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THE COMMITTEE on Aging and Medical Education of the Institute of Medicine (IOM) at the National Academy of Sciences has released a report that may have an important impact on the future of medical education and residency training programs. One of the most important recommendations of the committee was to incorporate "a broad and relevant body of knowledge" on aging into the formal curricula of medical students and to require every physician (except pediatricians) to have an appropriate exposure to the principles of geriatric medicine.1While realizing that there are features specific to geriatric practice, the committee failed to provide a definition of such a practice and recommends against the establishment of a subspecialty of geriatrics. Paul Beeson, chairman of the IOM committee, said that geriatric medicine should be considered as an academic specialty, rather than a practical field, comparable with infectious diseases, which "is weakly represented as a

The number of persons retiring from work early or at the "normal" age of 65 to 69 years is rapidly increasing owing to current social forces. The impact of retirement, one of life's major events, on a person's health is of particular interest for a physician counseling a patient on the advisability of retirement. Despite the common belief, held by the medical community and lay persons alike, that retirement has a profound negative impact on the health of the retired person, available scientific data indicate that retirement per se may have a positive or no effect on health. New medical philosophy and approaches to retirement are suggested after review of the literature pertaining to the relationship between health, life satisfaction, and retirement.(JAMA 1981;245:1752-1754)

To the Editor.—In their article "The Autopsy: Past, Present, and Future," Anderson and coauthors (242:1056, 1979) address an important issue: the unjustifiable and perhaps dangerous decline in the rate of autopsy and its role as focal point in the research, patient care, and educational activity of the hospital. This is particularly true regarding care of the elderly and related research.Studies show that the autopsy rate decreases with the age of the deceased. With regard to cause of this decline, investigators have stated that "Americans are satisfied with 70 years as a normal life span, both physicians and laymen feel no urgency in finding more about the cause of death in persons beyond this age."1 Death is an expected event for those of advanced age; it is perceived as an essential natural course of aging.In a discussion on aging that incidentally follows a discussion on incurability and death,

To the Editor.—I read the article about the initiative of the Veterans Administration to develop a new system of health care (242:1285, 1979) based on the experience in nursing home care. This system demonstrates that if patients can be matched more appropriately to the resources they need, then the quality of care will improve1 and cost of care will be reduced. The new initiative presumably takes into consideration that the average age of the veteran population will greatly increase over the next decade—much more than for the general population. Thus, the new system should in fact represent an effective geriatric care provision system.Yet, the authors of the initiative seem to disregard the valuable experience of well-established geriatric health care in Europe2 and some pioneers of such care in the United States. Leslie Libow was the first in the United States who proposed and established a multilevel

To the Editor.—Dr Kohn's suggestion to include a diagnosis of senescence as a cause of death in advanced age deserves several comments. Natural death secondary to the self-destruction of the aging organism is not a new idea, what is new is only the "set time" of natural death at age 85 years.1 In the 17th century, old age was given as a cause in death certificates side by side with other causes such as fever, vomiting, convulsion, or fright. The time of death of old age was considered at slightly older than 60 years.2 It was a time when tuberculosis was considered as an irreversible age-related condition, which is in the same vein as arteriosclerosis according to Kohn. Yet, a notable decline in mortality was observed during the last decade in the age group of 85 years and older. The death rate for this age group fell

To the Editor.—I found the question about the relationship between steam baths and a sense of relaxation (243:370, 1980) interesting, but the answer was discouraging without any scientific reason. Abramson's answer is seemingly based more on his personal negative experience with steam baths, which he compares with a severe pain experience, and he likens the feeling of well-being to a feeling of relief of pain. Neither I nor many persons who are used to regular steam bathing whom I have observed will agree with this analogy. The sense of well-being and its effect on the health or physical capacity of the person who uses steam bathing should not be dismissed because of the apparent lack of appropriate, valid indexes by which to measure it, and it likewise should not go unrecommended, provided, as Abramson mentions, there is no obvious contraindication, such as thyrotoxicosis, generalized atherosclerosis, or cardiac diseases. It

To the Editor.—Robert Butler, MD (1981;245:1435), and Knight Steel, MD, and Antoinette Hays, RN (1981; 245:1410), stressed in their communications the institutional setting (hospital and nursing home) as the most important site placements for teaching geriatrics to medical students and senior residents. However, after 25 years of experience in practicing and teaching geriatrics, British scholars advised the shifting of stress from institutions toward practice with the community to "rescue" British geriatrics from stagnation and the inability to attract qualified health professionals.1 Will American geriatrics repeat the same errors, and will it require 25 years to correct them?Butler's concept of a "well-geriatric" clinic needs a better definition. Some elderly can not be defined as geriatric patients based on their age. Certainly the President of the United States did not require services from geriatricians when he was hospitalized at the George Washington University Medical Center (GWUMC). We define geriatric

To the Editor.—The article "Senility Reconsidered: Treatment Possibilities for Mental Impairment in the Elderly" (1980;244:259) is probably the most comprehensive overview of the state of the art and current thinking about dementia. The presented, easyto-use diagnostic check list will be of great help for physicians who do not regularly see patients requiring thorough examination for organic brain disease. However, a few points, in particular the classification of dementia, should be elaborated.Following suggestions of other authors, presenile dementia and senile dementia are classified as one clinicopathological entity—Alzheimer's disease. However, the current dispute on the value and use of the concept of organic brain syndrome (OBS), with all of its pros and cons, widely discussed in psychiatric literature, is not presented. Alcoholic dementia; posttraumatic, postanoxic, and postinfectious encephalopathies; and dementia supervening on schizophrenia; multiple sclerosis; or Parkinson's disease are treatable, although not always reversible, forms of dementia. The use of

To the Editor.—The short but brilliant piece of art "Gomers" (243:2333, 1980) deserves the highest degree of praise. The case study of a 3-year-old patient successfully demonstrates that even if there are hopeless medical cases, they are not necessarily helpless. The little boy, Allan, using his childish naiveté, has asked the staff for help that is not considered in current practice as medical. Reading books to the sick child is, indeed, a more appropriate task for the parents. However, what if they are not around?Hopeless cases are presumably seen less frequently nowadays because of the establishment of scientific medicine. Yet, they are encountered in pediatrics, more often in adult practice, and in day-to-day practice in geriatrics. With further progress in medical science, we hope to see fewer and fewer hopeless cases. However, let us not allow ourselves to be seduced by this achievement. We will continue to see

To the Editor.—Regarding the study "Large Medicaid Practices and Medicaid Mills" (1980;244:2433), I share the concern of the authors that the Medicare-Medicaid legislation has not fulfilled the proposed principle goal of the incorporation of the elderly and the poor into "mainstream" medicine. However, the only sign of the failure according to the authors is an employment of less-qualified physicians by the Medicaid programs.The analysis of the study brings to mind additional comments. Despite the fact that nonsubsidized market of patient care is better paying, the income of physicians involved in small and large Medicaid practice is higher (authors' Table 1). The income is generated by seeing a larger volume of patients with substitution of nursing time for physician time. This perpetuates second-class care as we have suggested in an earlier publication (1980;243:123). Other sources of relatively high income are probably derived from inpatient hospital visits, emergency room visits,

To the Editor.—I read the article regarding the medical intensive care services for the elderly. The authors stress the high mortality and possible irreversible damage to the quality of life associated with this type of treatment. Hospice care is proposed as perhaps a better alternative. This conclusion is rather surprising and is contradictory, in my opinion, to presented data.Most studied elderly survivors demanded care that was no more expensive than the younger group. The nonsurvivors required even less expensive care. Most elderly have returned to their homes and continued to live there a year after discharge. The quality of their lives, according to the authors, could not be measured by the study. Therefore, the authors' pessimistic outlook on the value of intensive care for the elderly seems to be based only on the expected observation, ie, higher mortality of the elderly in ICUs.This observation can be made

To the Editor.—In the article "Separating Cardiac From Pulmonary Dyspnea" by Raffin and Theodore (238:2066-2067, 1977), it is recommended to give diuretics as a method of differentiation between cardiac asthma and bronchial asthma. A rapid response to diuretics will support the diagnosis of cardiac asthma. We would like to call attention to the danger of this approach in the case of bronchial asthma. The current recommendation for the treatment of bronchial asthma universally includes the fluid administration to prevent dehydration and inspissation of bronchial secretions,1 which could produce a mechanical obstruction of the bronchial tree and worsen the patient's status. Administering diuretics not only will not be helpful for the patient but also could be to the patient's detriment if the diagnosis is bronchial asthma. If the pulmonary edema is secondary to an acute asthmatic attack,2 then the diuretics will not be helpful in differentiating between the

To the Editor.—The answer by Richard A. Carleton, MD, to the question regarding diagnostic evaluation and therapeutic approach toward paroxysmal atrial fibrillation in the elderly patient (1980;244:835) does not take into consideration the possibility of thyrotoxicosis as a cause of the patient's complaint. The absence of a clinical picture suggesting hyperthyroidism should not preclude the investigation of this possible cause. Masked thyrotoxicosis manifested by few or only one symptom is particularly common in this age group. One of the most common presentations of the masked form of thyrotoxicosis mimics cardiovascular disease associated with atrial fibrillation. These patients are relatively insensitive to the digitalis glycosides, which is the problem in the discussed case.Several studies of older thyrotoxic patients1-3 indicate that in these cases thyrotoxic symptoms are often less pronounced and at time are totally absent. Only a high level of clinical suspicion combined with adequate ancillary tests can

To the Editor.—"Hip Fractures in the Elderly" (1982;248:564) brings to light an important issue related to the medical reason for nursing home placement. It is largely an unexplored area, despite the fact that it is the physician who ultimately makes the application for institutionalization. The high percentage of patients with hip fractures who were institutionalized in this study, 41%, is surprising and alarming. At any particular time, there is only a small population of patients with hip fractures residing in nursing homes: 8.3% of the total nursing home population in 1977 had hip fractures.1 The above data suggest that the decision of institutionalization made after discharge from this particular hospital was not made appropriately. It is possible that the functional scale used in the study would be more appropriately used in the decision-making process for institutionalization v discharge to the community.The patients who were predicted to be