The Geriatrician Shortage

In a 2006 New York Times article, Dr. Amit Shah, a physician at Johns Hopkins, recalled how other doctors looked down on him during his residency because of his chosen field. “The most memorable discouragement came during his residency, from a pulmonologist,” notes the Times. ‘When I passed him in the hall, [the pulmonologist] would shake his head and mutter, ‘waste of a mind,’” Shah said.

Dr. Shah’s sin? He had chosen to become a geriatrician.

You’d think that Shah would be applauded by his colleagues for choosing geriatrics, given that the U.S. is in the throes of a major geriatrician shortage: Since 2000, the number of geriatricians in the U.S. has fallen by a whopping 22 percent to a mere 7,100. According to a May Institutes of Medicine report, the outlook for the future isn’t much better: by 2030, there will be just 8,000 geriatricians, despite the fact that the U.S. will need about 36,000 to cover the workload as the number of Americans 65 years and older mushrooms.

Clearly, the U.S. needs more geriatricians. Yet the reason we don’t have more stems from the mindset of the pulmonolgist that scoffed at Dr. Shah: both our health care system and our medical schools devalue the kind of care that geriatricians provide.

Geriatricians are family or internal medicine physicians who have taken extra training in the area of aging and the special needs of seniors. In the words of Cheryl Phillips MD, a Sacramento geriatrician, “the particular focus of geriatrics training is the care of frail elders—where understanding how to assess and determine the individual’s ability to function is oftentimes every bit as important as understanding their diseases.” Thus geriatrics deals with coordinating long-term care for chronic conditions or helping seniors to manage their day-to-day life. Geriatricians tackle issues like confusion, dementia, incontinence, falls, depression, and the special effects that medications can have on the elderly. As the New York Times explains, “caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying non-medical solutions, like timed trips to the bathroom to improve bladder control.”

Unfortunately, our fee-for-service system, set by Medicare and mimicked by most private insurers, places a greater value on procedures than it does on  the type of care geriatricians provide. As Dr. Laura Mosqueda, a geriatrician from the University of California-Irvine, told MSNBC in 2006, “you’ll get reimbursed better if you remove a wart than if you take the time to talk about how somebody’s doing after their husband passed away.” Working with patients is seen as having less worth than working on patients.

So geriatricians, who do a residency in internal or family medicine and then a fellowship in geriatrics, find themselves near the bottom of the medical income ladder, averaging $150,000 a year.

As such, geriatricians are facing the same problem as primary care physicians: low compensation for important, exhausting work. Dr. David Reuben, head of UCLA’s geriatrics program, calls geriatrics “high touch” work. Speaking to Southern California Public Radio last month, Reuben said that the field is about “coordinating care. It's calling families. It's coordinating with other doctors. It's stuff that takes a lot of time, that is frequently off hours, at nights and on weekends, and also [cognitive] care that you're not compensated for.”

Ultimately the financial incentives to be a geriatrician are very low, and so it’s not a popular specialty for medical students. The Times also quoted Dr. Leo M. Cooney, a professor at Yale University School of Medicine, as saying that, “in a good year,” just “one of 45 medicine residents decides to be a geriatrician,” while the “the rest…choose ‘super specialties’ like cardiology or oncology.” Even those students who do choose geriatrics don’t stick around for long. According to the Association of Directors of Geriatric Academic Programs, the number of fellows enrolled in second or later year positions in geriatrics fellowships decreased by 55 percent since 2002. And as of October 2007, 64 percent of those enrolled in geriatrics fellowships in the U.S. were international medical school graduates.

This last data point is particularly interesting, because it speaks to how geriatrics is devalued not just by reimbursement systems, but also by U.S. medical education. Geriatrics is the third most popular specialty in Britain, due in part to a reimbursement system that scales up compensation with the age of patients—but also to the fact that every British medical school has a department of geriatrics. By contrast, according to the Times, “of 145 medical schools in the United States, only 9 have departments of geriatrics. Few schools require geriatric courses. And teaching hospitals graduate internists with as little as six hours of geriatric training.” In 1987, the Institute of Medicine recommended that at least nine faculty trained in geriatrics be part of each medical school in the country; in 2004, only 30 percent of medical schools in the nation had reached that target.

This is an important issue. Even if geriatrics were to become a better-paying field, it’s hard to see how students would readily discover it when they get so little exposure to it in their formative years.

This dearth of geriatrics programs stems in part from the same mindset that drives Medicare reimbursement: the idea that the only medicine of value is procedure-based. Maggie recently noted that there seems to be a cultural divide between proceduralists and cognitive physicians—the former are considered “doers” and represent some pinnacle of medical fortitude, while the latter are seen as “thinkers” or some variation of glorified therapists. It’s this skewed perspective that devalue geriatrics. Meanwhile, today 13 percent of Americans are 65 years old or over. By 2050, the proportion will be 20.7 percent. And as more seniors move into their seventies and eighties, they will need doctors who understand their special needs.

So what can be done? The most obvious solution is adjusting reimbursement rates so that geriatric care can get a little financial respect. The American Academy of Family Physicians thinks this can be done by relying, in part, on “a per-beneficiary, per-month stipend for care management, paid directly to the patients’ designated personal physician” (this capitated approach is meant to encourage efficiency, as opposed to volume, in care delivery). Jane Potter, a former president of the American Geriatrics Society, also notes that “Medicare reimbursement for cognitive evaluation and management has been losing ground compared with technological services. Reimbursement is also needed for telephone management, coordinating care in and across various settings, and communicating with family caregivers and with other health agencies.” Schools can also offer loan forgiveness to students who specialize in geriatrics in order to encourage broader recruitment.

But it’s not all about the money. The pulmonologist who scoffed at Dr. Shah probably wasn’t doing so purely for financial reasons; part of his condescension no doubt stemmed from the perception that geriatrics isn’t “real” medicine because it’s not super-technical and procedure-based. This is a dangerous bias. As much as we want people to become doctors because they love science or want to help people, we all know that prestige is one of medicine’s big draws. Why take care of crusty old people when you can be a brain surgeon who wows his guests at dinner parties?  Potter addresses this problem more tactfully when she notes that "strategies to increase recruitment to the field [of geriatrics] need to include not only better reimbursement but also getting the word out about how satisfying and enjoyable careers in geriatrics really are. Physicians must see that this work is valued not only by the patients but also by society."

A good way of indicating this value is by institutionalizing geriatrics within our medical schools—after all, it’s hard for doctors to think highly of geriatrics when they don’t see it well-represented in their educational institutions. To be fair, medical schools have clued into the coming crisis and are trying to beef up their geriatrics curricula. The Times points out that increasingly, schools are “teaching the core principles of their specialty to everyone, be they surgeons or discharge planners, because it is unrealistic to assume there will be enough geriatricians to go around.” This is a smart step, but it’s still a last resort—an option that schools exercise only because they don’t expect geriatricians to be around. That’s not the same as actively trying to expand the geriatrician workforce.

There are other measures that schools can undertake to mitigate the geriatrician shortage. Curricula can include mandatory rotations in geriatrics for students and residents; institutions should expand linkages with non-traditional medical sites like nursing homes or home visit programs, where much geriatric care takes place; and Medicare can reserve more money within its graduate research education fund for geriatric residencies (currently Medicare spends less than 0.5 percent of its dollars on training physicians to care for the elderly). Perhaps most importantly, medical schools need to make the conscious decision that geriatrics isn’t just a second thought, and they need to get serious about securing funding, professional connections, mentorship programs, and all the other components that make for a successful and permanent academic department in medical school.

It's critical that geriatrics receives these institutional boosts. Today, too many seniors are over-medicated.  Their bodies cannot handle the high doses the might be appropriate for a 40-year-old. Too many receive high-tech care that they don’t really want.

What many need is not more operations, but counseling, patience, and compassion. They need a doctor who listens, and who takes in an interest in their diet, in their fears and in their complaints. Rather than brushing off a 70-year-old who talks about muscle pain, a geriatrician would know that for those over 65, this is a common side effect of taking cholesterol-lowering drugs. Is heart disease really a major danger for this patient? Someone needs to talk to him about what we do and don’t know about the risk and benefits of the drug. Maybe he should stop taking it for a month. And then, someone needs to make a phone call to see if he’s feeling better.

The aging of America isn’t the end of health care as we know it; but it does provide us with a golden opportunity to rethink our doctrinaire faith in high-tech, expensive procedures and embrace a more nuanced approach to medicine.

Comments

[bruce quinn]

I think reimbursement is the major problem. Caring effectively for the frail elderly is a great challenge and with the mindset can be very rewarding. I have seen studies where average income was FAR lower than the 150K cited here. Slowly going from nursing home to nursing home (not paid to drive or sit in traffic) decimates the ability to bill Medicare. Plus follow-up calls and family conferences and other events outside the actual minutes of the face to face office visit are not separately reimbursed by Medicare for any doctor, but fall hardest on geriatricians. The UK example shows that by changing incentives a high proportion enter geriatrics. And as the author notes, the number of training slots is very minute in the US right now. It makes no sense from a national perspective.

[Cheryl E. Woodson, MD, FACP, AGSF]

The problem with Medicare reimbursement is that the program pays to do things TO people not FOR people. Medicare will pay for several head MRIs every year, but it will not pay geriatricians to make and explain the diagnosis of dementia, inform families another MRI will not change prognosis, tell them what they need to do to care for the patient, or advise about resources. Medicare was designed before the advent of chronic illness. The program believes people become ill and either recover completely, or die. Medicare supports technology designed to quickly figure out which camp the patient is in: recovery or not. Advances in medical practice have prolonged life, but not health; people live with disability from illnesses that would have been fatal in the past. There needs to be a paradigm shift from focus on CURE to CARE. This is what geriatricians do best.

We geriatricians need a procedure, but since the gerioscope has not been invented, we have to push Congress to approve reimbursement for the products of a comprehensive geriatrics assessment: the Level of Care prescription (LOCrx) and the care management conference.

I also think the way medical education is funded and the way academic advancement is evaluated both work against producing geriatricians. The lack of geriatricians is going to get much worse. There are only about 7000 of us now. The buzz at the national American Geriatrics Society meeting (May '08) was about the number of dedicated, gifted geriatricians who will not bother to pay the $1300. to recertify when the credential doesn't change reimbursement. I agree that geriatrics credentials actually decrease a physican's salary; I also agree the number is much less than $150K. I am going to recertify in Nov., because I'm stubborn, but I do not believe I will see a change in my professional lifetime. Young folks, hang in there if you can.

I share my ideas on the lack of geriatricians in the chapter, "Where are the Geriatricians" in my book TO SURVIVE CAREGIVING: A Daughter's Experience, A Doctor's Advice on Finding Hope, Help and Health. The book draws on my 25 years teaching and practicing geriatrics and 10 years as a caregiver for my mother who died of Alzheimer's Disease. This is a practical resource for family caregivers and the professionals who counsel them. Visit my website www.woodsonctr.com to order and to find out how I am trying to survive solo private practice after years in academics. You can also order the book on Amazon.com.

[Niko Karvounis]

Cheryl and Bruce, thanks for commenting, and also for pointing out that compensation for geriatricians is even LOWER than I had cited. Sad stuff.

Cheryl-when you say "the problem with Medicare reimbursement is that the program pays to do things TO people not FOR people," you hit the nail right on the head. The payment schedule is incredibly simplistic: "find condition, fix condition." But of course, medicine is about a lot more than that--often the coordination of care is the most important part of the whole process!

Bruce-Exactly. It just makes no sense. The system is starving itself form experts who do important work that is fully immersed in the "human" side of medicine--no less important than the high-tech & procedural aspects of the profession. It's frustrating to hear pundits and commentators talk about the onslaught of old Baby Boomers as though it's a catastrophe but say nothing about simple steps we can take to make sure that their care is humane and efficient...

[Wasif Hussain]

Rightly said about the comments of the pulmonologist. I think telling the truth to the doctors while they are learning and also the oldies who think of their specialty as super and regard others as low. Truth and actual facts about the things a geriatrician does and impact it has on the society and the patient. Payment is of course an issue but the mindset is something we need to fix as well.

Thanks

[Albert Henderson MD]

I am a physician who limits his practice to Nursing Home care. I think one of the problems with geriatrics practice is control of overhead expenses. Because I do not have to maintain an office practice, I probably bill about the same amount as other geriatricians, but I take home more. For one thing, I do my own Medicare billing. My overhead rate is 19%, compared with an average of 60% for office-based physicians. But my plan won't work for others. For one thing, 95% of the elderly are not in nursing homes. They need an office-based physician. And when a doctor is in the nursing home, he/she still has to pay payroll in the office. His/her time in the nursing home is cut short because "Mrs. Jones has been sitting for an hour on the exam table wearing only a paper gown. Where are you, Doctor?"
I favor a single-payer system of reimbursement, and capitation would help as well. That would help reduce the need for some of the doctor's payroll, especially if the mailing of bills to patients could be eliminated.

[Laura]

This is a well written article for everyone who works with the Senior population. Let's here it for Caregivers that can offer the patience, and compassionate care most needed for this growing population!

[Colin Powell (not THE Colin Powell)]

The article nicely covers the problems. The role of fee-for-service is usually a non-problem here in Canada but the recruitment problem is little different (in contrast to UK and Australasia: also largely non-FFS). Another factor, north of the border, has been the inordinate rise in student debt at the end of medical education over the last ten years: the pressure to earn money to reduce the debt is a major factor in seeking highly remunerative specialties. I think our only solution is outside our profession, i.e. the consumers, i.e. older adults. While they generally reject/fear the label 'geriatrics', they can be persuaded of our value as a group of doctors termed by my former colleague, Ken Rockwood as: those who care for people for whom 'usual care' has failed.

As one must remind every politician one meets: "older adults remember and they vote". It is only they who can challenge our educators with: why don't you educate health care professionals who know how to care for us? and our funders with: why don't you employ people who know how to care for us?

Best wishes, Colin Powell, M.B., F.R.C.P. Professor of Medicine, University of Calgary, Alberta, Canada

[Raydeen Springs]

I'd like to be referred to a geriatric physician here in the chicago area. I work for Total living Network in Aurora, Illinois. Our program and primary focus are for people over the age of 50 and up. It is a great show. I'd like to speak with someone who can refer me to the best one in chicago who maybe interested in speaking with me. 630-849-1053, or e-mail me at rsprings@tln.com, I thank you in advance.