With a growing elderly population of 12 million, it is projected that the U.S needs 17,000 geriatricians.
The “graying of America” has resulted in an increasing number of older adults with complex medical conditions needing comprehensive outpatient elder care. Americans are living longer, with many needing to manage a host of chronic diseases, including hypertension, arthritis, heart disease, diabetes, osteoporosis and dementia. This can also mean that more and more will need proper elder care assistance, including Assisted Living and Nursing Home Placement, Hospital and Nursing Home Crisis Intervention, Elder Care Monitoring, Elder Home Care Advisory, Long Term Care Planning, and more. One in 5 Americans will be eligible for Medicare by 2030, with people 65 and older expected to account for almost 20 percent of the nation’s population by then.
“We are not prepared as a nation. We are facing a crisis,” says Dr. Heather Whitson, associate professor of medicine at the Duke University School of Medicine in Durham, North Carolina. “Our current healthcare system is ill-equipped to provide the optimal care experience for patients with multiple chronic conditions or with functional limitations and disabilities.”
Despite the projected increase in the number of older Americans, few medical students are choosing geriatrics, putting the future supply of geriatricians in jeopardy. In 2010, only 75 residents in internal medicine or family medicine entered geriatric medicine fellowship programs, the American Geriatrics Society reported.
There are more than 7,500 certified geriatricians in the U.S. But the nation needs an estimated 17,000 geriatricians to care for about 12 million older Americans, according to AGS projections. AGS estimates that about 30 percent of the 65-plus patient population will need a geriatrician and that one geriatrician can care for 700 patients. Realistically that isn’t going to happen.
Nancy Lundebjerg, chief executive officer of the American Geriatrics Society, says the shortage “means that people who really need the services of a geriatrician won’t necessarily have access to that kind of expertise. That’s probably true right now across the country.” AGS is a nonprofit organization based in New York that focuses on improving the health and quality of life of older adults.
A geriatrician is a physician already certified in internal or family medicine who has completed additional training in the care of older adults. In addition to providing clinical care, geriatricians are skilled in navigating the labyrinth of psychological and social problems that often arise in the aging population.
“Part of the reason aging has such a negative connotation is this sense that you can’t cure older people’s problems,” said Dr. Kenneth Brummel-Smith, a professor of geriatrics at Florida State University College of Medicine in Tallahassee, Fla., a state with a particularly severe geriatrician shortage. “And yet a good geriatrician can bring someone back to functional status.”
Moreover, geriatrics fails to attract enough young doctors to the graduate fellowships it does offer. Leaving aside geriatric psychiatry, more than a third of 384 slots went unfilled last year, the American Geriatrics Society reports.
Geriatrics became a board-certified medical specialty only in 1988. An analysis published in 2018 showed that over 16 years, through academic year 2017-18, the number of graduate fellowship programs that train geriatricians, underwritten by Medicare, increased to 210 from 182. That represents virtually no growth when adjusted for the rising United States population.
People avoid the field for understandable reasons. Geriatrics is among the lowest-paying specialties in medicine. According to the Medical Group Management Association, in 2014, the median yearly salary of a geriatrician in private practice was $220,000, less than half a cardiologist’s income. Although geriatrics requires an extra year or two of training beyond that of a general internist, the salary for geriatricians is nearly $20,000 less.
Since the health care of older patients is covered mostly by Medicare, the federal insurance program’s low reimbursement rates make sustaining a geriatric practice difficult, many in the field say. Medicare disadvantages geriatricians at every turn, paying whatever is asked for medications and procedures, but a pittance for tough care-planning.
If one geriatrician can care for 700 patients with complicated medical needs, as a federal model estimates, then the nation will need 33,200 such doctors in 2025. It has about 7,000, only half of them practicing full time. (They’re sometimes confused with gerontologists, who study aging, and may work with older adults, but are not health care providers.)
The need for more expertly trained and passionate geriatric physicians is clear. Enhanced undergraduate, medical school, and residency exposure to geriatrics will increase interest in geriatric medicine. Strategies to promote the growth of geriatrics must include better reimbursement for clinicians with geriatrics training and certification. Young physicians who are often completing residency training with large school debt cannot choose a specialty field that is poorly reimbursed.
Perhaps advanced care nurses and PAs as critical members of the eldercare workforce can be the solution to the workforce concerns. Providing educational opportunities and certification in geriatric care for physician extenders such as advanced care nurses and physician assistants (PAs) as well as for others on the care team (e.g., pharmacists and social workers) is another example of an innovation hoping to address the health care needs of this population. Evidence in the literature reveals good outcomes and patient satisfaction for patients with complex medical needs being cared for by nurse practitioners (NPs) and PAs.
To encourage more primary care physicians to move into geriatrics, the has targeted specific research grants for them to “get their feet wet, and design a professional career plan that will create a niche for geriatrics,” says Susan Zieman, a medical officer in NIA’s geriatrics division.
While salaries and Medicare reimbursements are low and the public perception is that “aging isn’t very sexy in our society,” Jacobs says geriatricians are among the most satisfied clinicians. “They feel they are doing important work, and they are happy,” she says. “Those of us in the field love talking to older people and find them very enjoyable to take care of.
Educating non-geriatricians on key geriatric principles through continuing medical education (CME) courses can expand awareness of concepts in geriatric care more broadly and help guide when referrals to expert geriatricians are appropriate. A recent study found an inter-professional intervention by a geriatrician attending multidisciplinary discharge rounds twice weekly and advising when geriatrics consultation would be beneficial resulted in increased use of appropriate geriatric consultation and reduced time to consultation (Puelle et al., 2018). This is a creative mechanism to maximize the use of scarce geriatric resources.
An additional method to expand opportunities for patients to be evaluated by expert geriatricians is to provide telemedicine geriatric consultative services. Telemedicine offers many means to address the problems of geriatric care in creative ways. The use of electronic medicine, telecommunications, and information management has now found its way into the very fabric of health care. The use of telemedicine is a fait accompli in much of the world, and it continues to have an increasing role deeply embedded in our electronic practices coupled with social media.
The evidence for successful incorporation of telemedicine into practice is abundant and continues to accrue. This is a great opportunity for medical practice to evolve to new levels of engagement with patients and new levels of attainment in terms of quality elder care.
A long-term solution to the geriatrician recruitment crisis would include meaningful reform of the reimbursement system to guarantee financial incentives for those seeking a career in geriatrics. Although a permanent solution will involve changing Medicare reimbursement for geriatricians, other major health care reforms, or other health care system changes, an interim solution that appears feasible is to offer financial incentives that will partially offset the financial burdens for those seeking a career in geriatrics. Patients, caregivers, health care providers, and geriatric focused advocacy groups must advocate the restructuring of reimbursement to rectify the financial disadvantage of geriatricians, to improve care for our nation’s older adults.
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Photo Credits Ravi Patel and Caroline Hernand