Vol. XXVI, No. 4 Printed in U . S . A .
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1978 by the American Geriatrics Society
Interest in Geriatrics at a Universitv Department of Medicine J
ANDREW JOHN, MD and KNIGHT STEEL, MD, FACP*
Department of Medicine, University of Rochester School of Medicine, and Monroe Community Hospital, Rochester, N e w York
ABSTRACT: To estimate available resources for teaching geriatrics to medical students, a survey of the members of a university Department of Medicine was undertaken. Information was elicited in six areas: 1) personal data, 2) characteristics of each physician’s clinical practice, 3) potential interest in a Division of Geriatrics, 4) the comparative levels of aggressiveness indicated in the management of an old patient versus a young one, 5 ) the attitude of physicians toward the elderly, and 6) a rough measure of knowledge of the demographic characteristics of the elderly. The results suggest that a significant number of faculty members of a university medical school would indeed be interested in teaching and research in the field of geriatrics. In one of the first articles specifically advocating training in geriatrics, Zeman in 1949 wrote, “Geriatrics is an intrinsic part of internal medicine and as time goes on will most surely occupy more and more of the attention of both practitioners and specialists’’ (1). Indeed, since that time several authors have reported on medical school curricula in an attempt to determine the sufficiency of content of particular courses on aging or to devise new ones (2-4). Freeman, especially, has documented how medical education is lacking in this area and has pointed up the need for an increased number of educational opportunities in geriatrics in medical schools and residency training programs and as part of continuing educational programs (5, 6). In 1977 the Council of General Internal Medicine of The American Board of Internal Medicine mentioned geriatrics as one of the recommended elective areas of residency training programs in internal medicine (7). It has been suggested that the attitudes of physicians toward the elderly are at least partially responsible for the lack of interest in this subject. The attitude within medicine schools mirrors that generally found among the public at large (8). Most surveys have noted that old persons are held in low regard by our society. They -~ ~~~~
~
~~
~
~~~~
are usually stereotyped as feeble, demented, weak, useless, depressed, sloppy, irritating, opinionated and not infrequently living in a dirty nursing home. This lay attitude may well develop from an early age, as studies of children reveal that negative attitudes are formed early and are continually being intensified (9). Also, several studies have’ noted that older persons themselves have low opinions of their own age group, and at least one study has noted that they prefer to associate with people of the next younger generation rather than with persons of their own age (10). Even among professional workers there is a reluctance to work with the aged. Thus, in one study, psychology doctoral students rated the aged person as least desirable to be involved with because they were struck with a sense of “pessimism and hopelessness regarding the likelihood of effecting change in the behaviour of the older person” (11). Wolk and Wolk noted that among professional workers the attitudes of nurses are more positive than the attitudes of most others. It was conjectured that this may be partly due to their great personal contact and greater involvement with the physical needs of the elderly (12). Campbell (13), reporting on the results of a questionnaire to nurses in nursing homes, revealed that registered nurses were less willing to accept stereotyped administered statements about the elderly than were other personnel. Licensed practical nurses and nurse’s aides were
-
* Now at Boston University Medical Center. Address for correspondence: R Knight Steel, MD, Boston University Medical Center, 75 East Newton Street, Boston, MA 02118.
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A. JOHN AND R. K. STEEL
more willing to work with the older persons than were registered nurses. However, even nurses and aides were not exceptionally eager to work with the elderly; Campbell noted that a choice of shift and an increase in salary did not increase the willingness to work with an older aged group. Heller and Walsh (1976) postulated that a large program of lectures, visits to nursing homes and private homes and role playing with an accent on normal aging might lead to an increase in positive attitudes (14). A study by Spence et a1 assessing medical student attitudes toward the elderly revealed more negative attitudes among the senior students than among the freshmen (15). They noted a “failure of three years of medical education to mitigate factors injurious to a major and growing segment of the population - aged patients.” Gale and Livesley quoted a British medical student, “We come to clinical medicine with humanity and after three years they have educated it nut of us” (16). Cichetti reported on the effects of an 18-hour lecture course emphasizing the social and medical aspects of aging, followed by student interviews of the healthy elderly. They noted a minimal change in attitude of the first-year students following this course; indeed, willingness to consider geriatrics as a future speciality was less after the course than before (17). Thus a simple lecture series does not appear to effect a major change in attitude toward geriatrics. However, surveys of students in the health professions have shown that education in geriatrics from an enthusiastic faculty may result in a decrease in the negative attitudes of health care professionals toward the elderly and an increase in willingness to work with this population (13, 14). DESIGN OF THE STUDY A new approach to the training of medical students and perhaps other health care professionals seems indicated, to overcome these problems. In order to develop such a program an analysis of available resources is necessary. For most institutions there is no definable geriatric unit, and under any circumstances geriatrics spans many specialities and subspecialities, thus requiring input from a wide variety of persons. Hence, to develop a first-class geriatric program, many resources would be required from the more traditionally organized schools, departments and units. Since internal medicine is the mainstream of clinical teaching, it was to this department
150
that it seemed best to devote our attention initially. Therefore the present study was performed at the University of Rochester as part of a fourthyear medical school elective, to assess the attitudes and behavior patterns of members of the Department of Medicine and their interest in participating in a geriatric program. It should be specifically noted that the survey was made without a series of specified null hypotheses. A questionnaire (see Appendix) was designed to elicit information in six areas: 1) personal data; 2) characteristics of each physician’s clinical practice of medicine with regard to elderly patients; 3) potential interest on the part of the faculty member in a division of geriatrics; 4) two case presentations, one of an older person and one of a younger person, both with acute lifethreatening disease; a response as to the level of aggressiveness of management was required; 5) the attitude of the physicians, by means of a standard attitude questionnaire developed by Kogan in 1961 (18); and 6) a rough measure of knowledge by means of a five-question test of demographic aspects about older persons in America. These questionnaires were distributed to all full-time and clinical faculty of the Departments of Medicine and Neurology as identified by the university directory. The responses were to be anonymous. Included were some members of the Departments of Family Medicine and Dermatology who had double appointments with the Department of Medicine, as well as a few persons with a primary appointment in one of the preclinical sciences and also a clinical appointment. RESULTS OF SURVEY Of the 380 questionnaires distributed, 186 were returned, resulting in a 49 percent response rate. Of the full-time faculty 52 percent responded, and of the clinical faculty 46 percent responded. The age and academic position of those responding are shown in Tables 1 and 2. With respect to the personal data, it is of interest that 41 (40 percent) of the full-time faculty and 24 (29 percent) of the clinical faculty had had a grandparent or older person living in the home as a child. This is in rather striking contrast to the data on the present time period when only two members of the full-time faculty and two members of the clinical faculty had someone older than or equal to 65 years of age living at home. Nonetheless, in response to Question 14a, (7s (are) there one or more persons
INTEREST IN GERIATRICS AMONG UNIVERSITY FACULTY
April 1978
equal to or greater than 65 not living with you for whom you take significant social/financial responsibility?” -21 (20 percent) of the full-time faculty and 24 (29 percent) of the clinical faculty answered in the affirmative. This suggests that although the elderly may not be living in the same home as their children, they are cared for by their families to a significant extent. No data were collected to determine to what extent this same state of affairs pertained when the present faculty were children. Within the catchment area covered by this group of physicians, the elderly represent about 11 percent of the total population. This is of interest in that, of those who care for a population of patients (a few members of the Department of Medicine had no clinical practice and were therefore excluded), the question was asked as to what percentage of that population they believed to be 65 years of age or older. The answers do not reflect a survey by each physician of his or her population of patients. Thus, results as shown in Table 3 represent only the impressions of the physicians. What really is striking is that the elderly seem, at least to the physicians responding, to comprise a very sizable percentage of his or her patients. The clinical faculty members are more likely to make house calls on patients aged 65 or older TABLE 1 Ages of Full-Time and Clinical Faculty Members Full-Time
Clinical _-
% of Total
Age Group (yrs.)
Number
Responding
Number
of Total Responding
35 33 27 7 1 103
34 32 26 7 1 100
9 32 25 16 1 83
11 39 30 19 1 100
25-34 35-44 45-54 55-64 265
Totals
%
TABLE 2 Academic Ranks of Full-Time and Clinical Faculty Members Full-Time
Clinical
of To% of Total Retal ReNumber sDondine Number sDondina %
Academic Rank Instructor Assistant Professor Associate Professor Professor Totals
22 32
22 31
38 27
48 34
24
23
13
16
25 103
24 -
1 -
2 -
~~~~~
100
79
100
TABLE 3 Populations of Patients Aged 65 or Older A s Estimated by Full-Time and Clinical Faculties Full-Time Faculty
Clinical Faculty
~-_____ of Patients Aged 65 or Older
% of To-
%
110 10-33 34-67 68-90 >90
Number 7 37 37 3 0
tal Responding 8 44 44 4 0
Number
of Total Responding
4 26 46 4
5 33 58 5
0
0
%
(70 percent of the clinical faculty vs 19 percent of the full-time faculty). Furthermore, of the fulltime faculty none who made house calls had made in excess of 15 within the previous year. This is in contrast to the record of 31 members (54 percent of those who made house calls) of the clinical faculty, who exceeded that number of calls. Nonetheless, both full-time and clinical faculty, approximately 35 percent of each, did make regular telephone calls to check up on some of their patients even when no regular appointments were scheduled. Also, older physicians were more likely to make house calls (p I0.001). The responses to the question, “If there were to be a Division of Geriatric Medicine, which of the following ways might you wish to be involved (circle all appropriate answers)?” are shown in Table 4. In all, 29 full-time and 24 clinical faculty members circled at least one item which might be considered a major commitment, not including “consultant on clinical service.” In searching for possible correlations between an expressed interest in a Division of Geriatrics and a sizable number of personal and clinical characteristics it should be noted that there was no significant correlation between those who were interested in this Division and those who made house calls, or those who had had a grandparent living with them. The case reports on the two patients, one young and one old, were analyzed only with respect to the degree of aggressiveness which the responder indicated. It was noted that 67 percent of the fulltime faculty and 71 percent of the clinical faculty would care for those two critically ill persons with the same degree of agressiveness. But 29 percent of the full-time faculty and 28 percent of the clinical faculty would have been more aggressive with respect to the child and only 4 percent of the full-time faculty and 1 percent of the clinical faculty would have been more aggressive with respect to -the older person. This difference is quite striking. Although a
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A. JOHN AND R. K . STEEL TABLE 4 Number of Full-Time and Clinical Faculty Physicians Expressing Interest in-a Division of Geriatrics Type of Involvement
Full-Time
No likely involvement Full-time appointment Part-time appointment Consultant on clinical service Teaching geriatrics or gerontology to preclinical students Teaching geriatrics or gerontology to clinical students and housestaff Research in geriatrics or gerontology Other
30 0 8 57 2
Clinical 41 2 16 14 3
10
14
13
0
4
0
number of physicians may have been swayed to be especially vigorous with the child because of her “exceedingly overbearing” father who demanded “everything. . .be done,” it must not be forgotten that it is a rare child who does not have at least one very supportive parent under these circumstances. In contrast, many older patients do not have such family ties and, even with respect to those who do, many families do not press vigorously for “everything to be done” for a distant or even close relative, who is 85 and for whom death is often an expected event. Therefore, the two situations probably reasonably reflect two very real-life situations. The Department of Pediatrics was not surveyed, although this might have proved to be of interest for purposes of comparison. In analyzing the results of the attitude questionnaire by Kogan, it should be noted that there was little difference between the full-time and the clinical faculty when we used his scoring method. As would be expected, there was a less negative score (p < 0.05), i.e., a less negative attitude toward the elderly, compiled by those faculty members interested in a Division of Geriatrics. There was no difference between those who made phone calls and those who did not. However, those who made phone calls and house calls also had a less negative attitude toward the elderly, as judged by the results of this questionnaire. Five general questions abo,ut the demography of the elderly population in America were asked and the responses are shown in Table 5. Of note is the finding that the basic knowledge of a university faculty, both full-time and clinical, with respect to the demographic characteristics of the elderly is strikingly deficient. This is all the more obvious when one notes that for Questions 1 and 2, 16 percent of those surveyed, and for Questions 3, 4 and 5, 33 percent of those
152
surveyed, might have answered correctly just by guessing, and some of the possible answers (such as that more than half of those over 65 require hospitalization yearly) were obviously incorrect.
SUMMARY We wish to stress again that the survey was performed solely for informational purposes and any correlations are of potential interest only. Nevertheless, we believe that the following statements may be ventured: 1. A review of the literature suggests that needed attitudinal changes toward the elderly on the part of health care professionals will require more than a series of lectures. At the least it would seem to require an inspired and dedicated faculty - something which may now be increasingly available. This is in keeping with the general feeling expressed by the Conference on Geriatric Medicine at the National Institute on Aging on March 17-18, 1977 (19). 2. A significant number of faculty members of a university medical school are interested in teaching or research in the field of geriatrics, and a Division of Geriatrics would most likely be supported by and participated in by an adequate portion of the clinical and full-time faculties. 3. Knowledge concerning a few simple demographic facts about the elderly, among both clinical and full-time faculty members, was poor. It is unknown whether this lack of awareness was different from that exhibited by such clinicians about other age groups. It was, however, striking to discover just how meager the knowledge was in this instance. TABLE 5 Correct Answers to Demographic Questions by Full-Time and Clinical Faculty (see Appendix) Full-Time Question #1 #2 #3* #4 #5t
Number
%of Total
12 30 8 62 60
30 8 61
12
Clinical Number 10 34 8 43 50
%of Total 13 43 10 54 63
Total Number
%of Total
22 12 64 35 9 16 105 58 59 110 61 * Because of different projections in the percentage of the U. S. population older than or equal to 65 years of age in the year 2000, both 3) 9-12% and 4) 13-15% were accepted as “true.” P Because of differences in the percentages of those 65 years of age or older requiring hospitalization yearly reported from different sources, both 2) 11-20% and 3) 21-30% were accepted as “true.”
INTEREST IN GERIATRICS AMONG UNIVERSITY FACULTY
April 1978
APPENDIX I.
IDENTIFICATION:
After each question please circle the 1.
Age: 1) 25-34
2.
Position: 1)Instructor
ONE
2) 35-44
most appropriate answer. 3) 45-54
4) 55-65
2) Asst. Prof.
5) 2 6 5
3) Assoc. Prof.
4) Prof.
5) Other (please list) 3.
Faculty Appointment: 1) Full-time
2) Clinical 2) Surgery
4a Primary Appointment in Department of: 1) Medicine
3). Pediatrics
4) Other Clinical (please list)
5) Other Non-clinical (please list) b. Do you have a secondary appointment in: 1) Medicine 5.
2) Surgery
3) Biochemistry
Number of years on University of Rochester Medical School faculty: 1) 0-5
2) 6-10
3) 11-15
4) 16-20
6a. Research efforts make up of your time: 1) 0%
5) 21-25 2) 1-10%
b. If you conduct research, is your work primarily: 1) Clinical 3) Epidemiology
6) >25 3) 11-33%
4) 35-50%
5) >50%
2) Laboratory Science
5) Other (please state)
4) Health Delivery Systems
No
7a. Do you assume the medical care for a population of patients? Yes
b. If yes, what % of time do you devote to the practice of clinical medicine? 1) < l o
2) 10-33
3) 34-67
5) >90
4) 68-90
C. If yes, what % of patients you see that are 2 65? 1) (10
2) 10-33
3) 34-67
4) 68-90
d. If yes: i) Do you make house calls on your patients
5) >90 2 65?
ii) If yes, how many in the past 12 months? 1) 1-5
1) Yes
2) No
2) 6-15
3) 16-25
4) >25
e. i) Do you make regular telephone calls to check up on some of your patients 2 6 5 , even if they do not call you first? 1) Yes
2) No
ii) If yes, how many such calls do you make during a n average month: 1) 1-5
2) 6-15
3) 16-25
8a. Do you teach medical students? 1) Yes
4) >25 2) No
b. If yes, what % of time do you devote to teaching medical students: 1) < l o
2) 10-33
3) 34-67
4) 68-90
5) >90
C. If yes, the years you teach in are predominantly: 1) preclinical
2) clinical
3) both preclinical and clinical equally 9.
What % of your time is spent in house staff teaching? 1) 90
Please circle all the following organization of which you are a member: Gerontological Society American Geriatrics Society American Federation for Clinical Research Specialty society (list 1 or more)
153
A. JOHN AND R. K. STEEL 11.
Vol. X X V I
If there were to be a Division of Geriatric Medicine, which of the following ways might you wish t o be involved (circle all appropriate answers)? 1)no likely involvement 2) full-time appointment 3) part-time appointment 4) consultant on clinical 5) teaching geriatrics or gerontology t o perclinical students service 6) teaching geriatrics t o clinical 7) research in geriatrics or gerontology 8) other (please comment) students and housestaff
12.
Which of your parents are living? 1)mother or step-mother
13a. Do you have someone 2 65 living at home with you? 1) Yes b. If yes, is it: 1) mother or step-mother 4) father or step-father other person (state relationship)
2) father or step-father
3) both
4) none
2) No
2) father or step-father (spouses):
3) mother or step-mother
14a. Is (are) there one or more persons265 not living with you for whom you take significant social/financial responsibility? 1) Yes
2) No
b. If yes, for each person (A, B, C) are they living in a:
Person skilled nursing facility health related facility proprietary home own home other person’s home other (list) 15
B. C.
B B B B B B
C C C C C C
Person A Person B Person C
As a child did you have one or more grandparents or older persons living in your house? 1) Yes
11. A.
A A A A A A
Relationship
2) No
MEDICAL OPINIONS FEELINGS KNOWLEDGE
A. Medical Opinions At the end of each of the following sample cases check the choice that most closely agrees with your plan of treatment. An 85-year-old woman is found unconscious by her landlord. She lived alone in her apartment, had no family ties and did not participate in community activities. She was not known to have any active medical problems preceding this illness and was independent in activities of daily living. The patient is taken to the emergency department where she is found to be wasted, stuporous, and febrile with a fulminant bilateral pneumonia. Blood gas analyses reveal a Po, of 35 mm Hg and a Pco2 of 80. Your plan of treatment is: 1) Take her to the ICU, intubate, and treat aggressively 2) Treat with antibiotics and 0, without intubation 3) Treat only with 0, without intubation 4) Treat with antibiotics only 5) Make patient comfortable, expecting imminent death.
A 10-year-old girl with chronic myelogenous leukemia in remission for six months has, during that time, been going to school and leading a fairly normal life. She now is however, wasted and comes to the emergency department with a high fever and evidence of extensive bilateral consolidation of the lungs. A Gram stain shows many Gram-negative rods. The father is a n exceedingly overbearing man who demands “everything to be done” for his child. The child’s blood gases are Po, 35 mm Hg and Pco, 80. Your plan of treatment is:
1) Take her to the ICU, intubate, and treat aggressively 2) Treat with antibiotics and 0, without intubation 3) Treat only with 0, without intubation 4) Treat with antibiotics only 5) Make patient comfortable, expecting imminent death B. Feelings Place a check ( J ) in the appropriate space after each question that corresponds best to your reaction to the following statements about old people. “Old people” is defined as those persons 2 65.
154
April 1978
INTEREST IN GERIATRICS AMONG UNIVERSITY FACULTY Str.D. D. S1i.D. S1i.A.
= =
A.
= =
Str.A.
= =
strongly disagree disagree slightly disagree slightly agree agree strongly agree
A
D.
Str.D.
1. Most old people need no more love and reassurance than anyone else. 2. One of t h e most interesting and entertaining qualities of old people is their accounts of their past experiences. 3. Most old people tend to let their homes become shabby and unattractive. 4. It is evident t h a t most old people a r e very different from each other. 5 . Most old people would prefer to quit work as soon as pensions or their children can support them. 6. Most old people a r e irritable, grouchy and unpleasant. 7. Most old people should be more concerned with their personal appearance; they a r e too untidy. 8. Most old people a r e really no different from anyone else; they’re as easy to understand as young people. 9. Most old people are capable of new adjustments when the situation demands it. 10. It would probably be better if most old people lived in residential units with people of their own age. 11. Most old people a r e cheerful, agreeable, and good humored. 12. People grow wiser with t h e coming of old age. 13. If old people expect to be liked, their first step is to try to get rid of their irritating faults. 14. Most old people can generally be counted on to maintain a clean, attractive home. 15. Most old people make one feel ill at ease. 16. Old people should have more power in business and politics. 17. Most old people a r e very relaxing to be with. 18. I t would probably be better if most old people lived in residential units t h a t also housed younger people. 19. Most old people spend too much time prying into t h e affairs of others and giving unsought advice. 20. One seldom hears old people complaining about t h e behavior of t h e younger generation. 21. Most old people seem to be quite neat and clean in their personal appearance. 22. Most old people a r e set in their ways and unable to change. 23. It is foolish to claim that wisdom comes with old age. 24. Most old people tend to keep to themselves and give advice only when asked. 25. There a r e a few exceptions, but in general most old people a r e pretty much alike. 26. In order to maintain a nice residential neighborhood, it would be best if too many old people did not live in it. 27. Most old people make excessive demands for love and reassurance. 28. You can count on finding a nice residential neighborhood when there is a sizable number of old people living it it. 29. Old people have too much power in business and politics. 30. There is something different about old people; it’s hard to figure out what makes them tick. 31. Most old people would prefer to continue working just as long as they possibly can rather than be dependent on somebody. 32. Most old people bore others by their insistence on talking about the “good old days.” 33. When you think about it, old people have the same faults as anyone else. 34. Most old people a r e constantly complaining about the behavior of the younger generation. 35. The ethical principles on which medical decisions a r e made a r e different for old people.
C. Knowledge Please circle t h e answer which you feel is most nearly correct: 1. In 1974 which % of the US population was 2 6 5 years old? 1) 0-4
2) 5-8
3) 9-12
4) 13-15
5) 16-20
6 ) >20
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Vol. X X V I
A. JOHN AND R. K. STEEL 2. Of those persons 2 6 5 in the US, what % are in a long-term care institution?
I) 0-7
2) 8-15
3) 16-23
4) 24-31
5) 32-39
6) 2 4 0
3. In the year 2000 what % of the US population will be >65? 1) 0-4
2) 5-8
3) 9-12
4) 13-15
5) 16-20
6) >20
4. Do men or women 2 6 5 have the higher suicide rate? 1) Men 5. Of those 1) 50
Comments:
REFERENCES 1. Zeman FD: Teaching geriatrics, J Gerontol 4: 48, 1949. 2. Rodstein M (Chairman, Committee on Undergraduate and Continuing Medical Education of the Clinical Medicine Section of the Gerontological Society): A model curriculum for a n elective course in geriatrics, Gerontologist 13: 231, 1973. 3. Harris R Model for a graduate geriatric program a t a university medical school, Gerontologist 15: 304, 1975. 4. Lanoie-Blanchette PA: Curriculum Development in Geriatric Medicine. Schaumburg, Illinois, American Medical Student Association, 1976. 5. Freeman JT: A survey of geriatric education: catalogues of United States medical schools, J Am Geriatrics Soc 19: 746, 1971. 6. Freeman JT: Training in medical schools is the cornerstone of caring for the elderly, Geriatrics 29: 98, 1974. 7. Council on General Internal Medicine, American Board of Internal Medicine: Attitudes of the general internist and recommendation for training, Ann Int Med 86: 476, 1977. 8. Poe WD: Education in geriatrics, J Med Educ 50: 1002, 1075. 9. Hickey T and Kalish RA: Young people’s perceptions of adults, J Gerontol 23: 215, 1968. 10. Cameron P and Cromer A: Generational homophyly, J
156
Gerontol 29: 232, 1974. 11. Wilensky H and Barwack JE: Interests of doctoral students in clinical psychology work with older adults, J Gerontol 21: 410, 1966. 12. Wolk RL and Wolk RB: Professional workers’ atitudes toward the aged, J Am Geriatrics Soc 19: 624, 1971. 13. Campbell ME: Study of the attitudes of nursing personnel toward the geriatric patient, Nursing Research 20: 147, 1971. 14. Heller BR and Walsh FJ: Changing nursing students’ attitudes toward the aged, J Nursing Ed 15: 9, 1976. 15. Spence DL, Feigenbaum EM, Fitzgerald F et al: Medical student attitudes toward the geriatric patient, J Am Geriatrics Soc 16: 976, 1968. 16. Gale J and Livesley B: Attitudes towards geriatrics: a report of the King’s survey, Age & Ageing 3: 49, 1974. 17. Cicchetti DV, Fletcher CR, Lerner E et al: Effects of a social medicine course on the attitudes of medical students toward the elderly: a controlled study, J Gerontol 28: 370, 1973. 18. Kogan N: Attitudes toward old people: the development of a scale and a n examination of correlates, J Abnorm Soc Psycho1 62: 44, 1961. 19. Summary of the conference on geriatric medicine held a t National Institute on Aging, March 17-18, 1977.
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Copyright 0 1978 by the American Geriatrics Society
Interest in Geriatrics at a Universitv Department of Medicine J
ANDREW JOHN, MD and KNIGHT STEEL, MD, FACP*
Department of Medicine, University of Rochester School of Medicine, and Monroe Community Hospital, Rochester, N e w York
ABSTRACT: To estimate available resources for teaching geriatrics to medical students, a survey of the members of a university Department of Medicine was undertaken. Information was elicited in six areas: 1) personal data, 2) characteristics of each physician’s clinical practice, 3) potential interest in a Division of Geriatrics, 4) the comparative levels of aggressiveness indicated in the management of an old patient versus a young one, 5 ) the attitude of physicians toward the elderly, and 6) a rough measure of knowledge of the demographic characteristics of the elderly. The results suggest that a significant number of faculty members of a university medical school would indeed be interested in teaching and research in the field of geriatrics. In one of the first articles specifically advocating training in geriatrics, Zeman in 1949 wrote, “Geriatrics is an intrinsic part of internal medicine and as time goes on will most surely occupy more and more of the attention of both practitioners and specialists’’ (1). Indeed, since that time several authors have reported on medical school curricula in an attempt to determine the sufficiency of content of particular courses on aging or to devise new ones (2-4). Freeman, especially, has documented how medical education is lacking in this area and has pointed up the need for an increased number of educational opportunities in geriatrics in medical schools and residency training programs and as part of continuing educational programs (5, 6). In 1977 the Council of General Internal Medicine of The American Board of Internal Medicine mentioned geriatrics as one of the recommended elective areas of residency training programs in internal medicine (7). It has been suggested that the attitudes of physicians toward the elderly are at least partially responsible for the lack of interest in this subject. The attitude within medicine schools mirrors that generally found among the public at large (8). Most surveys have noted that old persons are held in low regard by our society. They -~ ~~~~
~
~~
~
~~~~
are usually stereotyped as feeble, demented, weak, useless, depressed, sloppy, irritating, opinionated and not infrequently living in a dirty nursing home. This lay attitude may well develop from an early age, as studies of children reveal that negative attitudes are formed early and are continually being intensified (9). Also, several studies have’ noted that older persons themselves have low opinions of their own age group, and at least one study has noted that they prefer to associate with people of the next younger generation rather than with persons of their own age (10). Even among professional workers there is a reluctance to work with the aged. Thus, in one study, psychology doctoral students rated the aged person as least desirable to be involved with because they were struck with a sense of “pessimism and hopelessness regarding the likelihood of effecting change in the behaviour of the older person” (11). Wolk and Wolk noted that among professional workers the attitudes of nurses are more positive than the attitudes of most others. It was conjectured that this may be partly due to their great personal contact and greater involvement with the physical needs of the elderly (12). Campbell (13), reporting on the results of a questionnaire to nurses in nursing homes, revealed that registered nurses were less willing to accept stereotyped administered statements about the elderly than were other personnel. Licensed practical nurses and nurse’s aides were
-
* Now at Boston University Medical Center. Address for correspondence: R Knight Steel, MD, Boston University Medical Center, 75 East Newton Street, Boston, MA 02118.
149
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A. JOHN AND R. K. STEEL
more willing to work with the older persons than were registered nurses. However, even nurses and aides were not exceptionally eager to work with the elderly; Campbell noted that a choice of shift and an increase in salary did not increase the willingness to work with an older aged group. Heller and Walsh (1976) postulated that a large program of lectures, visits to nursing homes and private homes and role playing with an accent on normal aging might lead to an increase in positive attitudes (14). A study by Spence et a1 assessing medical student attitudes toward the elderly revealed more negative attitudes among the senior students than among the freshmen (15). They noted a “failure of three years of medical education to mitigate factors injurious to a major and growing segment of the population - aged patients.” Gale and Livesley quoted a British medical student, “We come to clinical medicine with humanity and after three years they have educated it nut of us” (16). Cichetti reported on the effects of an 18-hour lecture course emphasizing the social and medical aspects of aging, followed by student interviews of the healthy elderly. They noted a minimal change in attitude of the first-year students following this course; indeed, willingness to consider geriatrics as a future speciality was less after the course than before (17). Thus a simple lecture series does not appear to effect a major change in attitude toward geriatrics. However, surveys of students in the health professions have shown that education in geriatrics from an enthusiastic faculty may result in a decrease in the negative attitudes of health care professionals toward the elderly and an increase in willingness to work with this population (13, 14). DESIGN OF THE STUDY A new approach to the training of medical students and perhaps other health care professionals seems indicated, to overcome these problems. In order to develop such a program an analysis of available resources is necessary. For most institutions there is no definable geriatric unit, and under any circumstances geriatrics spans many specialities and subspecialities, thus requiring input from a wide variety of persons. Hence, to develop a first-class geriatric program, many resources would be required from the more traditionally organized schools, departments and units. Since internal medicine is the mainstream of clinical teaching, it was to this department
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that it seemed best to devote our attention initially. Therefore the present study was performed at the University of Rochester as part of a fourthyear medical school elective, to assess the attitudes and behavior patterns of members of the Department of Medicine and their interest in participating in a geriatric program. It should be specifically noted that the survey was made without a series of specified null hypotheses. A questionnaire (see Appendix) was designed to elicit information in six areas: 1) personal data; 2) characteristics of each physician’s clinical practice of medicine with regard to elderly patients; 3) potential interest on the part of the faculty member in a division of geriatrics; 4) two case presentations, one of an older person and one of a younger person, both with acute lifethreatening disease; a response as to the level of aggressiveness of management was required; 5) the attitude of the physicians, by means of a standard attitude questionnaire developed by Kogan in 1961 (18); and 6) a rough measure of knowledge by means of a five-question test of demographic aspects about older persons in America. These questionnaires were distributed to all full-time and clinical faculty of the Departments of Medicine and Neurology as identified by the university directory. The responses were to be anonymous. Included were some members of the Departments of Family Medicine and Dermatology who had double appointments with the Department of Medicine, as well as a few persons with a primary appointment in one of the preclinical sciences and also a clinical appointment. RESULTS OF SURVEY Of the 380 questionnaires distributed, 186 were returned, resulting in a 49 percent response rate. Of the full-time faculty 52 percent responded, and of the clinical faculty 46 percent responded. The age and academic position of those responding are shown in Tables 1 and 2. With respect to the personal data, it is of interest that 41 (40 percent) of the full-time faculty and 24 (29 percent) of the clinical faculty had had a grandparent or older person living in the home as a child. This is in rather striking contrast to the data on the present time period when only two members of the full-time faculty and two members of the clinical faculty had someone older than or equal to 65 years of age living at home. Nonetheless, in response to Question 14a, (7s (are) there one or more persons
INTEREST IN GERIATRICS AMONG UNIVERSITY FACULTY
April 1978
equal to or greater than 65 not living with you for whom you take significant social/financial responsibility?” -21 (20 percent) of the full-time faculty and 24 (29 percent) of the clinical faculty answered in the affirmative. This suggests that although the elderly may not be living in the same home as their children, they are cared for by their families to a significant extent. No data were collected to determine to what extent this same state of affairs pertained when the present faculty were children. Within the catchment area covered by this group of physicians, the elderly represent about 11 percent of the total population. This is of interest in that, of those who care for a population of patients (a few members of the Department of Medicine had no clinical practice and were therefore excluded), the question was asked as to what percentage of that population they believed to be 65 years of age or older. The answers do not reflect a survey by each physician of his or her population of patients. Thus, results as shown in Table 3 represent only the impressions of the physicians. What really is striking is that the elderly seem, at least to the physicians responding, to comprise a very sizable percentage of his or her patients. The clinical faculty members are more likely to make house calls on patients aged 65 or older TABLE 1 Ages of Full-Time and Clinical Faculty Members Full-Time
Clinical _-
% of Total
Age Group (yrs.)
Number
Responding
Number
of Total Responding
35 33 27 7 1 103
34 32 26 7 1 100
9 32 25 16 1 83
11 39 30 19 1 100
25-34 35-44 45-54 55-64 265
Totals
%
TABLE 2 Academic Ranks of Full-Time and Clinical Faculty Members Full-Time
Clinical
of To% of Total Retal ReNumber sDondine Number sDondina %
Academic Rank Instructor Assistant Professor Associate Professor Professor Totals
22 32
22 31
38 27
48 34
24
23
13
16
25 103
24 -
1 -
2 -
~~~~~
100
79
100
TABLE 3 Populations of Patients Aged 65 or Older A s Estimated by Full-Time and Clinical Faculties Full-Time Faculty
Clinical Faculty
~-_____ of Patients Aged 65 or Older
% of To-
%
110 10-33 34-67 68-90 >90
Number 7 37 37 3 0
tal Responding 8 44 44 4 0
Number
of Total Responding
4 26 46 4
5 33 58 5
0
0
%
(70 percent of the clinical faculty vs 19 percent of the full-time faculty). Furthermore, of the fulltime faculty none who made house calls had made in excess of 15 within the previous year. This is in contrast to the record of 31 members (54 percent of those who made house calls) of the clinical faculty, who exceeded that number of calls. Nonetheless, both full-time and clinical faculty, approximately 35 percent of each, did make regular telephone calls to check up on some of their patients even when no regular appointments were scheduled. Also, older physicians were more likely to make house calls (p I0.001). The responses to the question, “If there were to be a Division of Geriatric Medicine, which of the following ways might you wish to be involved (circle all appropriate answers)?” are shown in Table 4. In all, 29 full-time and 24 clinical faculty members circled at least one item which might be considered a major commitment, not including “consultant on clinical service.” In searching for possible correlations between an expressed interest in a Division of Geriatrics and a sizable number of personal and clinical characteristics it should be noted that there was no significant correlation between those who were interested in this Division and those who made house calls, or those who had had a grandparent living with them. The case reports on the two patients, one young and one old, were analyzed only with respect to the degree of aggressiveness which the responder indicated. It was noted that 67 percent of the fulltime faculty and 71 percent of the clinical faculty would care for those two critically ill persons with the same degree of agressiveness. But 29 percent of the full-time faculty and 28 percent of the clinical faculty would have been more aggressive with respect to the child and only 4 percent of the full-time faculty and 1 percent of the clinical faculty would have been more aggressive with respect to -the older person. This difference is quite striking. Although a
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A. JOHN AND R. K . STEEL TABLE 4 Number of Full-Time and Clinical Faculty Physicians Expressing Interest in-a Division of Geriatrics Type of Involvement
Full-Time
No likely involvement Full-time appointment Part-time appointment Consultant on clinical service Teaching geriatrics or gerontology to preclinical students Teaching geriatrics or gerontology to clinical students and housestaff Research in geriatrics or gerontology Other
30 0 8 57 2
Clinical 41 2 16 14 3
10
14
13
0
4
0
number of physicians may have been swayed to be especially vigorous with the child because of her “exceedingly overbearing” father who demanded “everything. . .be done,” it must not be forgotten that it is a rare child who does not have at least one very supportive parent under these circumstances. In contrast, many older patients do not have such family ties and, even with respect to those who do, many families do not press vigorously for “everything to be done” for a distant or even close relative, who is 85 and for whom death is often an expected event. Therefore, the two situations probably reasonably reflect two very real-life situations. The Department of Pediatrics was not surveyed, although this might have proved to be of interest for purposes of comparison. In analyzing the results of the attitude questionnaire by Kogan, it should be noted that there was little difference between the full-time and the clinical faculty when we used his scoring method. As would be expected, there was a less negative score (p < 0.05), i.e., a less negative attitude toward the elderly, compiled by those faculty members interested in a Division of Geriatrics. There was no difference between those who made phone calls and those who did not. However, those who made phone calls and house calls also had a less negative attitude toward the elderly, as judged by the results of this questionnaire. Five general questions abo,ut the demography of the elderly population in America were asked and the responses are shown in Table 5. Of note is the finding that the basic knowledge of a university faculty, both full-time and clinical, with respect to the demographic characteristics of the elderly is strikingly deficient. This is all the more obvious when one notes that for Questions 1 and 2, 16 percent of those surveyed, and for Questions 3, 4 and 5, 33 percent of those
152
surveyed, might have answered correctly just by guessing, and some of the possible answers (such as that more than half of those over 65 require hospitalization yearly) were obviously incorrect.
SUMMARY We wish to stress again that the survey was performed solely for informational purposes and any correlations are of potential interest only. Nevertheless, we believe that the following statements may be ventured: 1. A review of the literature suggests that needed attitudinal changes toward the elderly on the part of health care professionals will require more than a series of lectures. At the least it would seem to require an inspired and dedicated faculty - something which may now be increasingly available. This is in keeping with the general feeling expressed by the Conference on Geriatric Medicine at the National Institute on Aging on March 17-18, 1977 (19). 2. A significant number of faculty members of a university medical school are interested in teaching or research in the field of geriatrics, and a Division of Geriatrics would most likely be supported by and participated in by an adequate portion of the clinical and full-time faculties. 3. Knowledge concerning a few simple demographic facts about the elderly, among both clinical and full-time faculty members, was poor. It is unknown whether this lack of awareness was different from that exhibited by such clinicians about other age groups. It was, however, striking to discover just how meager the knowledge was in this instance. TABLE 5 Correct Answers to Demographic Questions by Full-Time and Clinical Faculty (see Appendix) Full-Time Question #1 #2 #3* #4 #5t
Number
%of Total
12 30 8 62 60
30 8 61
12
Clinical Number 10 34 8 43 50
%of Total 13 43 10 54 63
Total Number
%of Total
22 12 64 35 9 16 105 58 59 110 61 * Because of different projections in the percentage of the U. S. population older than or equal to 65 years of age in the year 2000, both 3) 9-12% and 4) 13-15% were accepted as “true.” P Because of differences in the percentages of those 65 years of age or older requiring hospitalization yearly reported from different sources, both 2) 11-20% and 3) 21-30% were accepted as “true.”
INTEREST IN GERIATRICS AMONG UNIVERSITY FACULTY
April 1978
APPENDIX I.
IDENTIFICATION:
After each question please circle the 1.
Age: 1) 25-34
2.
Position: 1)Instructor
ONE
2) 35-44
most appropriate answer. 3) 45-54
4) 55-65
2) Asst. Prof.
5) 2 6 5
3) Assoc. Prof.
4) Prof.
5) Other (please list) 3.
Faculty Appointment: 1) Full-time
2) Clinical 2) Surgery
4a Primary Appointment in Department of: 1) Medicine
3). Pediatrics
4) Other Clinical (please list)
5) Other Non-clinical (please list) b. Do you have a secondary appointment in: 1) Medicine 5.
2) Surgery
3) Biochemistry
Number of years on University of Rochester Medical School faculty: 1) 0-5
2) 6-10
3) 11-15
4) 16-20
6a. Research efforts make up of your time: 1) 0%
5) 21-25 2) 1-10%
b. If you conduct research, is your work primarily: 1) Clinical 3) Epidemiology
6) >25 3) 11-33%
4) 35-50%
5) >50%
2) Laboratory Science
5) Other (please state)
4) Health Delivery Systems
No
7a. Do you assume the medical care for a population of patients? Yes
b. If yes, what % of time do you devote to the practice of clinical medicine? 1) < l o
2) 10-33
3) 34-67
5) >90
4) 68-90
C. If yes, what % of patients you see that are 2 65? 1) (10
2) 10-33
3) 34-67
4) 68-90
d. If yes: i) Do you make house calls on your patients
5) >90 2 65?
ii) If yes, how many in the past 12 months? 1) 1-5
1) Yes
2) No
2) 6-15
3) 16-25
4) >25
e. i) Do you make regular telephone calls to check up on some of your patients 2 6 5 , even if they do not call you first? 1) Yes
2) No
ii) If yes, how many such calls do you make during a n average month: 1) 1-5
2) 6-15
3) 16-25
8a. Do you teach medical students? 1) Yes
4) >25 2) No
b. If yes, what % of time do you devote to teaching medical students: 1) < l o
2) 10-33
3) 34-67
4) 68-90
5) >90
C. If yes, the years you teach in are predominantly: 1) preclinical
2) clinical
3) both preclinical and clinical equally 9.
What % of your time is spent in house staff teaching? 1) 90
Please circle all the following organization of which you are a member: Gerontological Society American Geriatrics Society American Federation for Clinical Research Specialty society (list 1 or more)
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A. JOHN AND R. K. STEEL 11.
Vol. X X V I
If there were to be a Division of Geriatric Medicine, which of the following ways might you wish t o be involved (circle all appropriate answers)? 1)no likely involvement 2) full-time appointment 3) part-time appointment 4) consultant on clinical 5) teaching geriatrics or gerontology t o perclinical students service 6) teaching geriatrics t o clinical 7) research in geriatrics or gerontology 8) other (please comment) students and housestaff
12.
Which of your parents are living? 1)mother or step-mother
13a. Do you have someone 2 65 living at home with you? 1) Yes b. If yes, is it: 1) mother or step-mother 4) father or step-father other person (state relationship)
2) father or step-father
3) both
4) none
2) No
2) father or step-father (spouses):
3) mother or step-mother
14a. Is (are) there one or more persons265 not living with you for whom you take significant social/financial responsibility? 1) Yes
2) No
b. If yes, for each person (A, B, C) are they living in a:
Person skilled nursing facility health related facility proprietary home own home other person’s home other (list) 15
B. C.
B B B B B B
C C C C C C
Person A Person B Person C
As a child did you have one or more grandparents or older persons living in your house? 1) Yes
11. A.
A A A A A A
Relationship
2) No
MEDICAL OPINIONS FEELINGS KNOWLEDGE
A. Medical Opinions At the end of each of the following sample cases check the choice that most closely agrees with your plan of treatment. An 85-year-old woman is found unconscious by her landlord. She lived alone in her apartment, had no family ties and did not participate in community activities. She was not known to have any active medical problems preceding this illness and was independent in activities of daily living. The patient is taken to the emergency department where she is found to be wasted, stuporous, and febrile with a fulminant bilateral pneumonia. Blood gas analyses reveal a Po, of 35 mm Hg and a Pco2 of 80. Your plan of treatment is: 1) Take her to the ICU, intubate, and treat aggressively 2) Treat with antibiotics and 0, without intubation 3) Treat only with 0, without intubation 4) Treat with antibiotics only 5) Make patient comfortable, expecting imminent death.
A 10-year-old girl with chronic myelogenous leukemia in remission for six months has, during that time, been going to school and leading a fairly normal life. She now is however, wasted and comes to the emergency department with a high fever and evidence of extensive bilateral consolidation of the lungs. A Gram stain shows many Gram-negative rods. The father is a n exceedingly overbearing man who demands “everything to be done” for his child. The child’s blood gases are Po, 35 mm Hg and Pco, 80. Your plan of treatment is:
1) Take her to the ICU, intubate, and treat aggressively 2) Treat with antibiotics and 0, without intubation 3) Treat only with 0, without intubation 4) Treat with antibiotics only 5) Make patient comfortable, expecting imminent death B. Feelings Place a check ( J ) in the appropriate space after each question that corresponds best to your reaction to the following statements about old people. “Old people” is defined as those persons 2 65.
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April 1978
INTEREST IN GERIATRICS AMONG UNIVERSITY FACULTY Str.D. D. S1i.D. S1i.A.
= =
A.
= =
Str.A.
= =
strongly disagree disagree slightly disagree slightly agree agree strongly agree
A
D.
Str.D.
1. Most old people need no more love and reassurance than anyone else. 2. One of t h e most interesting and entertaining qualities of old people is their accounts of their past experiences. 3. Most old people tend to let their homes become shabby and unattractive. 4. It is evident t h a t most old people a r e very different from each other. 5 . Most old people would prefer to quit work as soon as pensions or their children can support them. 6. Most old people a r e irritable, grouchy and unpleasant. 7. Most old people should be more concerned with their personal appearance; they a r e too untidy. 8. Most old people a r e really no different from anyone else; they’re as easy to understand as young people. 9. Most old people are capable of new adjustments when the situation demands it. 10. It would probably be better if most old people lived in residential units with people of their own age. 11. Most old people a r e cheerful, agreeable, and good humored. 12. People grow wiser with t h e coming of old age. 13. If old people expect to be liked, their first step is to try to get rid of their irritating faults. 14. Most old people can generally be counted on to maintain a clean, attractive home. 15. Most old people make one feel ill at ease. 16. Old people should have more power in business and politics. 17. Most old people a r e very relaxing to be with. 18. I t would probably be better if most old people lived in residential units t h a t also housed younger people. 19. Most old people spend too much time prying into t h e affairs of others and giving unsought advice. 20. One seldom hears old people complaining about t h e behavior of t h e younger generation. 21. Most old people seem to be quite neat and clean in their personal appearance. 22. Most old people a r e set in their ways and unable to change. 23. It is foolish to claim that wisdom comes with old age. 24. Most old people tend to keep to themselves and give advice only when asked. 25. There a r e a few exceptions, but in general most old people a r e pretty much alike. 26. In order to maintain a nice residential neighborhood, it would be best if too many old people did not live in it. 27. Most old people make excessive demands for love and reassurance. 28. You can count on finding a nice residential neighborhood when there is a sizable number of old people living it it. 29. Old people have too much power in business and politics. 30. There is something different about old people; it’s hard to figure out what makes them tick. 31. Most old people would prefer to continue working just as long as they possibly can rather than be dependent on somebody. 32. Most old people bore others by their insistence on talking about the “good old days.” 33. When you think about it, old people have the same faults as anyone else. 34. Most old people a r e constantly complaining about the behavior of the younger generation. 35. The ethical principles on which medical decisions a r e made a r e different for old people.
C. Knowledge Please circle t h e answer which you feel is most nearly correct: 1. In 1974 which % of the US population was 2 6 5 years old? 1) 0-4
2) 5-8
3) 9-12
4) 13-15
5) 16-20
6 ) >20
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Vol. X X V I
A. JOHN AND R. K. STEEL 2. Of those persons 2 6 5 in the US, what % are in a long-term care institution?
I) 0-7
2) 8-15
3) 16-23
4) 24-31
5) 32-39
6) 2 4 0
3. In the year 2000 what % of the US population will be >65? 1) 0-4
2) 5-8
3) 9-12
4) 13-15
5) 16-20
6) >20
4. Do men or women 2 6 5 have the higher suicide rate? 1) Men 5. Of those 1) 50
Comments:
REFERENCES 1. Zeman FD: Teaching geriatrics, J Gerontol 4: 48, 1949. 2. Rodstein M (Chairman, Committee on Undergraduate and Continuing Medical Education of the Clinical Medicine Section of the Gerontological Society): A model curriculum for a n elective course in geriatrics, Gerontologist 13: 231, 1973. 3. Harris R Model for a graduate geriatric program a t a university medical school, Gerontologist 15: 304, 1975. 4. Lanoie-Blanchette PA: Curriculum Development in Geriatric Medicine. Schaumburg, Illinois, American Medical Student Association, 1976. 5. Freeman JT: A survey of geriatric education: catalogues of United States medical schools, J Am Geriatrics Soc 19: 746, 1971. 6. Freeman JT: Training in medical schools is the cornerstone of caring for the elderly, Geriatrics 29: 98, 1974. 7. Council on General Internal Medicine, American Board of Internal Medicine: Attitudes of the general internist and recommendation for training, Ann Int Med 86: 476, 1977. 8. Poe WD: Education in geriatrics, J Med Educ 50: 1002, 1075. 9. Hickey T and Kalish RA: Young people’s perceptions of adults, J Gerontol 23: 215, 1968. 10. Cameron P and Cromer A: Generational homophyly, J
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Gerontol 29: 232, 1974. 11. Wilensky H and Barwack JE: Interests of doctoral students in clinical psychology work with older adults, J Gerontol 21: 410, 1966. 12. Wolk RL and Wolk RB: Professional workers’ atitudes toward the aged, J Am Geriatrics Soc 19: 624, 1971. 13. Campbell ME: Study of the attitudes of nursing personnel toward the geriatric patient, Nursing Research 20: 147, 1971. 14. Heller BR and Walsh FJ: Changing nursing students’ attitudes toward the aged, J Nursing Ed 15: 9, 1976. 15. Spence DL, Feigenbaum EM, Fitzgerald F et al: Medical student attitudes toward the geriatric patient, J Am Geriatrics Soc 16: 976, 1968. 16. Gale J and Livesley B: Attitudes towards geriatrics: a report of the King’s survey, Age & Ageing 3: 49, 1974. 17. Cicchetti DV, Fletcher CR, Lerner E et al: Effects of a social medicine course on the attitudes of medical students toward the elderly: a controlled study, J Gerontol 28: 370, 1973. 18. Kogan N: Attitudes toward old people: the development of a scale and a n examination of correlates, J Abnorm Soc Psycho1 62: 44, 1961. 19. Summary of the conference on geriatric medicine held a t National Institute on Aging, March 17-18, 1977.
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