped. Flexible term roles must be developed during and as part of the educational experience. "It is in this area that we can *gerontologize' several professions, simultan eously” (Linn & Carmichael, 1974, p. 478). Since the elderly have multiple illnesses, they are especially difficult to treat. There are few physicians, at present, who have the special interest or the special training to treat the maladies the old fall heir to. "The elderly, probably more than any other population need an organized system of health care especially designed to their need" says Dr. Leslie L. Libow, Director of the Jew ish Institue for Geriatric Care (Newsweek, 1977, p. 64). At the institute the goal is to train physicians to act as co ordinators of a team approach in caring for the elderly. There should be a representative of every specialty that might be needed to treat the aged patient, including out- 94 patient care, visiting nurses and other services. These services could include those of a trained gerontologist. Another important factor is the institutional care faced by many aged, the quality of care varies in these homes, and here too, the gerontologist could be a welcome addition. At this writing the nation's first endowed chair of geriatric medicine has been established at New York Hospital. /Cornell University. A one million dollar grant from the Gladys and Rolan Harriman Foundation will form the Irving Sherwood Wright Professorship of Geriatrics (Older American Reports, 1977). It has been said that specialization is a natural con sequence of increased knowledge, if indeed this is true, then certainly gerontology is destined to become a special profession. Whether a formalized form of training in geriatrics and gerontology comes into wide acceptance or not, more teachers and practitioners are becoming aware of special features of the physiology and pathology of aging. A gerontological orientation is useful for the interpreta tion of the progress of many diseases. The science of gerontology as a phase of biology, and the field of geri atrics are seen as a part of the changes in the medical and i social scene. I 9iJ CHAPTER V THE PROFESSIONAL STATUS OF GERONTOLOGY Introduction According to the operational definitions used in the context of this study, a discipline has professional stand ing if it meets the established criteria. These are: (1) a body of knowledge; (2) university education; (3) pro fessional ideology; (4) professional association; (5) code of ethics ; (6) self-regulation; and, (7) public sanction. If one uses these guidelines, law, medicine, nursing and social work can be considered professions, while adult education, counselor education and public administration are moving toward professional standing. Increased numbers and greater longevity have made the elderly a significant and recognizable aggregate in our society, and it is ques tionable whether these disciplines can adequately meet the needs of the aged. The field of gerontology could address 96 itself to these needs and has the ability to implement and provide for a uniform system of research, education, and service delivery. The following chapter will examine the historical trends in the field of gerontology, will support the need for gerontology, and will examine whether or not geron tology meets professional status according to the desig nated criteria. Trends of Gerontology Gerontology, according to Breen (1970) , is a field which is no more than three decades old. It has taken at least this period of time for gerontology to be recognized as "a systematic examination of data and logical sets of conclusions concerning the aging process" (p. 89). Gerontology has been defined in a variety of ways and in volves numerous disciplines. Clark Tibbitts (1960) has helped popularize the term "social gerontology." Social gerontology focuses upon two points of view; (1) one view is concerned with the scientific and psychological forces upon the organism; and the other (2) is concerned with the manner in which the environment and the organizational structure of culture influences the individual. Breen | I (1970) identifies five separate stages in the development | I of gerontology as a discipline. These include the philo- i I sophical stage, biological stage, psychological stage, | social stage, and political stage. ; ____ 97J Philosophical concern in aging dates back to Ari stotle's time. Lengthy dialogues of Aristotle, Cicero, and Homer reflect upon the interest and concern of growing old. Cicero's "De Senectute" (106-43 B.C.) addresses the prob lems of old age and expresses that it is a time of joy rather than a time of despair. The biological interest in aging dates back to the 1800's. Birren (1970) credits Quetelet as the first geron tologist, although it was not until the late 1930's that an active interest in aging began to develop. During the 1930's the number of individuals aged 65 increased 35 per cent as contrasted with an increase in the general popula tion of 7.2 percent (Birren, 1970). In 1939 a group of British scientists became interested in age-related changes in cells, organs, and tissues and decided to form an Inter national Club for Research on Aging (Tibbitts, 1960). The publication of Cowdry's Problems of Aging in 1939 and the establishment of the Gerontological Society in 1945 illu strate the growing interest in the biological aspects of aging (Kleemeir, Havighurst & Tibbitts, 1967). Psychological interest in the elderly paralleled the development of institutional facilities for the aged. Long-4 term care facilities and interest in "senility" promoted the! I awareness of the mental health needs of the elderly. The ^ I first marked contribution was Stanley Hall's book on 1 98 Senescence published in 1923 (Kleemeir et al., 1967). The first systematic attempt to investigate the psychological aspects of aging occurred when the Stanford Later Maturity Research Project conducted a study (Tibbitts, 1960). Social interest in aging began when increasing numbers of the aged affected various aspects of society. Issues such as housing, economics and health became pressing social concerns. The establishment of the Journal of Geron tology in 1946 evidenced interest in the problems of aging in the social science area. The National Conference on Aging was organized in 1950 and was devoted to social, economic and related aspects of aging. The political phase of gerontology developed in the mid-thirties. While primarily an economic issue, the Social Security Act of 1935 was also indicative of polit ical interest in aging. In 19 34, Simmons published a work entitled. The Role of the Aged in Primitive Society and provided a basis for comparing the elderly in agricultural and industrial society. In 1948 a report on Social Adjust ment in Old Age indicated that sociological interest in aging was beginning to carry itself through the develop mental stages of life. The 1950's revealed a proliferation of publications and continued research. At this time eight sections of the first National Conference on Aging were organized and the Inter-University Training Institute in Social Gerontology was conceptualized and supported (Tibbitts, 1960). In 1965 the first White House Conference on Aging and the passage of the Older Americans Act provided for the development of the Administration on Aging and the Social Security amendments. In addition, the establishment of the National Retired Teacher's Association, American Associa tion of Retired Persons, the National Council on Aging, the Senate Sub-committee on Aging, National Center on Black Aging, and the National Institute on Aging are indicative of the growing interest and stature of the field of geron tology . Documentation of Needs The need to address the aged and their problems is be coming more apparent. Kleemeir (1965) states that the be lated attention now given to the problems of aging and the aged is the result of changing perceptions of the elderly, rather than the significant increase in the elderly popula tion. Due to changing perspectives and demographical sta tistics, the fact remains that there is a need for special ized training in working with older adults. Krauss (1963) and Kleemeir (1965) further substantiate this need. Krauss ; (1963) states that it is obviously becoming more evident ; I that meeting the needs of the aged requires a specialized j body of knowledge in modern society. Kleemeir (1965) adds ; 100 that there is both a need in society and in science for a major investment of effort directed toward the alleviation of the problems of aging. Certain problems, areas, methods, techniques, knowledge, professional personnel and institu tions should clearly be seen as having an intimate, pre dominate, or exclusive concern for aging with different disciplines contributing to a central area of concern. The need for special training in the area of aging was identified by the White House Conference on Aging in 1961. A committee concerned with the role and training of pro fessional personnel designated four occupational groups which they felt needed gerontological training. These in cluded; (1) medical services; (2) social work; (3) educa tional, religious, and recreational services ; and, (4) en vironmental planning and administration. In addition, Tibbitts (1967) describes the following four categories of personnel needed to work with the aged; (1) direct pro viders of services; (2) planners, administrators, and pro gram directors; (3) researchers; and, (4) teachers. Present economic, housing, health and legislative trends further support the need for gerontological training. The spread of technology and an industrial economy have i i presented problems for the elderly. Retirement income for ! I a person over 65 is provided by the Social Security Act. 1 The original intent of Social Security was to help the elderly meet the risks of old age and unemployment (U.S. Department of Health, Education, and Welfare, 1973). Until recently, coverage excluded governmental, agricultural, domestic, casual and non-profit employees and the self- employed. In the 1970's coverage has been broadened so that 90 percent of the population 65 and over is eligible for Social Security benefits (Fitzpatrick, 19 75) . Social Security is presently the major source of retirement income and a 1968 study indicates that over 60 percent of the aged received no other periodic retirement benefits (Krumboltz, 1966). Private pensions were received by only 12 percent of the aged and these generally were people who received higher Social Security benefits (Fitzpatrick, 1975). Al though social benefits have increased within recent years, they have not kept up with escalating costs of living. Many of the elderly cannot meet rising food costs, taxes, and medical expenses. The enactment of the Supplementary Security Income Program has provided additional monies on the basis of "need" rather than right. Presently, maximum Supplementary Security Income payments in the state of California are $259 for an individual and $488 for a couple. Payments I vary according to living arrangements and disabilities and j not all eligible people get the maximum benefits. A sub- ! stantial gap exists between minimum benefits and the living I costs of the elderly. , 102 1 In 1974 the median income for all American families was $12,836, while the median income for families 65 or older was $7,298 (Current Population Reports: Special Studies, 1976). Approximately 50 percent of the elderly are poor and have incomes less than $3,000 (U.S. Congress House Select Committee on Aging, 1976). Low income makes home ownership and maintenance difficult. As costs for repairs, utilities and property taxes rise, the elderly find themselves with a dwindling supply of funds to cover these needs. It has been projected that by 1978 about 8.3 million elderly people will be living in 3.7 million sub standard housing units (U.S. Congress, House Select Com mittee on Aging, 1976) . The steady increase in the elderly population effects health trends. The elderly utilize health services more frequently, since the frequency of hospitalization and length of hospital stay increase with age. One out of every four persons is likely to be hospitalized within a given period, and approximately 71 percent of persons 65 or older visit a physician at least once a year (Loether, 1975). Twenty-eight percent of the $80 billion spent na tionally for personal health care in 1973 was for older perH sons who constitute 10 percent of the population. The per | capita health costs for an older person are $1,052, as com- | 1 pared to $385 per capita for younger adults (U.S. Department 103 of Health, Education, and Welfare, 1976). Medicare in surance helps pay for hospitalization and certain post hospital care of people 65 and older. The elderly are re sponsible for paying 28 percent of doctor bills and related medical expenses and the government pays the balance (Medi care Increase, 1977). This does not include medical costs of the elderly not covered by Medicare or Medi-Cal. A growing interest in the elderly is indicated by legislative trends of the recent past. Governmental bodies such as the Veterans Administration, the National Institute of Child Health and Human Development, the Administration on Aging, U.S. Senate Special Committee on Aging, Social Security Administration, and Area Agencies on Aging are in dicative of interest in the elderly. Gerontology can provide a distinctive educational and research oriented discipline which deals specifically with the phenomenon of aging. Social, economic and legislative trends document the need for specialized training in work ing with the aged and promote the development of geron tology towards professionalism. Gerontology on the Continuum of Professionalism This study has operationally defined seven attributes which most authors regard as constituents of professional status. The seven criteria for professionalism are as follows: (1) body of knowledge; (2) university education ; 104 (3) professional ideology; (4) professional associations; (5) code of ethics; (6) seIf-regulation; and, (7) public sanction. This section will examine the field of geron tology with respect to each of the criteria and determine the professional status of gerontology. Body of Knowledge Gerontology is in the process of developing an identi fiable body of knowledge. Kleemeir et al. (1967) note "the body of specialized knowledge is there and is accumulat ing" (p. 140). Traditionally, gerontology is a multi disciplinary field, which borrows knowledge from the sciences and social sciences. As previously mentioned, Birren (1970), Breen (1970), and Tibbitts (1960) have docu mented the accumulation of knowledge in the fields of philosophy, biology, sociology, physiology, and politics. University interest in gerontology dates back to the 1950*s when several universities initiated gerontological programs. Cornell University developed programs in educa tion, industry and business; the University of Chicago was an innovator in pre-retirement programs ; and, Duke Uni versity brought various departments in the university to gether to examine problems of the aged. In addition, the University of California developed a research program, the University of Iowa developed a gerontology institute, and, the University of Michigan started the first Institute of 105 Gerontology. Each of the schools has made a significant contribution to knowledge in the field of gerontology. In 1975, the University of Southern California set precedent by establishing a separate school of gerontology. The Leonard Davis School of Gerontology is dedicated to de veloping and identifying a distinct set of theories, method ologies and principles which form the technical base of professional practice. It offers courses which concentrate on biological theories, developmental processes and psycho social needs as they relate to the aging individual. The creation of governmental bodies such as the Admin istration on Aging, the U.S. Senate Sub-committee on Aging (1959), followed by the Senate Special Committee on Aging, the National Council on Aging (1960), the Administration on Aging (1965), the National Institute on Aging, and the National Institute on Child Health and Human Development have added new dimensions to the current body of knowledge. They are subsidizing research, publishing literature, and have become strong advocates in the field. In addition, the proliferation of publications and governmental grants are also indications of an ever growing body of knowledge that pertains specifically to gerontology. Professional Education At present there are no specific courses required for one to be considered a "gerontologist." In the field of 1 0 6 I adult education, for example, many teachers are considered gerontologists even though they have had no formalized training in the area of aging. Although the recent Ryan Act (1970) has made requirements for receiving a credential much more stringent in California, educators of adults are still not required to take courses which deal specifically with the aging individual. Nevertheless, there is a growing consensus that a uni versity education is necessary in the field of gerontology. In 1956 the Gerontological Society sponsored a conference to consider the problems of training in the social science aspects of gerontology (Shock, 1957) . As a result, the Inter-University Training Institute in Social Gerontology was established (Breen, 1970). Shock (1957) felt that pro fessional workers had not received adequate exposure to the aspects of aging and stated. There is a definite need for the organization of course material on our knowledge about aging for pre sentation to undergraduate and graduate students. . . . More system atic instruction is imperative if we are to attract potential competent research and professional workers into this field. (p. 10) There are differing points of view on whether gerontology should eventually become a separate discipline or whether it should be incorporated into traditional fields of study. Breen (1970) questions whether one can have a separate 2^7 \ scholarly discipline in gerontology and train specialists in the field. Some educators argue that training should be at a generalist level in gerontology with scholarly training specialization in traditional fields such as biology or sociology (Breen, 1970). Kuhlen, Kreps, Kushner, Osterbind and Webber (1967) emphatically state that spe cialization is possible and should be required within social gerontology. In 1957 Kleemeir took the position that geron tology could be considered a distinctive area of teaching and research. As a separate entity, he said, it could be contained within the university with its own administrative authority, faculty and academic rights and responsibilities. Within the last few years, gerontology has become a recognized course of study in university education. A na tional survey on education activities which was conducted in 1961 by the University of Michigan showed that progress was being made in the field. From 1958 to 1961, 112 insti tutions and 116 departments reported on 221 research pro jects in gerontology and 137 theses and dissertations were written. The dissertations were produced in the fields of sociology, psychology, and human development, and the greatest number of master's degrees were in the field of social work. A survey in 1964, conducted by the Geron tological Society, identified 159 institutions giving some training in gerontology (Breen, 1970). Of the total number 1 0 ^ of institutions, 80 were academic, 40 were medical or pro fessional , and the rest were agencies. Research programs in gerontology had 199 students who were enrolled or who had completed a program, while 1,089 students were in the applied programs. Recommendations were made to increase funding for research and training and to develop facilities and resources. It was suggested that interdisciplinary mechanisms and inter-university cooperation should be undertaken. Breen (1970) concluded that this report held great promise for the future of gerontology. In 1967, Donahue identified a number of university programs, centers, and institutes of gerontology which were multidisciplinary in nature and offered graduate training as well as research programs. Examples given were as follows: Duke Center for Aging Research and Human Develop ment; University of Chicago Program of Adult Development and Aging; the University of Southern California Rossmore- Cortise Institute for Study of Retirement and Aging; and, the University of Michigan-Wayne State Institute of Geron tology . I I More recently, the expansion of gerontology has spreadj to colleges and universities throughout the country. In | 1976, the Association for Gerontology in Higher Education ' compiled a directory to inform educators, professionals, 1 and students of available gerontology-related courses, : 109^ degree programs, research programs, educational services, and training programs. The study indicates that there are approximately 1,275 institutions in the United States which offer gerontology courses. In California alone, 104 insti tutions offer gerontology courses. These institutions may be community colleges, vocation and technical institutes, colleges, universities, professional schools, or non-degree granting institutions (U.S. Department of Health, Education and Welfare, Office of Human Development, Administration on Aging, 1976). The interest in gerontology is shown through the pro liferation of training schools in various institutions. More colleges and universities are recognizing the future importance of gerontology. At the same time, however, there appears to be disagreement as to whether gerontology should become an independent discipline. Presently, the majority of schoools are incorporating gerontology into traditional fields of study. Until this issue becomes re solved, individual institutions will have to decide if a separate and distinct school for gerontology is necessary. One must conclude that educational requirements for geron tology are presently in a state of development which marks a definite step toward professional standing. Professional Ideology A professional ideology should center around three im- portant aspects: the notion of service, an emphasis on professional judgment based upon knowledge, and belief in professional freedom and autonomy (Elliot, 19 72). Pres ently, a formalized written ideology for gerontology does not exist. There are indications that the need and poten tial for establishing such an ideology is growing. As mentioned previously, housing, health, economic, and demographic trends support the need for special train ing in the gerontological field. In the past, governmental organizations and private organizations have recognized the responsibility for providing services to the elderly. How ever, as Kleemeir and Birren (1967) note,". . . while this movement is discernible in many places and agencies, its essential gerontological character tends to be obscured, becoming identified with the fostering agency, or in the case of instructional and research programs, with tradi tional scientific disciplines" (p. 6). There is a need for "a major, visible and unambiguous investment of effort directed toward the solution or alleviation of the problems of aging" (p. 6). Gerontology, as a self-standing disci pline would have a predominant and exclusive concern with the aged, thereby affirming the ideological interest in i service. ! I Research in the field of gerontology has been occur- I ring for several decades. The desire for developing geron-i tology as a separate discipline in the area of academia, however, has been a recent development. In 1967 gerontol ogy had cursory programs throughout the country. In 1975 the University of Southern California established the Leonard Davis School of Gerontology and set precedent by combining a training and research center for the aged which was housed in a separate school of gerontology. Since July 1976 a national directory published by the Association of Gerontology for Higher Education, listed 1,275 educa tional programs that dealt with the aged (Watkins, 1977). Thus, as Ruth Weg states, "The study of aging has come of age" (Weg, as quoted by Watkins, 1977, p. 4). Since gerontology is an emerging field, the need for qualified practitioners is still unmet. One can expect that very few specialists have had gerontological training. Due to this situation, an emphasis on professional judgment and the freedom and autonomy to make choices are ideals which have not yet been tested and/or attained. The indi cations are that the potential for growth in the field will eventually lead to more trained specialists who will be responsible for making sound, professional, and autonomous judgments. ! j Professional Associations I In order for gerontology to be considered a profession, organizations must be established which set criteria for i membership in the field. There are presently three organi zations which deal specifically with gerontology. The Gerontological Society is the authoritative voice as author and critic in the formulation of national policy and re flects upon the status of gerontology in modern society (Freeman, 1971). Jerome Kaplan (1970) states that the formation of the Gerontological Society in 1945 marks the most significant contribution on a national scope. The society is devoted to research on aging and encompasses training and evaluation of services for older people. Re search is conducted in biology, clinical medicine, psychol ogy, social sciences, and social welfare. The Society publishes two journals: The Journal of Gerontology and the Gerontologist. The Journal of Gerontol ogy issues quarterly reports of original research in the affiliated fields mentioned above. The Gerontologist is also published quarterly and carries articles of general interest in the areas of medical care, recreation, housing, social welfare, employment and any other area which is re lated to aging. The Western Gerontological Society and Association for Gerontology in Higher Education are two organizations whose ! focus is educational in nature. The primary goal of the ! Western Gerontological Society is to work for the well- ’ I being of older residents of western states by promoting ! communication, fostering better understanding of gerontol ogy, stimulating research, and by encouraging professional preparation for gerontological research. Membership in the Association for Gerontology in Higher Education is limited to institutions. Currently, neither the Gerontological Society nor the Western Gerontological Society have professional require ments for admission. The Gerontological Society requires that one complete an application and have two standing members sign the form, while the Western Gerontological Society invites any individual or organization with an in terest in aging to become a member. Both these societies represent rudiments of a professional association, but if they are to exist as such, they must become increasingly regulative and set definite standards for admission. In addition to the three organizations previously men tioned, there are other organizations which have vested in terests in aging. The American Association of Retired Per sons, -toerican Association of Homes for the Aging, American Nursing Home Association, and the National Council on Aging are greatly involved with the elderly. The American Asso ciation of Retired Persons was founded by Dr. Ethel Percy Andrus in 1958 and is dedicated to research, counseling, and correspondence. The organization is voluntary, non profit and non-partisan. The American Association of Homes 114 ; for the Aging was founded in 1961 and is dedicated to im proving programs and standards of institutions serving older people. The American Nursing Home Association spon sors educational meetings and seminars and the National Council on Aging is the leading national voluntary agency which provides professional services for those concerned with the elderly. Code of Ethics Cox (1976) notes that a lack of formalized standards of professional conduct severely limits the professional status of gerontology. Cox believes that the lack of ethi cal codes is due to the diversity of skills, training and tasks of membership. The diversity of skills and training is primarily due to the nature of gerontology. Gerontology is of a multi disciplinary nature; that is, a combination of specialized fields, and therefore fosters and produces generalists in this area. Many people who enter the field are already working in a specialized area and their gerontological in terest is a part of their professional responsibilities. In addition, the fact that gerontological associations have an extremely broad-based membership hampers the development of a stringent code of ethics. The need for ethical standards is quite apparent. The fact that human beings are involved in research and prac- 115 ; tice mandates that ethical standards be considered. Ac cording to Eisdorfer and Wilkie (1970), when one utilizes human subjects in research, three basic elements of techni cal practice are involved. These include: consent, con fidence, and standard or accepted procedure. Regulation of standards encompassing gerontology has not yet come about. Guinne (1970) feels that standards may only develop when people begin to pay for professional ser vices. Since there appears to be some question as to whether or not gerontology can best provide for the needs of the elderly, professional services have not yet been recognized. Thus, people are not paying gerontologists for services but are paying those professionals who have vested interests within the field. Time and public recog nition of gerontology as the provider of needs and services for the elderly will support and initiate the formation of a code of ethics. Self-regulation Self-regulation has been operationally defined as the professional mechanism which maintains the ability of the discipline to autonomously govern and regulate its members, establish standards of service, enforce the code of ethics, assume responsibility for disciplinary action and be pub licly accountable for the actions of its constituency. At this point in time there is no mechanism which controls 116 self-regulation in the field of gerontology. Since admis sion to the Gerontological Society and Western Gerontolog ical Society is open to all, regulation of its members is non-existent. For example, many of the people who work in the field are professionals or semi-professionals in some other field such as teaching, nursing, social work, counsel ing, etc. As stated previously, their primary allegiance is not directed towards gerontology. The diversity of edu cational background and of services performed is likely to make it difficult for those in gerontology to meet a stan dard of self-regulation which would qualify them as profes sionals . It is possible, as suggested by Linn and Carmichael (1974) that there will be a division in the field which will be broken down as follows : (1) a broad group of para- professionals of different degrees of skill who work daily with the aged; (2) an intermediate level of semi-profes sionals ; and, (3) an apex of highly trained academic and scientific personnel for research and training. Future events will show whether or not these highly differentiated groups will be able to unify to the extent necessary to ad vance gerontology to the level of a profession. Public Sanction Since there is no legislation which regulates this practice of gerontology by means of licensure or certifica 117 ; tion, formal approval by the community does not exist. Nevertheless, an increase in publications, professional organizations, governmental programs and community services indicates informal sanction by the public and a growing awareness and interest in aging. Mass media and publications help project an image of gerontology to the public. Newspapers, magazines and jour nals are currently disseminating information about the elderly. The Los Angeles Times has run a series of articles on nursing homes, attitudes and stereotypes toward the aged, Social Security benefits and legislation for the elderly. Magazines which have recently published articles dealing with the aged are as follows ; Saturday Evening Post, Psychology Today, New West, Ladies Home Journal and McCalls, Subjects discussed dealt with sex after 60, stress and aging, death and dying, time and leisure, and housing. Professional journals also help to relate facts and know ledge on aging . Examples of these include : Aging, Age and Aging, Long-Term Care, Educational Gerontology, Journal of Gerontology, Experimental Age, and Research and Current Literature on Aging. There are also a number of national and scientific professional organizations which are interested in aging. The American Public Welfare Association has a section de voted primarily to the problems of the aged. The National Council for Homemaker Services, the American Medical Asso ciation, Group Advancement of Psychiatry and the Adult Edu cation Association have divisions working with the aged. In addition, the Division of Later Maturity, established by the American Psychological Association; the American Socio logical Society, the American Hospital Association; and, the National Association of Social Workers concern them selves with issues which involve aging. The American Geri atrics Society deals with medical issues which are related to aging. As mentioned previously, governmental interest in the aging stems back to the 1930's. The Veterans Administra tion on Aging, Commission on Aging, Senate Sub-committee on Aging, the Social Security Administration and Area Agencies on Aging give evidence of governmental involvement with issues relating to aging. In addition, the increase in community services for the elderly illustrates the current importance of gerontological issues. The following repre sent a sampling of services provided in the Los Angeles area; advocacy, counseling and social services, health care services, home services, information and referral ser- I vices, legal services, nutrition services, outreach, re- ! creation and transportation are offered by various agencies. Among the agencies included are: Retired Senior Volunteer ; I Program, Los Angeles City Parks and Recreation Senior Citizens Centers and the Los Angeles City Office on Aging. This increase in the available public services gives evidence that aging is a challenging and pressing issue in our society. It is debatable whether the field of geron tology warrants public recognition as the provider of ser vices. At present, the terms "gerontology" and "gerontol ogist" have no specific meaning to the general public. Measures must be taken to define gerontological terms so that the public will regard the field as society's advo cates for the elderly. Conclusion This chapter has inevestigated the status of gerontol ogy on the continuum of professionalism. At this point there are areas in which gerontology does not fully meet the standards set by the researchers to qualify as a pro fession. While there is increasing acceptance that a uni versity education is needed to work in the field of geron tology, there is as yet no such requirement. Many people working with the aged have a strong commitment to service to the elderly, but as yet there is no clearly developed ideology. It may well be that establishment of a code of ethics will provide the basis for development of an ideol ogy. As the professional organizations in the field of gerontology develop more stringent membership requirements, it is likely that there will be emphasis placed on self 120 j regulation. At present, there is no licensing requirement to practice in the field of gerontology. In spite of this, there is developing public acceptance of gerontology as a discipline with recognizable status. The areas in which gerontology shows the most progress toward professional standing is in its proliferating body of knowledge and its active professional associations. Gerontology lacks some of the designated criteria needed to be considered ^ profession. It must be concluded that gerontology is currently recognized as a field of specialty with major educational and career emphasis still resting within the established professions. Nevertheless, a growing public awareness, an increasing number of elderly persons and pressing needs indicate that gerontology has proclivity towards increasing structure, standardization and regulation of the field. .121 CHAPTER VI METHODOLOGY Introduction The previous chapters have presented information on the nature of professionalism, on medicine, and on geron tology as professions, and on the relationships between medicine and gerontology. Since education plays a vital role in the preparation of a professional, much of the remainder of this study deals with the educational aspects of training personnel for practice in their respective dis ciplines . One of the major purposes of this study was to assess the gerontological content of curriculums in courses of study leading toward a degree in the following disciplines at accredited colleges and universities in the state of California: adult education, counselor education, den tistry, law, medicine, nursing, public administration, and social work. This chapter will discuss the procedures and methods of collecting this and related information. Due to the nature of the survey design, no research hypothesis was formulated. There is the hope that future studies in this area will formulate research hypotheses from the conclu sions of this study. For the presentation of the material, this chapter has been divided into four sections: (1) pro cedures ; (2) selection of colleges and universities for study; (3) description of survey questionnaires; and, (4) treatment of the data. Procedures for Entire Project The initial step of the investigation was to form groups to study the eight disciplines and the accredited educational counterparts of: adult education, counselor education, dentistry, law, medicine, nursing, public admin istration, and social work in the state of California. These disciplines were selected for study because relation ships between them and aging people exist. Student inter est in researching these disciplines was also a factor in the selection. With only two exceptions, the members of the groups in this study were using it as their master's I project. Each group produced a thesis based upon the study! of their discipline. | Once the groups were selected, the researchers were j given guidance in the form of an outline of seven areas to j lllj cover (see Appendix G). The first of these steps was an extensive review of the literature on professionalism. This included a generic review of professions such as: de finitions, criteria and development of professions, respon sibilities within professions, between professions, and to the public at large. The next step was a similar review of the literature respective to the disciplines chosen by the groups of this project. Each discipline was related to the previous section on professions. This included a history of the discipline and the processes leading to the development, establishment and activities of the discipline as a profession. The third step was an examination of the relationship of the individual discipline to the field of gerontology. The fourth step, was a study of the relation ships of the field of gerontology to the individual disci pline as each developed along the professional continuum. This step also included an examination of gerontology as a developing profession. The first and fourth steps were re searched by all members of the project, and were incorpor ated into each thesis. The second and third steps were re searched by individual groups and were included into each thesis according to discipline. The fifth step was a study of the educational institu tions and their curriculum in gerontology for each disci pline. Two separate, specialized questionnaires were de- 124 , ___-J vised to collect the data. One was specifically con structed for the purpose of recording material secured through the 1976-1977 catalogues and bulletins of the schools studied (see Appendix A, Information Collection Form, IGF). The second questionnaire was developed to re cord the information not available in the catalogues or which needed clarification (see Appendix B, Introductory Letter and Interview Data Collection Form, IDCF). A letter explaining the study and a copy of the interview question naire was sent to the dean of the surveyed departments. The letter alerted the dean or his/her representative that a research team member would be in telephone contact within 30 days to enable the completion of the enclosed Interview Data Collection Form. The researchers conducted a special session with supporting faculty on interviewing techniques, before the interviews took place, as a major method to demonstrate and refine these techniques. This was to assure maximum data return to meet survey goals. Personal interviews were conducted if the participat ing educational institution was within a 100-mile radius of the University of Southern California. Otherise, telephone interviews were necessary to be cost effective. The proto-! col for the telephone and personal interview was the same. In some cases, the Interview Data Collection Form was com- { pleted and returned to the researchers by mail before con- ' 1 2 .5 , tract was made for an interview appointment. In other in stances, respondents would not comply with an interview of any kind, but did complete and return the Interview Data Collection Form. A study of the credentials and licensing procedures was undertaken to enable the completion of step six. This includes the requirements for gerontological knowledge needed for each type of license or credential. The seventh and final step involved the establishment of the conclu sions and proposals for the profession of gerontology in the future as related to each of the eight disciplines. Specific Procedures for Medicine The group studying medicine sent a copy of the Inter view questionnaire and the introductory letter to the deans of the eight accredited medical schools in California. In all cases the letter was forwarded to another faculty mem ber or administrator. In two cases the interview question naire was completed and returned by mail (University of California, San Diego and Loma Linda University). Personal interviews were conducted at the University of California, Irvine and the University of Southern California. The re spondent of the University of California, Los Angeles was unavailable for a personal interview, but was interviewed by telephone. Telephone interviews were also conducted with representatives of the following schools : University of California, Davis; University of California, San Fran cisco; and Stanford University. The two licensing boards that affect the licensing of physicians are the California Board of Medical Examiners and the National Board of Medical Examiners. Both of these "boards" were sent letters explaining the study and asked for responses on the amount of gerontological content re quired and/or expected of prospective physicians. Both "boards" responded that no gerontological information was included directly in the licensing examinations and that gerontology was not a subject required for licensure. Selection of Colleges and Universities for Study Accredited California Institutions of higher education offering courses of study leading to degrees in the follow ing disciplines served as the sample population for this survey; adult education, counselor education, dentistry, law, medicine, nursing, public administration, and social work. The dean of the school, department chairman, or pro gram director served as the initial respondent for the study. In the event this person was unavailable, subsequent contacts were made with a representative of that person. There are eight accredited medical schools in Califor nia. These eight schools served as the sample for this ex ploratory survey. In all cases the dean of the medical school served as the initial recipient of the interview 127 i questionnaire, and in all cases referral was made by the dean to another faculty member or administrator for subse quent contacts. The eight medical schools are listed as follows; University of California, Davis; University of California, Irvine; University of California, Los Angeles; University of California, San Diego; University of California, San Francisco; Loma Linda University; Stanford University ; and. University of Southern California Description of Survey Questionnaire Following the literature review on professionalism and on the eight disciplines included in the sample, two ques tionnaires were developed by a student-faculty group. These questionnaires were for the purpose of obtaining factual and attitudinal information about schools which grant degress in each of the eight disciplines and the pro grams which they offer. The goal was to assess the avail- j I ability of gerontological content and the gerontological | exposure students receive in the schools offering degrees in the eight mentioned disciplines. The questionnaires were developed in order to gather information in the follow ing areas ; degrees offered, courses with gerontological 1 2 8 j content, field practicums, student population, faculty pop ulation f continuing education, instructor membership in professional gerontological associations, dissertations and theses written about gerontology, journals subscribed to by the school library, plans for future gerontology courses, training of instructors in gerontology and attitudinal questions about the importance of gerontology to the school. Information was obtained from the 1976-1977 course catalogues and was transcribed to the library questionnaire (see Appendix A). The variables in the questionnaires are : types of degrees/certificates offered by the department, courses in the departmental curricula as indicated in the course catalogue that contain content related to gerontol ogy, requirement by the department of a field practicum, internship or traineeship, student population of the insti tution, faculty population of the department, number of faculty holding doctorates within the department, re searcher rating of the availability of gerontology in the department curriculum, continuing education offerings by the department and continuing education classes with geron tological content. The interview questionnaire (IDCF, Appendix B) was de veloped to allow the investigator to collect information not readily available in the course catalogues. An inter- 1 2 9 , view with the dean or representative appointed by the dean, was used to complete this questionnaire. The variables in cluded in the interview questionnaire are: number of stu dents enrolled in the department, courses offered within the department curricula that contain gerontology content, instructors membership in either the Gerontological Society or the Western Gerontological Society, number of agencies used for field practicums, number of students in field practicums, agencies that provide students with the oppor tunity to work with or on behalf of older adults, number of doctoral dissertations and master's theses related to aging written in the department since 1971, aging journals sub scribed to by the school library, future plans for geron tology, percentage of department faculty that teach aging related courses with gerontological training, and three attitudinal questions about the importance of gerontology to the department curriculum, the discipline, and to the future of the discipline. In order to determine the reliability or dependability of the three attitudinal questions (numbers 5, 6, and 12) on the interview questionnaire, a stability or test-retest interpretation of reliability was obtained in the following manner. Three attitudinal questions were reproduced on a single sheet of paper and were administered to 15 graduate students of the Leonard Davis School of Gerontology at the Leonard Davis School of Gerontology at the University of Southern California. The subjects were given no more in formation than to answer the three questions in relation to their own discipline. A week later, a retest of the same three questions were administered to the same subjects. The three attitudinal questions were found to be reliable. The data from the reliability test is available in Appen dices C, D and E. Treatment of the Data The purpose of the statistical analysis was to assess any associations among variables of the questionnaires. The data was treated with descriptive statistics using a programmable calculator (HP65) and presented in narration, raw numbers, percentages, frequencies and tables. The measures chosen were appropriate to examine the possible associations between variables, within each of the eight disciplines; and between the eight disciplines. The investigators in medicine first present a narra tion of each educational institution and its offerings. Tables are presented that report the responses of the questionnaires. Additional tables are presented that ex amine possible relationships of variables from the inter view Data Collection form. All data will be examined in the next chapter on results. 131 : J CHAPTER VII RESULTS AND DISCUSSION Introduction The eight accredited medical schools in California served as the sample for this investigation. Data was gathered using the library and interview questionnaires previously mentioned. The library questionnaires were com pleted by the researchers using the current medical school catalogues. Five of the interview questionnaires were com pleted during the interview in person or by telephone. Two were completed and mailed back, and one was left uncom pleted and returned. The University of California, Irvine, had no medical school catalogue, therefore, data for the library question naire was collected during the personal interview and from the admissions and administrative offices. The University of Southern California does not have conventional course 132 numbers or titles, rather they teach by organ system. Sub sequently, it was necessary to list these courses in a different manner. Neither a personal or telephone inter view was available at the University of California, San Diego. Numerous attempts were made to contact the person referred to the researchers by the dean, but no interview was granted, personal or otherwise. However, the library questionnaire and as much of the interview questionnaire, as possible, was completed by the researchers and is re ported. The results are reported in two parts. The first section is a brief description of general statistics of the medical schools: number of students, number of faculty, courses with gerontological content, degrees offered, and continuing education courses with gerontological content. Following this is a description of the relationships made among the variables, the raw data, and tables of the asso ciations found between the variables. In reporting the data, no distinction is made on whether faculty holding doctorates hold a Ph.D., M.D. or M.D.-Ph.D. The category of "faculty holding doctorates" is collapsed to include all doctoral degrees. Description of Medical Schools as summarized in Table 1: use - The University of Southern California has a 133 ( U rH g T S Q ) > 1 O Ü w I —I < 0 Ü •rH T S Q ) s m o c o 4J •rH CO ^ 0 - p > 1 rd 4 - ) S H Ü Ü ( d o k Q I —I : 3 Ü ( d h 00 o> o> 00 1 —1 o o 00 m o CM ro CM o o C4 cn VO ro ro in 00 0 I H > o U 0 1 3 p 0 U] 0 0 o u M p r —1 p o o 2 3o r H ( d Ü •H T S s 00 o\ o 00 o o o 00 ro o ro ro in in VO CM ro VO ro ro in 00 C N a > V£> 00 o VO TP o o o o CM m rH in o in o o o m ro ro VO ro TP in VO •H 4J +J c cu 0 •H -P in CM o o TP o o o kl 0 C 00 00 o o CM o o o Ü 4-) 0 ro VO o m r~ o o VO 0 Ü3 g * . k . * . * . * . • f c 0 rH ro (T\ o CM CM VO TP <3> Q rH rH CM 1 — 1 rH iH CM 0 0 4-) P o c E4 W 0 TS n3 c P •H O A 44 , Q k C 0 < rH U H w 0 Q e P) o [/] U u U -P U o U o o o D D [/] n PI o 4: Ü • Ü3 rH CM ro in VO r- 00 134 : total student population of 23,385, The school of medicine has a population of 550. Degrees offered are : A.B., M.S., Ph.D. (anatomy, biochemistry, microbiology, pathology, pharmacology, physiology); M.D.-Ph.D. (medical research); and M.D. There are 638 full-time faculty, all holding doctorates. The courses with aging content are listed be low. The interviewee stated she could make no estimate about the percent of aging content of the courses listed below: Introduction to Clinical Medicine Neurology Clerkship Psychiatry Clerkship There are no classes with gerontological content offered through the department of continuing education in the medical school. UCI - The University of California, Irvine has a total student population of 9,682. The school of medicine has 316 medical students. There are 209 full-time faculty members, all with doctorates. The M.D. degree is the only degree offered. The courses with aging content and percent of course pertaining to aging is listed below. Physiology 1-2% Community and Environmental Medicine 2-3% Pharmacology 1% Examination of the Patient 2% 135 ____J Surgery Clerkship 2-3% Medicine Clerkship 3% Psychiatry Clerkship 4-5% Rehabilitation Clerkship 10-15% Family Medicine Clerkship 5-10% No classes with gerontological content are offered through the department of continuing education. UCSD - The University of California, San Diego, has a total student population of 10,000. There are 354 medical students. There are 330 full-time faculty, 329 with doctorates. Degrees offered include: M.A. (Health Science) Ph.D. (medical research), M.D.-Ph.D., and M.D. Courses in the medical school catalogue that indicate they included gerontological subject matter are listed below: Medicine Clerkship Surgery Clerkship Neurology Clerkship Gynecology Clerkship No courses with gerontological content are offered through the department of continuing education. UCSF - The University of California, San Francisco has a total student population of 2,500. There are 600 medical students. There are 638 full-time faculty, all with doc- ! torates. Degrees offered include: B.S. (medical sciences, ■ I physical therapy, medical technology), M.S. (medical ' 136 sciences), M.D.-Ph.D. (joint program with University of California, Berkeley), and M.D. The first three listed courses and amount of aging content are from the interview. No estimate was made on the fourth listed course during the interview and the final three courses were derived from a supplemental Psychiatry course listing sent to the re searchers after the interview. Terminal Patient - One lecture Human Sexuality - One lecture Death and Dying - One lecture Introduction to Ambulatory and Community Medicine Human Development Human Life Cycle - Adulthood Human Behavior All clinical courses were reported by the interviewee to have some aging content. The department of continuing education offers the following courses with gerontological content: Arthritis (three courses offered) Program on Geriatrics Death and Dying Geriatrics Estrogen and Menopause Stanford - Stanford University has a total student population of 12,724. There are 350 medical students. Degrees offered include: B.S. (medical science, medical microbiology), M.S. (health science, medical microbiology, physical therapy), Ph.D. (anatomy, biochemistry, genetics, medical microbiology, neurological sciences, pharmacology, physiology, hearing and speech, surgery), and M.D. There are 340 full-time faculty, 321 hold doctorates. Courses with aging content are listed below. No estimate by the respondent was made regarding percent of course with aging content: Basic Dermatology Family in Health Care Organized Health and Welfare Services of the Community Aging at the Cellular Level Mammalian Cell as a Microorganism Hearing and Speech Sciences There is no department of continuing education. UCD - The University of California, Davis has a total student population of 16,000. There are 400 medical stu dents. There are 350 full-time faculty, 300 hold doctor ates. Degrees offered include : M.A., M.S., Ph.D., and M.D. Only one class was reported to have aging content and miscellaneous clerkships were reported by the respondent to having aging content and miscellaneous clerkships were re ported by the respondent to have "exposure to the aged." The course with aging content and the percent of aging con 138 tent is listed below; Human Development - 10% The department of continuing education offers no courses with gerontological content. LOMA LINDA - Loma Linda University has a total student population of 4,000. There are 500 medical students. There are 550 full-time faculty, 520 hold doctorates. Degrees offered include : M.A. and M.S. (public health), Ph.D. (health science), and M.D. No courses with aging content are offered and there is no department of continuing educa tion. UCLA - The University of California, Los Angeles has a total student population of 29,600, There are 602 medical students. There are 848 full-time faculty, all hold doc torates. Degrees offered include: M.A. (social psychiatry) Ph.D. (anatomy, biochemistry, biomathematics, microbiology, immunology, medical physics, pathology, pharmacology, physiology, neurological sciences), and M.D. Courses that contain aging content are listed below. No estimate of aging content was made by the respondent. Biological Chemistry Consultation Psychiatry 1 Inpatient Psychiatry Psychiatry - first year ! Psychiatry - third year Psychiatry - fourth year _________________________ ^ ________________U?-j Pathology - second year Geriatric Ward Program No courses with aging content are offered by the department of continuing education. Since the number of medical schools in California total only eight, the researchers used raw numbers rather than percentages for reporting the data. In addition, question number seven pertaining to master's thesis and doctoral disserations was omitted because it was not rele vant to medical education. Table 1 presents some vital data : the schools sur veyed, the total student enrollment, the number of medical students, the number of courses with gerontological con tent, the number of full-time faculty, and the number of full-time faculty with doctorates. Although the total stu dent populations range from 2,500-29,600, the latter more than tenfold the former, the number of medical students ranges only 316-602, a difference of only 286. Although the institutions surveyed may vary by as much as 25,000 in total student enrollment, the number of medical students remains relatively the same. Three of the schools surveyed are private: University of Southern California, Loma Linda ; University and Stanford University. The remaining five are' public and are part of the University of California system. I Table 2 presents responses from four selected questions 140 _____I T a b le 2 Responses to Questions 3, 9, 10 and 11 Question 3 - If applicable, do the instructors teaching the courses with Gerontological content hold membership in the Gerontological Society (GS) or the Western Gerontological Society (WGS)? GS 0 WGS 0 Both 0 Don't know 7 Question 9 - Do you plan to implement aging related courses into your school curriculum within the next two years, three to five years? Within next two years 0 Within three to five years 2 Don't know 1 Already have such courses 1 None planned 2 If you do not plan to implement aging related courses into your curriculum, is it because of; Lack of money 0 Lack of qualified faculty 1* Lack of student interest 0 Lack of faculty interest 1* Lack of relevance to Medicine 0 Other 1** Question 10 -If applicable, how many of your faculty, who teach aging courses have had specific geron tological training? Less than 5% 5-15% 15-25% 25-35% 35-50% 50-75% 75% Unknown * UCD answered two times for this question ** Other - students required to learn too much already 141 , Table 2 (Cont'd.) Question 11 - If applicable, do you feel that faculty who teach your aging related courses should have specific gerontological training? Yes 4 No 0 Not applicable 1 Yes practical - no theoretical 1 1 4 2 , from the interview questionnaire. These four questions are concerned with faculty association and training in gerontology as well as curriculum planning by the medical school. It is interesting to note that all respondents answered "don't know" for the latter part of question 3, regarding faculty membership in gerontological societies. It would appear that outside of specialized gerontological circles, these organizations may not be particularly well- known. With the implemention of age related courses into the school curriculum, question 9, two schools responded that such classes would be started in the future and one reported that such classes already existed. The two schools reporting that such classes would be started in the next two years are ranked first and fourth in the number of courses offered with gerontological content. The school reporting such classes already exist is ranked second in number of courses offered. The school ranked third in course offerings reported no such classes were planned be cause "gerontology is not a division." A possible explana tion is that schools reporting future concerns for geron tology reflect that interest in the current number of course I and content offerings. In response to the second question ! asking the reasons that such classes would not be intro duced, two schools reported that no such classes were planned and that the reasons were attributed to faculty feelings that medical students are required to learn too much already and gerontology not being a division. The three schools that responded negatively about aging courses rank third, sixth and seventh in number of courses. These schools that reported no future concern reflect that lack of interest by offering few such courses. No school stated that lack of money, lack of student interest, or lack of relevance for medicine was the reason. Question 10, concerning faculty training in gerontol ogy, showed that specialized gerontological training among faculty that teach aging courses would appear to be minimal] Three schools reported that between 5-15 percent of the faculty had any such training, one reported less than 5 per cent, and three did not estimate the percentage. The school that reported less than 5 percent offers 6 courses with gerontology content. With 6 courses offered, 5 per cent of the faculty teaching these courses is numerically less than one, which may imply no one is appropriately trained. The same situation is applicable to one school reporting 5-15 percent that offers two courses. Only the schools offering 7 and 9 such courses that reported 5-15 I percent faculty with training, are numerically feasible. Apparentlyf some of the respondents were inaccurate in their knowledge, quite possibly a reflection of the degree of im portance of gerontology to the school. The question may also have been poorly worded. 144 I Question 11 asked whether faculty should have special ized training in gerontology ^ Four schools responded yes one responded both no and yes, yes for practical and no for theoretical courses, one answered no and one answered not applicable. Of the five schools that responded yes, three of those five did not answer the previous question on percentage of faculty with gerontological training. The schools reporting no and not applicable also reported less than 5 percent and 5-15 percent respectively to the pre vious question regarding percent of faculty with gerontol ogy training. It seems odd that schools that report geron tology training as important for faculty do not respond to the question regarding the actual percent of faculty with such training. Table 3 presents the responses from the three atti- tudinal questions from the interview questionnaire. Ques tion 5 rated the importance of courses with aging content in relation to the medical school curriculum. Six schools rated the relationship as having some importance in varying degrees. When assigning numerical values to the answers to j question 5, very important-5, important-4, somewhat impor- | tant-3, not very important-2, no importance-1, the mean ! response is 3.71. Oddly enough the school offering the most classes with aging content (9) rated the question as i not very important and the school offering the least number 145 ; T a b le 3 Responses to the Attitudinal Questions (5, 6 and 12) From the Interview Questionnaire Question 5 - How important would you rate courses with aging content, in relation to your total school curriculum? Of no importance 0 Not very important 1 Somewhat important 2 Important 2 Very important 2 Question 6 - How important would you rate aging issues, in comparison with all other issues your profes sion is concerned with? Of no importance 0 Not very important 0 Somewhat important 2 Important 2 Very important 2 Question 12- Do you feel that the content of gerontology has important implication for the future of your discipline? Very important 2 Important 3 Somewhat important 1 No importance 0 146 of classes (0) rated the question as very important. As signing the same numerical values to question 6, the im portance of aging issues in comparison with all other is sues in medicine, the mean response is 3.85. It appears that there is a slightly stronger feeling about the impor tance of gerontology toward the field of medicine than to the medical school curriculum. The numerical assignments for question 12, the importance of gerontology subject matter for the future of medicine, was different: very important-1, important-2, somewhat important-3, not impor- tant-4, and the mean response was 1.66. Apparently the respondents show a stronger feeling about the importance of gerontology subject matter for the future of medicine than the two previously discussed questions (importance of aging issues and importance of gerontology subject matter). The responses of the three attitudinal questions (im portance of courses with gerontology content, importance of aging issues, importance of gerontology content) were collapsed into two categories: important and not impor tant. The responses from the questions regarding the im portance of courses with aging content and importance of aging issues were collapsed as follows: important (some- waht important-3, important-4, very important-5) and not important (no importance-1, not very important-2). Re sponses from the question regarding importance of gerontol- 147 ogy content were collapsed differently because the re sponses on the questionnaire are different. The collapsed categories are as follows: important (very important-1, important-2, slightly important-3) and not important (no importance-4). These collapsed categories, important and not important, were compared with whether or not courses with gerontology content were offered. Only one school re sponded in the not important category for importance of courses with aging content. Ironically, this, the lowest response was made by the school offering the most number of courses with aging content. No responses of not impor tant were made for the other questions regarding importance of aging issues or importance of gerontology content. The analysis of the responses of the attitudinal ques tions and whether or not courses with gerontological con tent are offered is difficult because only one school did not offer such courses and only one school responded in the not important category. All other schools for all of the other attitudinal questions responded in the important category. Conclusions can be made from the results. All schools, except one, offering courses with gerontology con tent feel such courses are important to the medical school curriculum. All schools feel aging issues are important, whether or not courses with aging content are offered. Schools offering greater numbers of courses with gerontol- 148 ogy content tend to feel more positive about the importance of gerontology subject matter for the future of medicine than do those schools who offer fewer such courses. The researchers felt that an association between the number of courses with aging content and the number of medical students might be indicative of student interest in the field of gerontology. Table 4 presents an associa tion of the number of courses with aging content and the number of full-time medical students using Pearson r cor relation (r = .069). This demonstrates that there is no apparent relationship. It is interesting to note that the school with the least number of students offered the most courses. The schools ranked first and second in number of students were ranked second and third respectively in num ber of courses. A similar relationship was examined between the total number of students at the institution and the number of aging courses offered using Pearson r correlation (r = 0.10). Again, the relationship was not significant. In terestingly enough, the institution with the most students was ranked second in the number of courses offered. The institution with the least number of students did not offer any classes. This data is presented in Table 5. Table 6 presents an association between the number of courses with aging content and the number of full-time 149 T a b le 4 Association of the Number of Courses with Aging Content Offered by Each School and the Number of Full-time Medical Students using Pearson r School Courses Students UCI 9 316 UCLA 8 602 UCSF 7 600 Stanford 6 350 UCSD 4 354 use 2 550 UCD 1 400 Loma Linda 0 500 r =.069 (p = n.s.) The results indicate that no correlation exists between the number of courses with aging content offered and the number of full-time medical students. 150 T a b le 5 Association of the Number of Courses with Aging of Students at Content and the the Institution Total Using Number Pearson r School Courses Students UCI 9 9,682 UCLA 8 29,600 UCSF 7 2,500 Stanford 6 12,724 UCSD 4 10,000 use 2 23,385 UCD 1 16,000 Loma Linda 0 4,000 r = 0.10 (p = n.s.) The results indicate that no relationship exists between the number of courses with aging content offered and the total student population of the institution. 151 Table 6 Association of the Number of Courses with Aging Content at Each School and the Number of Full-time Faculty at the School Using Pearson r School Courses Faculty UCI 9 209 UCLA 8 848 UCSF 7 638 Stanford 6 340 UCSD 4 330 use 2 638 UCD 1 350 Loma Linda 0 550 r = 0.01 (p = n.s.) The results indicate that no correlation exists between the number of courses with aging content offered and the number of full-time faculty at each school. 152 faculty using Pearson r correlation (r = 0.01). This im plies that no relationship exists between these two vari ables. However, the school with the most full-time faculty are ranked second in number of courses offered and the school offering the most number of courses has the fewest number of faculty. Table 7 presents the responses to question 8 regarding journals subscribed to by the library of the school of medicine. Seven schools subscribed to 20 journals, the Journal of Gerontology being taken at all seven schools and two, the Gerontologist and Geriatrics being taken at six. use subscribed to the most journals, 14, and UCLA subscribed to the least, four. The school offering the most number of courses with aging content took 10 journals and the school offering the least took five. Once the results were analyzed, the researchers noticed an almost 1:1 ratio of full-time faculty and full time medical students. These ratios are presented in Table 8 by school, number of full-time faculty (faculty), full-time medical students (students), and full-time faculty/full-time medical student ratio (fac/stu). The range of this ratio is 0.66 - 1.41 with a mean of 1.02. There are four schools above the mean and four below. The total number of courses with aging content offered by the first four schools is 17 and the number of similar courses 153 k . H Q H U U e n u D e n u D D o Q ' k . ' k . Q e n H e n 'Ü U e _ ) p u P D D 0 m 0 iw * k c • k C < H U T 3 ( d T 3 f d (3 U e n u +j 4 J U n ÏD O m e n O m e n D k . c k . ' c • k " k Q ( d H ( d Q < d Q Q e n U -p U + 3 U U u 0 3 c D e n D e n D ^ D n iH •H < o 1 - 3 • w w 1 - 3 . k . k 0 Q Q ( d Q ( d u f d f d 0 3 f d e n O y T J 5 T 5 T J ü fi e u D C D C C c e n O o D •H • H ^ •H •H O 1 - 3 1 - 3 . < k |3 H 3 3 iH 1 3 • w ( d ( d u ( d ü . k ' < ( d T J f d D f d f d ü e n U 1 - 3 c e C g g g •H e n U •H o •H o ^ Q o T 5 D D H 3 1 - 3 k 3 k 3 Q ► 3 3 < 1 3 H e n S * k * k rd -O (d *-o " k « k H Q e u D e u n U U U < u U U o e n o e n e n e n e n 1: D D k 3 D 1 - 3 n n D D s g D D H O D g B U en D 8 D U U e n e n D D < ü rH 13 f d &H >1 1 3 S T5 < ü 1 3 •H J - l ü 0 3 e n u < ü 1 3 n in in eo in VD rH - Ç J ' CM CN CM fi 0 3 - p > 1 o r H c - P i H O J f d d ) e u f d c g • H ü C p a ü • H O 'S 0 0 O >i t P i • H f 3 o r — 1 e n t r » O - P f d f d n Q ) O ü ü > 0 3 fi O Q ) ü ■ H e p m > 1 0 ) ü O - P e n • H P c g u C 3 ■ H - p - p - p c f 3 - P • H o f d M c c 0 3 o 1 • H f d e n p C - P Q ) o • H . p r H • H < 1 3 f d f d g u e p e u f d U P m ■ H g • H 0 4 Q ) o e j 3 ü e u ip c » 3 p U 0 U r - 4 • H f d f d e u O • H œ e u i H O c • H • H - P 0 1 u 0 3 Q ) 4 - > ■ H e u C P e r > M - f > 1 0 3 1 3 p ü > 0 C S o o o p g 0 ) c c • H Q ) O 0 3 1 3 f — i fi - p 0 3 g Z r H f d f d P C 3 fi p Q ) ü 0 1 0 o r H f d ■ H di f d ü - P f d Q ) ü P - P - p - p f d * H f 3 0 C 3 C e p ■ H f d C c u f 3 f d 0 4 c f 3 f 3 1 3 f d 1 — 4 P U c c M • H f d p f d e u P o o P O 1 3 e u Q ) 3 • H • H Q ) U g 0 Q ) > 0 3 e u p p 0 >i o > T J O e p t T i ( U 3 o 1 3 T J e u X Q ) ( D O 0 3 Q ) ( U O n < < u H < 0 3 H e u e u 0 4 S Q S 154 +J C 8 ( Ü rH JQ f O EH rH H CO c v i ro C M rH r-H rH 155 T a b le 8 Full time -time Faculty and Full- Medical Student Ratio School Faculty Students Fac/S UCLA 848 602 1.41 use 638 350 1.16 Loma Linda 550 500 1.1 UCSF 638 600 1.06 Stanford 340 350 0.97 UCSD 330 354 0.93 UCD 350 400 0.88 UCI 209 316 0.66 156 offered by the remaining four is 20. Faculty/student ratios are relatively consistent from school to school which provides a relatively equal opportunity for greater faculty involvement in the aging field and with students interested in gerontology. Table 9 shows the responses of the three attitudinal questions 5, 6 and 12 (importance of courses with aging content, importance of aging issues, importance of geron tology content) from the interview questionnaire. Such a table might provide visible evidence in responses viewed over the three questions. The abbreviations and their re spective numerical value are listed according to question number and school: very important - VI, important - I, somewhat important - SI, not very important - NVI, not im portant - NI. the mean response by question is also listed. Overall, the mean response was greatest toward question 12, having to do with importance of gerontology for the future of medicine (mean = 1.66), yet two of the schools responding very important to this question were not planning any gerontology programs for the future. This indicated that the responses are questionable in regards to validity. Question 6, regarding importance of gerontol ogy in relation to other issues in medicine was overall ranked second (mean = 3.85). Question 5, importance of aging courses in relation to the medical school curriculum 157 < T \ Q ) rH g I Q C CO 'g ( 0 <N c ( 0 V O m C O a o •H 4-» (Q < u s ( 0 'H 1 +J •H +j IT) m m m ro m m in < U C N C N C N C N Ü rH O O Q ) •H H 4J 3 C Q 4 - > m C N C N m in in m (0 C Q « 0 V O ro V O C O ■P C CQ -H 0 Cn m m n m m H H H H H H m m m m m cn m in m in C Q -H 0 tr in in CN cn cn M M M H M M -H 158 ranked last (mean = 3.71). Ironically, the lowest response given, not very important, was made by the school offering the most number of courses with aging content (nine) and one of the two schools giving the highest response, very important, offered the least number of such courses (none). Although this table demonstrates no apparent trend, the mean rank of the three attitudinal questions shows USC, UCSF, and Loma Linda as having the strongest feeling about the importance of aging courses, aging issues, and future concerns for gerontology. Summary Four common hypotheses were examined by the groups in this survey and are listed as follows: there is a signi ficant relationship between the size of the department (total number of students) and the number of courses with gerontological content offered; there is a significant re lationship between the number of courses with geronto logical content offered and the importance of such courses (response to question 5); there is a significance between the number of students placed at agencies that work with the aged and the importance of age related courses; there is a significant relationship between the number of courses with gerontological content offered and the number of full time faculty. The first hypothesis (department size and number of 159 courses) is presented in Table 4 and is analyzed with a Pearson r (r = .069). This clearly demonstrates that no significant relationship exists between the relationship. The second hypothesis (number of courses and importances of such courses) cannot be accurately tested because one school did not provide information aboiit the importance of courses with gerontology content. A significant relation ship seems highly unlikely because the school offering the most courses gave the lowest rating on the importance of such courses and the school offering no courses gave the highest rating on the importance of courses. The third hypothesis (students placed at agencies and importance of courses with gerontology content) is rather inappropriate for medicine since all the students have exposure to older people in varying degrees during the clerkships at the teaching hospitals. The fourth hypothesis (number of courses with gerontology content and the number of faculty) is analyzed in Table 6 using a Pearson r (r = .01). This table clearly illustrates that no significant relationship between these variables exists. The eight medical schools offer an average of 4.625 courses with gerontology content. Although this number is not very high, we see an overwhelming opportunity for med ical students to further their interests and studies in gerontology through the teaching clerkships which expose 160 all students to older people and through personal faculty guidance becasue of the 1:1 average faculty/student ratio. We also feel that students interested in specializing in gerontology would continue in a post-doctoral residency such as family medicine or internal medicine. This study also demonstrates a strong feeling in all schools surveyed regarding the importance of aging courses, aging issues, and aging content for the future of medicine. Only two schools had no plans for incorporating more geron tology content into their medical programs. This strong feeling regarding the importance of gerontology and medi cine indicates that more emphasis will be placed in geron tology in the future. The offering of courses with geron tology content and the opinions voiced in completing this survey indicate that these schools recognize the need for gerontology in medical education. Hopefully, these courses and interests will become a larger part of every medical student* s curriculum in the future. 161 CHAPTER VIII SUMMARY Introduction This research was conducted as part of a larger ex ploratory study of eight disciplines in the state of California. The researchers of this section explored the discipline of medicine in its relationships to gerontology. In order to evaluate the evolution and relationship of the two disciplines as professions, a literature review of pro fessionalism was undertaken. Seven steps were developed as prerequisites of a profession: (1) a body of knowledge; (.2) a university education; (3) a professional ideology; (4) professional associations ; (5) a code of ethics; (6) self-regulations; and, (7) public sanction. Using these steps, the researchers examined the fields of medicine and gerontology as they move along the continuum of profes sional status. 162 Two questionnaires were developed which examined edu cational curricula in medicine. The first questionnaire concerned information in course catalogues and bulletins. The second questionnaire was sent to the deans of the medical schools in the state of California. This second questionnaire regarded attitudes toward the relevance of gerontology ahd the prospects for the future development of courses in aging and was followed up by a telephone or personal interview. Eight departments in accredited uni versities were included in the California survey. In the final chapter the authors will provide con clusions and implications based upon the literature review and the results of the survey. The literature review has provided information about the medical profession and gerontology, where these fields lie on the continuum of professional status and how these two fields interface. The results of this study have brought to light some important facts which must be considered. There does, in fact. Seem to be a basis from which some conclusions can be drawn, it would seem that there are few medical schools in California that are offering courses with gerontological content as far as the education of medical students is concerned. However, a trend may be in evidence, as shown by the establishment of the first geriatric chair in medi cine, referred to elsewhere and the fact that there are 163 gerontology courses being taught, though these are diffi cult to confirm. Many such courses may not have been spe cifically listed as such in the curriculum, also the re searchers were not able to contact any person in the inter view that had sufficient correct knowledge to confirm the number and kinds of courses that are being taught in the eight California medical schools. Curriculum Development This survey addressed the question of curriculum de velopment by asking respondents about the importance of aging issues in comparison with all issues with which the profession is concerned and the importance of gerontology for the future of medicine (question six). The results indicate that of the eight medical schools questioned, seven respondents regarded aging issues as having importance in varying degrees. This may indicate that the medical profession is aware of the relevance of gerontology for medicine but do they see the need to expand medical education to meet this need? To test this question the respondents were asked (question 5) about the impor tance of courses that had aging content in relation to the department curriculum. Six schools rated the relationship as having some importance, again in varying degrees, one school offering many courses with specific gerontological content thought it was not very important, and one school 164 did not answer the question. This is puzzling and only speculations can be made regarding these results. Since there was such diversity among the respondents, it might be assumed that curriculum with gerontological content has not been given high priority by medical educators. It is interesting to note that the Department of Health, Education and Welfare published a report on aging and education that listed among other fields, medicine. In California, two schools were mentioned (University of Californiat at Davis and Stanford) as offering courses with gerontological content. It seems to be contradictory that neither of the schools mentioned could give any information on this when contacted by interview and questionnaire. Perhaps those questioned were unaware of the HEW reference, and their inclusion in the report. It would seem that faculty and staff are not aware of what courses with geron tological content are available at their respective uni versities, even though it was included in the report. Curriculum that includes content related to aging can occur in two ways. First, entire courses devoted to under standing the process of aging should become a part of the curriculum for medical students. These should be taught by someone trained in the field of aging. The objectives of such training would be to impart correct information re garding aging, dispel stereotypes and show the relationship 165 between medicine and gerontology. Secondly, aging informa tion should be integrated into existing courses wherever it is relevant. Classes which teach techniques of working with and treating the aged should include ways to improve relationships with the elderly. For example, doctors need to be more aware of the impact on the individual of the physical losses which occur with aging in such areas as hearing, sight, and mobility, and to make accommodations for such losses in order to effectively treat the older adult. Medical education in geriatrics is being called for by a wide segment, Robert Butler (1976) stated that the subject of geriatric medicine should be pursued in the following ways : (1) curriculum development; (2) faculty development; (3) study of teaching in the United Kingdom; (4) collaborations with American Foundations ; and (5) Co ordination with Veterans Administration hospitals, espec ially where there are Geriatric Research Educational Clinical Centers, and these are only a few of the possibil ities . Limitations of the Study The researchers are aware of the limitations of the present study. Limitations presented in this research are those common to survey design research project, as well as those specific to the subject matter of the project. By 166 design the project studied only medical schools in Califor nia. Larger implications of the findings are limited be cause of the omission of schools from states other than California. There are over 300 medical schools in the United States that may or may not offer programs or courses with gerontological content. The findings may indicate a similar in-depth study needs to be done on a nationwide basis, to determine exactly what strides, if any, have been made in this field. Omission of some important information may have oc curred. Despite role play training in interview techniques the researchers have different levels of interviewing skills, therefore these varying skills may have elicited varying levels of answers from the respondents. Also, since only eight professions were studied, the results cannot be generalized to professions beyond this group. The design and characteristics of medical education may not be particularly well-suited for this survey. The first two years of medical education concentrates heavily on medical science subjects in order to provide a solid scientific base of knowledge for the duration of the stu dent's education. Most courses offered during these years are science-oriented and probably reflect little geronto logical content. One of the objectives was to interview the deans of 167 the medical schools and garner their perceptions, as well as information pertinent to the study. In no case was the dean interviewed and in no case could the respondent fully answer the questionnaire. For example, to adequately answer the questions regarding the percentage of aging material in courses it would have been necessary to inter view all instructors of all courses to determine whether or not aging material was included. Next would be the deter mination of what percentage of that class was devoted to aging. Considering that each school has at least 300 full time faculty, this task was not realistic. One possible explanation for the respondents* inability to fully answer the questionnaire might be the size and complexity of medical schools. The researchers felt this to be a major limitation of the study; the respondents * failure to fully and factually answer the questionnaire. No individual contacted, could possibly determine the amount of aging content in the learning experience that provides students the opportunity to learn directly about the patient. For example, if the patient was of advanced age during the cardiology clerkship, the student would learn about cardi ology in old age. Much of the students learning takes place at the bedside and could not be included in the study. To be included, the clerkship instructor would have been interviewed to determine the number of aging 168 patients that students were exposed to during the clerk ship. We must assume that clerkships in Family Medicine, Community Medicine, Internal Medicine, Rehabilitation, and Psychiatry have more aging content than other clerkships. Conversely, one school (Stanford) replied that due to the heavy geriatric patient exposure during clerkships, there was no need for specific aging courses. It was beyond the scope of this study for this valuable learning tool (the clerkship) to be included. The last part of the medical students* education is the internship which may or may not be at the medical school attended for the first four years, and this is yet another aspect that has been ex cluded from the study. The internship is best viewed as a year long clerkship, but without an instructor. The amount of gerontological material covered during this time de pends heavily on the hospital setting and the interests of the intern. Still another factor is that of the student * s aspirations in medicine. Those medical students seeking careers in the field of gerontology may elect to take spe cial problem courses (similar to a research course) and focus on the interrelationship of medicine and gerontology. Also important to the study is the fact that all medical specialties require post-graduate education and training. It follows that those interested in the "legally unrecognized" but practiced specialty of geriatrics would 169 concentrate in the post-graduate fields of Internal Medi cine, Family Medicine, Community Medicine, Rehabilitation or Psychiatry. While post-graduate education for careers in geriatrics was not studied from this project, it should be considered since those who would practice this specialty would receive most of their training about the aging in these settings. In the field of continuing medical education, courses are offered through medical schools, but courses are also offered at other institutions such as hospitals, clinics, and professional association meetings. It is highly prob able that since continuing education is now mandatory in California, there are many more courses offered that deal with some aspect of aging than have been listed in this study. Recommendations for Future Action Medical educators need to examine current programs and ways of treating the elderly so that they can choose the best method for integrating gerontological content into the medical program in an innovative way. If older adults are to get appropriate medical care, some changes will have to be made in the medical education of physicians. To effectively meet the medical needs of the older population, medical school educators must address themselves to the 170 primary issues in the following areas : (1) the training of doctors with special knowledge in aging; (2) curriculum de velopment; and (3) continuing post-graduate education and research. Legislation regarding health care (which directly af fects*.thé . medical profession) for and about the aged is presently underway. Enactment of National Health Security bills continues to be high priority and health care must be individualized to meet all the needs of the aged. At pres ent, the National Council of Senior Citizens is advising the 95th Congress to "appropriate sufficient funds to in sure the development of courses of study in geriatric medi cine in all medical and nursing schools" (Senior Citizen News, 1977, p. 5). The researchers concur with the stand taken by the National Council of Senior Citizens, the Gray Panthers, and all other advocate groups that schools of medicine pre pare faculty to teach in depth the principles of gerontol ogy, and that curriculum be developed that will incorpor ate these principles into the practice of medicine. The researchers suggest that immediate steps be taken by medical education programs to integrate gerontology into the curriculum. The respondents to the survey indicated that they were aware of the importance of gerontology as an emerging area of concern for their profession, but that the 171 necessary curriculum changes needed to train faculty in the area of gerontology are not necessarily taking place. A further study might be undertaken to examine why the medi cal profession and the medical schools are lagging in this direction. Perhaps some feel that it is not the purpose of the medical school to offer classes in specific aging issues. However, it is vitally important that students be exposed to aging issues and be given the opportunity to continue and expand their theoretical and practical knowledge in this area. The researchers feel that the medical schools in California should provide flexibility in their medical programs to accommodate those students seeking careers in gérontologie medicine. The somewhat new mandatory continu ing medical education program for California should con tinue and even perhaps enlarge the opportunity for physi cians to enroll in courses related to gerontology. The present state of education in gerontology and medicine should provide medical students and practicing physicians more opportunity to concentrate and study in depth geron tology. In a medical setting, students could be encouraged to participate in studies which benefit the older patient. While it is acknowledged that the medical student does, in fact, treat older patients during his clerkship, as well as 172 younger ones, the study points to the fact that he has had no special (or insufficient) preparation for this. Courses related to aging should be developed to stimu late interest which could be further developed by the medi cal student. An instructor trained in gerontology and having various community contacts in age related areas would be able to establish resources among a variety of gerontological settings from which medical students might benefit. Thus, the relationship between medicine and gerontology could be further enhanced. Conclusion In conclusion, the researchers recognize that there is not a significantly large amount of gerontological in formation in medical school courses, as evidenced in the eight California medical schools. Thirty-six courses that do contain gerontological subject matter, to some degree, were listed by the respondents from all of the medical schools combined. Surely not an impressive figure. Further, of the six schools that have a department of con tinuing education, only one offers continuing education courses with aging content (eight courses covering five subjects). Another interesting finding was that neither the California Board of Medical Examiners or the National Board of Medical Examiners require specific gerontological material be covered prior to issuance of the license to practice medicine. 173 This study found that all schools offered some geron tology, but an accurate assessment was not possible. To get a more clearly defined picture, it would be necessary to talk to each professor in the system to determine the gerontological content of his particular course. Perhaps if this were done it could yield more qualitative data. It was found, however, that all schools contacted did seem to be planning to put more gerontological content into their medical school education. The researchers find that it is necessary for medical educators to become more responsive to the needs of older adults, and to become more aware of just what kinds of courses are being taught in their schools. The major find ings of this study were: (1) lack of knowledge among med ical faculty about whether or not gerontology was, in fact, being taught to students; and, (2) a general agreement of the respondents that gerontology was important. It is apparent that there is a great need for under standing the special needs, problems and potentialities of the later years of the life span. By expanding the know ledge of human aging, the quality of life will be enhanced. 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Encroachment, charlatanism and the emerging pro fession: Psychology, sociology and medicine. American Sociological Review, 1960, 25, 902-914. . The theoretical limits of professionalism. A. Etzioni (Ed.), The Semi-Professions and Their Organizations. New York: The Free Press, 1969, 148- 153. . The librarian from occupation to profession? Library Quarterly, 1961, 33^, 306-318. Greenwood, E. Attributes of a profession. T. Tripodi, I. Epstein, P. Fellin and R. Lind (Eds.), Social Workers at Work. Itsaca, 111.: F.E. Peacock, 1972, 161-170. Guinne, K.K. Professional Nurse. New York : McMillan Co., 1970. Hall, O. The stages of a medical career. American Journal of Sociology, 1949, 5^, 243-253. Halmos, P. The Personal Service Society. New York: Shocken Books Cambridge University Press, 1970. Harries-Jenkins, T. Professionals in organizations. J. A. Jackson (Ed.), Professionals and Professionaliza- tion. Great Britain: Cambridge University Press, 1970, 84-89. 180 Hauser, H. Objectives in American Medical Education; A Survey of Medical Faculty Opinions. Iowa: University of Iowa Press, 1974. Hodkinson, H. An Outline of Geriatrics. New York: Academic Press, 1975. Hughes, C. Medical care. D. Sills (Ed.), Intern a t i on a1 Encyclopedia of Social Sciences. McMillan Co. and the Free Press, 1968, 194-208. Hughes, E.C. Professions. Daedalus, 1963, 9^, 655-668. Hughes, E.C. Education for the Professions of Medicine, Law, Theology and Social Welfare. New York: McGraw- Hill Book Co., 1973. impact. American Medical Association, September 27, 1976. Isaacs, B. An Introduction to Geriatrics. Baltimore, Md.: Williams and Wilkins Co., 1965. JAMA, August 9, 1976, 236. Special supplement to the Jour nal of the American Medical Association, Continuing Education Programs, p! 141. Jackson, J.A. (Ed.), Professions and Professionalism. Great Britain: Cambridge University Press, 1970. Kaplan, J. Voluntary organizations. A. Hoffman (Ed.), The Daily Needs and Interests of Older People. Chicago, 111.: Charles C. Thomas, 1970. Kleemeir, R.W. Gerontology as a discipline. The Géron tologie, 1965, 5, 237-239, 276. Kleemeir, R.W. and Birren, J.E. Society and the study of aging. R.E. Kushner and M.E. Bunch (Eds.), Graduate Education in Aging. Ann Arbor, Michigan: University of Michigan Press, 1967, 137-148. Knowles, J. H., M.D. The struggle to stay healthy. Time, August 9, 1976, 60-62. Koller, M.R. Recommended curricula in social gerontology. Geriatrics, April 1962, 17, 260-264. 181 Krauss, T. C., M.D. Indoctrination of medical students in principles of geriatrics. Gerontologist, December 1963, 3, 152-155. Krumboltz, J.D. Behavioral goals of counseling. Journal of Counseling Psychology, 1966, 153-159. Kuhlen, G.R., Kreps, J.M., Kushner, R.E., Osterbind, R. and Webber, I. Research training in aging within the single disciplines. R.E. Kushner and M.E. Bunch (Eds.), Graduate Education in Aging. Ann Arbor, Michigan : University of Michigan Press, 1967, 104-110. Lee, R., M.D. Distinguishing the health care needs of the aging. Journal of American Gerontological Society, February 1968, 20-21. Lenzer, A. The role of the university in gerontological training. The Gerontologist, 1966, 6 _ , 105-110. Levy, C.S. On the development of a code of ethics. Social Work, 1974, 3^, 207-216. Lewis, R. and Maude A. Professional People. London: Phoenix House, 1952. Linn, M.W. and Carmichael, L.P., M.D. Introducing pre- professionals to gerontology. The Gerontologist, 1974, 476-478. Lippord, V. A Half Century of American Medicine : 1920- 1970. New York : Josiah Macy, Jr. Foundation, 1974. Lloyd, W. Science of Medicine. Philadelphia, Pa.: Lippincott, 1968. Loether, H. Problems of Aging. Los Angeles, Calif.: Dickenson Publishing Co., 1975. Marshall, T.H. The recent history of professionalism in relation to social structure and social policy. Cana^ dian Journal of Economics and Political Science, 1939, 5, 325-340. McGlone, F.B. and Schultz, P.R. Problems in geriatric health care and delivery. Journal of the American Geriatric Society, 1973, 21, 553-537. 182 Medicare Increase. Senior Citizens Today, January 1977, 2. Moore, W.E. The Professions; Roles and Rules. New York: Russell Sage Foundation, 1970. Morton, J., M.D. Licensure and certification in the United States. Journal of the American Medical Association, January 3, 1977, 237, 164-169. National Association of Social Workers. Building Social Work Knowledge. New York : National Association of Social Workers, 1964. Newsweek. The graying of America., February 28, 1977, 1, 50-65. Older American Reports, Washington, D.C., February 15, 1977, 1. Pavalko, R.M. Sociology of Occupations and Professions. Florida : F.E. Peacock Publishers, Inc., 1974. Posz, G.S., Jun, J.S. and Storm, W.B. Administrative Alternatives in Development Assistance. Cambridge, Mass.: Ballinger Publishing, 1973. Pumphrey, R.E. and Pumphrey, M.W. The heritage of American social work. Article by Abraham Flexner. Professional Organization. New York : Columbia University Press, 1961. , Rayack, E. Professional Power and American Medicine. New York: World Publishing Co., 19 67. Ritzer, G. Professionalism and the individual. E. Fried- son (Ed.), The Professions and Their Prospects. Beverly Hills, California: Sage Publications, 1973. Schein, E.H. Professional Education. San Francisco, Calif McGraw-Hill Co., 1972. Schott, R.L. Public administration as a profession: Problems and Prospects. Public Administration Review, 1976, 36, 253. Schwartz, A.N. A transactional view of the aging process. A.N. Schwartz and I.N. Mensh (Eds.), Professiona1 Obligations and Approaches to the Aged. Springfield, 111.: Charles C. Thomas, 1974, 5-28. 183 Senior Citizen News. Washington, D.C. , June 1977, 4^, 5-8. Sheps, L. and Seipp, J. Teaching Modern Medicine. Boston; Houghton & Mifflin, 1972. Shock, N. Trends in Gerontology. Stanford, Calif.: Stanford University Press, T9S1. . An Institute of Gerontology. Stanford, Calif.: Stanford University Press, 1957. Shryock, R. Medicine in America. Baltimore, Md., Johns Hopkins Press, 1966. Smith, H. Contingencies of professional differentiation. American Journal of Sociology, 1958, 410-414. Sperry, W. The Ethical Basis of Medical Practice. Minneapblis, Minn.: P. B. Hoeber, Inc., 1956. Stone, S. and Shertzer, B. Careers in Counseling and Guidance. Boston: Houghton Mifflin Co., 1969. Storey, P. Continuing Medical Education. AMA: Circula tion and Records Department. Strauss, A.L. Professions, Work and Careers. San Fran cisco, Calif71 The Sociology Press, 1971. Taylor, L., Jr. The Medical Profession and Social Reform: 1885-1945. New York: Saint Martins Press, 1974. Tibbitts, C. Development of gerontology. C.B. Vedder (Ed.), Gerontology: A Book of Readings. Springfield, 111.: Charles C. Thomas, 1960. Social gerontology in education for the professions R.E. Kushner and M.E. Bunch (Eds.), Graduate Education in Aging. Ann Arbor, Mich.: University of Michigan, 1967. Time, Medicine : A new type of doctor emerges, November 8, 1971, 61-62. Turner, C. and Hodge, M.N. Occupations and professions. J.A. Jackson (Ed.), Professions and Professionalism. Cambridge, Mass.: University Press, 1970. 184 U.S. Congress. House Select Committee on Aging. Report by the Sub-committee on Housing and Consumer Interest. Washington, D.C.: U.S. Government Printing Office, 1976. U.S. Department of Health, Education and Welfare. Office of Human Development. Administration on Aging. National. Directory of Educational Programs in Gerontology. Washington, D.C.: U.S. Government Printing Office, 1976. U.S. Department of Health, Education and Welfare. Office of Human Development. Administration on Aging. Facts About Older Americans. Washington, D.C.: National Clearinghouse on Aging, 1976. U.S. Department of Health Education and Welfare. Social Security Programs in the United States. Washington, D.C.: U.S. Government Printing Office, 1973. Van der Koot, H. Aging and Social Policy. New York: McGraw Hill, 1973. Vodicka, B.E. Medical discipline. Journal of American Medical Education, September 8, 1975, 233, 119-124. Vollmer, H.M. and Mills, D.L. (Eds.) Professionalization. Englewood Cliffs, N.J.: Prentice-Hall, 1966. Watkins, B.G. Gero comes of age as an academic field. Chronicle of Higher Education (newspaper), March 21, 1977, Weiss, li.B. and Spence, A.B. A Guide to the Health Pro fessions. Cambridge, Mass.1 Harvard University Print- ing Office, 1973. West's California Codes. San Francisco, Calif1, 19 69, 85. Wickendon, W.E. Quoted from The General Manager. London: British Institute of Management, 1950. Wilensky, H.L. The professionalization of everyone. American Journal of Sociology, 1964, 7^, 137-158. Woodruff, D.S. and Birren, J.E. Training for professionals in the field of aging: Needs, goals, models and means. A.N. Schwartz and I.N. Mensh (Eds.), Professional Ap proaches and Obligations to the Aged. Springfield, 111.: Charles C. Thomas, 1974, 245-300. 185 World Health Organization, Planning and organization of geriatric services, 1974. World Medical Association, Inc. Proceedings of the fourth conference on medical education. J. Bryant (Ed.), Educating Tomorrow* s Doctors, 1973. 186 APPENDIX A 187 APPENDIX A Information Collection Form (IGF) LDS STUDENTS, PROFESSIONALISM PROJECT 1. Name of Institution (1-3) 2. Name of department/discipline (4-5) 3. Types of degrees/certificates offered by department Certificates ; (6-20) Bachelors : (21-30) Masters ; (31-40) Academic doctorate (indicate specialty) Professional doctorate: 188 Do courses in the departmental curricula - as indicated in the course catalog description - contain content re lated to gerontology? (1) 1_____Yes 2_____No If YES, list course titles and check appropriate spaces (2-76, 77, 78, 79) (80=2) Required Overview Graduate Does the department offer a dual degree, minor or emphasis in gerontology at the graduate level. Check all categories which apply. (1-4) 1 None 2_____ Dual Degree 3_____Minor 4____ Emphasis Does the department require a field practicum, intern ship, or traineeship? (5) 1 Yes 2 No 189 7. What is the student population of the institution? (6-8) # of students 8. What is the total number of faculty members comprising the department? (9-10) __________ # of faculty members 9. What is the total number of faculty holding doctorates within the department? (11-12) __________ # of faculty members 10. On a scale from one to seven, using the information you have assimilated from reading the university cata log of your department, rate the extent to which this department incorporates the subject matter of geron tology into its department curriculum. (13) Does not incorporate Does incorporate gerontological subject gerontological subject matter matter 11. Is there anything else, not on this data collection form that you would like to address yourself to in terms of how this department relates to the field of gerontology? Please respond freely (14-79) (80=3) 190 12. Does department/school have a division of continuing education? (1) 1 Yes 2_____No If YES, please list the course titles containing aging (i.e., gerontological) content within the continuing education curriculum. (2-78) Course titles : (80=4) 191 APPENDIX B 192 APPENDIX B Introductory Letter November 15, 1976 To: Deans, Directors, and Department Chairmen of Professional Programs Dear The Leonard Davis School of the Andrus Gerontology Center has been funded a grant by the National Retired Teachers Association/American Association of Retired Persons to ex amine several disciplines and their relationships to geron tology and professionalism. Students from the Davis School are involved in the data collection and analysis under the guidance of Margaret Hartford, Ira Hirschfield, William Albert, and myself. This project will be helpful in increasing our knowledge of the gerontological offerings of the colleges and universi ties in California and the expectations of professional credentialing boards. The study will facilitate the future planning of the involved disciplines and the advancement of services, research, and education of problems of aging. As part of this study, a group of graduate students and faculty are conducting a survey of the content on aging in professional curricula. Within the next few weeks, an attempt will be made by one of these groups to interview you either in person or by telephone. The research group has had the opportunity to review your current bulletin, and other materials to determine the nature of your pro gram and evidence of content on aging. The interview will be for the purpose of filling in neces sary data. The researcher will want to make inquiry about faculty teaching gerontology content, the extent of con tent, and the number of students participating in the classes with aging content. Enclosed is a copy of the questionnaire for your perusal. 193 Page two of Introductory Letter We want you to know that the school has authorized this study and that we hope you can assist our students in pro ducing the necessary information. Thank you for your time and consideration. Sincerely James E. Birren, Ph.D. Executive Director Andrus Gerontology Center Margaret E. Hartford, Ph.D Director Leonard Davis School of Gerontology MEH/jel Enc. 194 Interview Data Collection Form (IDCF) 1. What is your name and complete title, inclusive of discipline? (1-2) _ 2. What is the number of students enrolled in your department/school? ____________ _# of students 3. If applicable, please list the course titles contain ing aging (i.e., gerontological) content within your departmental/school curricula, and please estimate what percentage of each course is devoted to aging content. (6-79, 80=5, 1-6) Course titles % If applicable, do the instructors teaching the above courses hold membership in the Gerontological Society (GS), or the Western Gerontological Society (WGS)? (7) 1 GS 2 WGS 3 Both 4 Don't Know 195 If your department requires a field practicum, traineeship, or internship - What is the total number of agencies/settings being utilized? (8-9) _____total # of agencies/settings being utilized About how many students are placed in such agencies/ settings? (10-12) ____ # of students placed in all agencies/ settings utilized About how many agency/settings, which provide students with the opportunity to work with or on behalf of older adults, are being utilized? (13-14) # of agencies which provide students with the opportunity to work with or on behalf of older adults About how many students are placed in these agencies/ settings? (15-17) # of students placed in agencies/settings which provide opportunity to work with or on behalf of older adults If applicable, would you please list the names of the agencies/settings being utilized which provide students with the opportunity to work with or on behalf of older adults (18, 19, 20-21) Names of agencies: 5. 8. How important would you rate courses with aging (i.e., gerontological content, in relation to your total departmental/ school curriculum? (22) 1___ Of no importance 2___ _Not very important 3___Somewhat important 4 Important 5___ Very important 6. How important would you rate aging (i.e., geron tological) issues, in comparison with all other issues your pro fession is concerned with? (23) 1 Of no importance 2 Not very important 3___Somewhat important 4 Important 5___Very important If applicable, about how many doctoral dissertations and master's theses related to aging (i.e., gerontol ogy) have been completed in your department/school since 1971? (24-25, 26-27) # of dissertations related to aging completed since 1971 _____# of master's theses related to aging completed since 1971 To which of the following journals does your depart mental/school library subscribe? Please check all that apply. (28-50) _____Aging Aging and Human Development American Geriatrics Society Current Literature on Aging Developments in Aging Educational Gerontology Experimental Aging Research ’ Geriatrics "Human Development Industrial Gerontology Journal of Gerontology Journal of Gerontological Nursing "The Gerontologist Any other aging related journals? list them If YES, please 197 Do you plan to implement aging related courses into your departmental/school curriculum within the next 2 years, or 3 to 5 years? (51) 1 Within next 2 years 2 Within next 3 to 5 yrs If you do not plan to implement aging related course into your school/departmental curriculum, is it be cause of - (Please check all that apply). (55-57) 1__Lack of money 4___Lack of faculty interest 2__Lack of qualified 5___Lack of relevance for faculty to teach your discipline courses 6___Other reasons, please 3 Lack of student interest If you do plan to implement aging related courses in to your school/departmental curriculum within the next 1 to 5 years, in what topical areas of your dis cipline would such courses be implemented? Please list such areas. (57-79, 80+6, 1-40) Topical areas where aging related courses would be implemented: 10. If applicable, what percentage of your faculty, who teach aging related courses, have specific gerontol ogy training? (41) 1_____5-15% 2_15-25% 3 __25-35% 4___35-50% 5 50-75% 6 75+% 198 11. If applicable, do you feel that faculty who teach your aging related courses should have specific gerontological training? (42) 1___Yes 2 No 12. Do you feel that the content (i.e., subject matter) of gerontology has important implications for the future of your discipline? (43) 1___It has very important implications 2__It has important implications 3__Its implications are slightly important 4__The implications of gerontology have no importance for my discipline This interview was - (44, 80=7) 1__Face to face 2 Over the telephone THANK YOU FOR YOUR COOPERATION 199 APPENDIX C 200 APPENDIX C Data From Test-retest for Reliability, Question 5 How important would you rate courses with aging (i.e., gerontological) content, in relation to your departmental/ school curriculum? 1 Of no importance 2 Not very important 3__Somewhat important 4 Important 5 Very important Subjects Test Score Retest 1 5 5 2 4 3 3 5 5 4 5 5 5 4 4 6 4 3 7 5 5 8 5 5 9 5 5 10 3 4 11 4 4 12 5 5 13 5 5 14 5 5 15 5 5 Difference 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 Spearman rank-order coefficient of correlation = r = 0.9953 At the .01 level of significance, the critical value is 0.715. The null hypothesis is rejected and a positive correlation is demonstrated between the answers given on the test and the retest for question 5. 201 APPENDIX D 202 APPENDIX D D ata From T e s t - r e t e s t f o r R e l i a b i l i t y , Q u estio n 6 How important would you rate aging (i.e., gerontological) issues in comparison with all other issues your profession is concerned with? 1 Of no importance 2 Not very important 3__Somewhat important 4 Important 5_ Very important Subjects Test Score Retest Difference 1 5 5 0 2 4 4 0 3 4 4 0 4 5 5 0 5 4 3 1 6 4 3 1 7 5 5 0 8 5 5 0 9 5 5 0 10 3 5 2 11 4 4 0 12 5 5 0 13 5 5 0 14 5 5 0 15 5 5 0 Spearman rank-order coefficient of correlation = 6D n(n-1) r - 0.9893 At the .01 level of significance, the critical value is 0.715. The null hypothesis is rejected and a positive correlation is demonstrated between the answers on the test and retest for question 6. 203 APPENDIX E 204 APPENDIX E D ata Prom T e s t - r e t e s t f o r R e l i a b i l i t y r Q u estio n 12 Do you feel that the content (i.e., subject matter) of gerontology has important implications for the future of your discipline? 1__It has very important implications 2 It has important implications 3__Its implications are slightly important 4___The implications of gerontology have no importance for my discipline Subjects 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Rest Score 1 2 2 1 2 2 1 1 1 3 2 1 1 1 1 Retest 1 2 2 1 2 2 1 1 1 2 2 4 1 1 1 Difference 0 0 0 0 0 0 0 0 0 1 0 3 0 0 0 Spearman rank-order coefficient of correlation = 6 D r = 1 - n(n-1) r = 0.981 At the .01 level of significance, the critical value is 0.715. The null hypothesis is rejected and a positive correlation is demonstrated between the answers given on the test and the retest for question 12. 205 APPENDIX F 206 APPENDIX F Continuing Medical Education Courses from JAMA Supplement Courses listed in JAMA for California under the subject Geriatrics. Courses are sponsored or co-sponsored by AMA, "Advances in Gerontology" Offered at University of California, Los Angeles "Progress on Geriatrics" Offered at University of California, San Francisco "Aging" Offered at University of California, Davis "Geriatrics" Offered at University of California, San Francisco "34th Meeting of American Geriatrics Society" Offered at "meeting" in San Francisco 207 APPENDIX G 208 APPENDIX G Seven Topical Areas Covered in Project 1. Literature review on professionalism. 2. Literature review on the development of specific dis ciplines as it moves toward (or how it became) profes- ' sional status. Relate to criteria from #1. 3. An examination of the relationships between the dis ciplines and the field of gerontology. 4. An examination of where the field of gerontology is on the continuum of professional status. 5. A study of educational institutions and their offerings in gerontology in your discipline. 6. A study of credentialing boards and their processes and expectations as related to gerontology. 7. Conclusions, next steps and proposals for gerontology. 209 APPENDIX H 210 APPENDIX H Definition of Terms The following are operational definitions of terms which are being used within specific parameters for the purposes of this study; Generic Terms 1. Gerontology is a multidisciplinary study of the pro cesses and the phenomena of aging, including knowledge from the biological, psychological, sociological and the behavioral sciences. 2. A profession is an occupation which requires a liberal education and meets the following criteria: (1) a body of knowledge; (2) a university education; (3) a code of ethics; (4) professional association; (5) public sanc tion; (6) professional ideology; and, (7) self-regula tion. All criteria need not be fully developed, but the discipline must be progressing along the continuum of professionalism to be considered a profession. 3. References to the elderly, older adults and the aged at all times refer to those persons 60 years of age and older. Educational Terms 4. Course Offerings are those classes indicated in the course catalog or in response to the interview ques tionnaire which are available to students in the in stitutions studied, 5. Required courses are courses which need to be taken in order to meet the specifications of the program as listed in the course catalog. 6. A major is the principal field of academic specializa tion of a candidate for a degree in a college or uni versity (Morris, 1969) . 7. A minor is an area of Specialized study of a degree candidate in a college or university which requires fewer class hours or credits than a major (Morris, 1969), 211 8. An overview course is an introductory course with no specified prerequisites. 9. An area of emphasis is not specified in the catalog, but applies to 12 or more semester units in a subject which are taken by a student. 10. Graduate courses are those courses which are offered beyond the bachelor’s degree and are usually spe cialized or professional. 11. Field experiences are supervised work situations in which theoretical material learned in the classroom may be applied in an out-of-classroom setting. Uni versity credit is usually but not always earned for field experiences. For the purpose of this investi gation, practicum and internship are considered synonymous with field experience. 12. Dual degree is to mean that a student has earned, in addition to a degree in gerontology, another degree in a related area such as social work or public administration. 13. Doctoral degrees a. For purposes of quantifying data for this study, Ph.D.'s and D.Sci degrees are being classified as academic doctorates. b All other doctoral degrees are being classified as professional degrees. 14. Faculty inclkuded in this study are limited to full- time teaching employees of the educational institu tions as indicated in the university catalogs. 212

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Creator Davidson, Normal (author), Fisher, Bernice (author)

Core Title Educational status and trends in gerontology and medicine

School Leonard Davis School of Gerontology

Degree Master of Science

Degree Program Gerontology

Degree Conferral Date 1978-01

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

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