The Geriatrician Shortage

Who will care for our seniors?

Share on Facebook

The Geriatrician Shortage - If things don’t change, says 84-year-old Beth Dale, she’ll have to kiss Sun City goodbye and...Share on Twitter

Feed

If things don’t change, says 84-year-old Beth Dale, she’ll have to kiss Sun City goodbye and move to Sacramento—just to be near Michael McCloud, M.D., one of the area’s few geriatricians.
“It’s a desperate situation,” she says.
Dale, who searched for years for an elder care specialist before finding UC Davis’ McCloud, would prefer not to move out of her Roseville home. But there are no geriatricians in her area, she says, and since neither she nor her 83-year-old husband can drive, moving closer to their doctor seems the only answer.
“I could give you literally hundreds of names of other seniors who are just as frustrated as I am,” says Dale. “People are always asking, ‘Where can we get a doctor who will pay attention to us and understand our needs?’”
The geriatrician shortage spreads beyond Sacramento and across the nation—and the timing couldn’t be worse. Just as the United States is going grayer than ever, with baby boomers heading for retirement and adults age 85 and older making up the fastest-growing segment of the population, the shortage of qualified elder care specialists is expected to grow more acute. According to the American Geriatrics Society, there are now approximately 7,600 certified geriatricians in the United States, and another 14,000 are needed to care for the elderly population adequately. By 2030, the nation will need 36,000 trained geriatricians to serve some 70 million adults age 65 and older—the largest Medicare generation in history.

A Definition of Geriatrician

Although the California Medical Board reports that 109 board-certified geriatricians are in Sacramento County, McCloud contends that the number of actual practicing geriatricians in the area is so small that “they’ve all sat around my dining room table together—and it’s not a very big table.” He explains that while many doctors may hold a “certificate of added qualifications” in geriatrics—which at one time only required physicians to pass a test and pay a $1,000 fee (the requirements have since been raised)—holding a certificate does not necessarily a practicing geriatrician make. “The operative word is practicing,” he says. By his own calculations, McCloud estimates there are fewer than 15 practicing geriatricians in the Sacramento area, including those who specialize in such areas as geriatric psychiatry.
Even the term geriatrician can pose some confusion, notes Cheryl Phillips, M.D., a geriatrician for Sutter Medical Group. “Geriatricians are those who are trained as either family or internal medicine physicians and who have taken extra training in the area of aging and the special needs of seniors,” she explains. “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.” Geriatricians are taught to recognize and treat the medical issues that are more likely to affect elders, such as confusion and dementia, urinary incontinence, falls and depression, and they are taught how medications can affect seniors differently than they do younger adults.
During their first meeting with McCloud, Beth Dale recalls, it became immediately clear that it was this kind of expertise she and her husband had been lacking. “One of the first things Dr. McCloud did was change our medications,” says Dale, who suffers from high blood pressure and age-related macular degeneration. “He said that some of the medications we were taking didn’t work well on elderly people. No doctor ever said anything to me about that before.”

Specialists vs. Generalists: The Great Debate

Statistically speaking, Dale is one of the lucky ones: Only one in 5,000 adults age 65 and older are under a geriatrician’s care, according to the American Geriatrics Society. So what are the remaining seniors to do? Can they get the kind of specialized care they need from the family doc?
The answer, of course, is that it depends on the doctor.
“We have a number of superb general internists and physicians in our community, and many of them do have the necessary skills to care for the frail elderly population,” says McCloud. “But many more believe they have those skills, and simply don’t.” McCloud says he routinely sees patients who are overmedicated and/or given inappropriate medication and aren’t receiving proper treatment for incontinence, memory disorders, and other age-related issues. “The physicians who are treating them are fine, compassionate physicians,” he says. “But like the vast majority of American physicians, most of them did not have a single hour of geriatric training in medical school.”
In most cases, doctors are simply learning as they go, notes John Howard, M.D., an internist with Mercy Medical Group who also does rounds at two skilled nursing facilities. “I’m not trained as a geriatrician per se, but I think you can get a good sense of how to provide quality care to the geriatrics population by simply doing it on a regular basis,” says Howard, who feels fortunate to have received some training in geriatrics while in residency at UC Davis. “But there does seem to be a general shortage of folks who are able to treat the elders.”
Michael GuntherMaher, M.D., a geriatrician and medical director of Elder Care Services for Kaiser Permanente, takes a slightly more optimistic view. “The vast majority of patients will get adequate care from general medical practitioners,” he says. “They have for decades, they will for decades.” The larger issue, he says, is that appropriate care for the more vulnerable elderly requires a team of health professionals, “and that mostly doesn’t happen. Where do you find social workers, psychiatrists, nurses, and pharmacists and integrate them with doctors? Providing more geriatricians alone will not likely solve this problem.” Critical shortages in nursing and other allied health professions are also complicating the issue.

Looking Ahead

Experts see little hope that the geriatrician shortage will be resolved any time soon, largely because so few doctors elect elder care as a specialty. Geriatrics fellowships produce only about 300 new practitioners a year nationwide—a problem partly blamed on Medicare.
 “Almost all of the reimbursement for geriatricians is defined by very specific payments under Medicare,” says Sutter’s Phillips. “Geriatrics is probably the only area in medicine where the physician can spend a year or two in additional training and end up making less than if they had never done so.”
Attracting more medical students into the specialty depends on making the specialty more attractive, adds McCloud. “I think we need to correct the societal perception that this is a nonglamorous or nonrewarding specialty.” Though the issue has been on McCloud’s front burner since arriving at UC Davis six years ago, he is chagrined to report that the school’s geriatrics fellowship training program is turning out only one or two geriatricians a year.
On the bright side, notes Phillips, basic geriatrics training is increasingly being added to medical school curriculums and residency programs, giving hope that physicians of the future will be better equipped to handle older patients than were their predecessors. “This is certainly far better than it was even five or 10 years ago,” she says. “But we still have a long way to go.”