A shortage of health care providers who specialize in geriatrics at a time when the number of people ages 65 and older is rapidly growing threatens to jeopardize the health of older Americans, according to experts in the field.
“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 health care system is ill equipped to provide the optimal care experience for patients with multiple chronic conditions or with functional limitations and disabilities.”
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.
Demand for Care on the Rise
Americans are living longer, with many needing to manage a host of chronic diseases, including hypertension, arthritis, heart disease, diabetes, osteoporosis and dementia. 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 routinely see people over 100 years old. It’s remarkably common,” says Dr. Wayne McCormick, AGS president and professor of medicine in the University of Washington’s division of gerontology and geriatric medicine at Harborview Medical Center in Seattle, Washington.
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 AGS 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,” McCormick says.
Economics is one factor contributing to the shortage: A career in geriatrics can be financially unattractive for doctors carrying large medical school debt. Geriatricians treat patients who are covered by Medicare and Medicaid, which traditionally have lower reimbursement rates than private health insurance companies.
“Geriatrics is the only sub-specialty where physicians can expect to ultimately earn less even though they did extra years of training,” Whitson says. “We need a restructuring of the reimbursement system so there isn’t a financial disincentive to go down this career path.”
Developing Geriatric Skill Sets
Lundebjerg says AGS will continue pushing for additional funding to educate future geriatricians. “But given the shortage of geriatricians, we’re also focused on how we can help the rest of the workforce be ready to care for older patients,” she says.
The Geriatrics-for-Specialists Initiative, for example, helps medical specialists develop the tools and knowledge they need to care for older adults. Last year, the initiative worked with surgeons to release guidelines on post-operative delirium. Emergency medicine physicians spearheaded an effort to define the elements of a geriatrics-friendly emergency department. The initiative has led to about 100 “champions” nationwide, with many conducting research on age-related aspects of their specialties.
Medical schools and residency programs also need to include geriatrics in the curriculum, in the same way that all students are exposed to pediatrics even if they don’t plan to become pediatricians. “It’s beginning to happen,” Whitson says.
Non-medical disciplines — such as nursing, physical therapy, occupational therapy, home health care and clinical social work, which are part of the care team for older adults — require additional training, as well. “The national need for more geriatrics education and training extends to all those disciplines, rather than just medical school and medical residency,” Whitson says.
Holistic Care
Unlike other physicians who might specialize in one organ system or disease, geriatricians must be adept at treating patients who sometimes are managing five to eight chronic conditions. “The focus is on understanding the patient’s goals and preferences, which could mean pulling back on some of the aggressive care for certain medical conditions,” Whitson says. “Otherwise you develop a care plan that is not feasible.”
Geriatricians also “pay special attention” to a person’s cognitive and functional abilities, including walking, eating, dressing and other activities of daily living, McCormick says. “Geriatricians take a holistic approach. We look at how we can help patients to be as functional as possible and exist in the community in the best way possible,” he says.
For example, older adults may have a hearing or visual deficit that impacts their physical health and quality of life. Something as simple as eye glasses or hearing aids can make a world of difference.
“We look for little things that can improve quality of life and surprisingly enough you can often make things quite a bit better,” McCormick says.
Geriatricians typically work across many settings as part of an interdisciplinary team that includes medical specialists, nurse practitioners, registered nurses, physical therapists, occupational therapists, social workers, mental health professionals and others.
Whitson, for example, is part of an interdisciplinary team that works with surgeons to improve perioperative outcomes for frail and at-risk older adults who must undergo surgery. McCormick sees patients at home, the hospital, nursing homes, assisted living centers, rehabilitation centers, community clinics and hospice.
“Following people as they move into different settings is one of the things I enjoy most about being a geriatrician,” he says. “I like sticking with people through thick and thin.”
Despite the challenges that lie ahead, McCormick is optimistic the next generation of physicians will be prepared to address the health care needs of older people.
“They know they are going to need a good tool box of geriatric care skills to be effective providers in the future,” he says.
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Doctor Shortage: Who Will Take Care of the Elderly? originally appeared on usnews.com
