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.

9 thoughts on “The Geriatrician Shortage

  1. What you allude to but don’t make explicit is that after doing an extra year-long fellowship in geriatrics at a fellow’s salary, geriatricians can look forward to making LESS than their colleagues who do not do a fellowship. According the the American Geriatrics Society, the average salary for a geriatrician is $161,888, while a family doctor who did 3 years of training and no fellowship can expect an average salary of 164,021 and a general internist who had exactly the same 3 year training as his peer who did a geriatrics fellowship, except he stopped at 3 years and didd not do an extra year, can expect an average salary of 177,059. You get what you pay for, America! (Don’t get me started on the 15K salary differential between a family physician and a general internist who both had 3 years of residency training).

  2. Geriatrics shortage

    Niko Karvounis writes on the geriatrician shortage. As baby boomers approach Medicare age, finding doctors to coordinate their care is becoming more challenging. This is due to the same reasons exacerbating the primary care shortage.
    Money, as always,

  3. Family Med Resident,
    Since when did you think that your income was going to be determined by the number of years of training? Otherwise, why do dermatologists and radiation medicine docs make so much more than those with comparable years in post medical school training? And what about the hospital CEO that probably makes more than all of them with only 2 years post undergraduate training? Years in school do not necesaarily equate to higher income.

  4. Salary incentives aside, I am certain our profession of medicine could focus less on official credentials, and work toward understanding the natural evolution during a career. Older texts mentioned how an internist’s practice over time included more cardiology, as one’s patients aged, and their needs changed with them. Likewise, the OB-Gyn could retire from the allnighters in the Labor & Delivery suite and limit practice to Gyncology (without OB) as the fertile and maternal became menopausal, then elderly. Now we have sub-sub-specialties, and new doctors come out of the process with a small box around their domain, and their responsibility.
    Certainly progress follows specialization and vice versa, but without a plan for career evolution, something goes missing.
    How many obituaries or personal life stories have you read or heard where someone notable hasn’t come from the structured system of higher education, whether business, science, medicine, etc? In recent but bygone times, seems good folks just were encouraged to develop interests and follow their inclinations. (The movie ‘The Aviator’ about Howard Hughes comes to mind – flat rivets – and no training in advanced aerodynamics.)
    Getting back to geriatrics, and medicine, is it necessary to be an official geriatric residency grad to understand and apply current understanding of the care of the elderly?
    Demographic trends in the US predict a demand for elder care that will overwhelm current resources. Attracting new MDs to geriatrics is fine, but doctors now in mid-career should also be considered candidates for this role. Most pulmonologists, surgeons, FPs, radiologists, etc. are familiar with the elderly and many quite receptive to tuning in to the particulars of geriatric care. Geriatrics could and probably MUST serve as an example of Post- postgraduate education and training, simply to meet that demographic demand.

  5. You’re right, Keith, income is not based on years of training. But it’s hard to convince people to do a year-long fellowship when their reward at the end is a $16,000 salary cut. As I said, you get what you pay for, and when the ranks of the elderly swell they’re going to find that there are no doctors to take care of them.

  6. Two things occur to me. 1) Is there a real shortage of geriatric doctors? It seems our society has done alright without them for the last 50 years or so, 2) As Maggie Mahar pointed out in her book Money-Driven Medicine, increasing supply of anything in the medical field merely increases costs. For some reason the laws of supply and demand don’t work well, or at all, in this industry.

  7. Family Med Resident, Keith, Rich and Mike–
    Thanks for your comments.
    Mike–
    On the one hand, there is a real need for geriatricians who are specially trained to care for the elderly.
    For example, many primary care physicians prescribe the same dosage of a medication for a 70-year-old that they would prescribe for a 40-year-old. But often, the 70-year-old’s body cannot take it and he winds up over-medicated.
    That said,as you suggest, simply adding more geriatricians might mean that many elderly people who now receive most of their care from a cardiologist would simply add a geriatrician to the group of 6 or 7 specialists they see, and if no one is co-ordinating the care (and communicating with the 7 specialists) we’re simply looking at more doctors’ bills, and care that is stil fragmented and un-cordinated.
    This is why, if we are going to pay geriatricians more, I think we should pay them more for providing proof that they are co-ordinating care, keeping an electronic medical record that includes information on what all of the specialists the patient is seeing are doing and prescribing, and taking appropraite steps to make sure that the patient isn’t being over-treated.
    For example, the geriatrician might make sure that the patient has a chance to share in decision-making. If his cardiologist is talking about by-pass surgery, the geriatrician might want to make sure the patient has–and understands–all of the information we have about risks as well as benefits, as well as recent reserach on serious memory loss among patients who have had by-pass.
    Rich– I definitely agree.
    As a doctors’ practice ages, it may make a lot of sense for him to think about post-post-graduate training in geriatrics.
    He knows these patients. They know him. And no doubt, over the years, he has already begun to adjust the way he treats them to the fact that they are aging . .
    But I would stress that geriatrics is a special body of knowledge, and so doctors should get additional training and certification.
    Keith- and Family Med Resident
    Keith- You are right, years of training is only one factor to be considered in deciding how much to pay doctors in various specialties.
    And I would add that while we should compensate a doctor for an eatra 2 years of training, at what point, over the course of a 35 or 40 year career, do you stop compensating for those extra two years?
    It seems to me that starting salaries shoudld be higher–because the doctor has more debt and is that much older. But should a specailist with two more years training be making 50% more than a family doctor after 20 or 25 years?
    The Medicare Payment Advisory Commission has made an interesting suggestion: perhaps we also should consider the Value of the Service to Medicare when deciding how to pay.
    Right now we consider the Cost of the Service to the Doctor in terms of years of training, stress, physical effort, mental effort, hours involved, etc.
    But how about the Value of the Service to Medicare–which really means the Value of the Service ot the Patient?
    If we think in those terms, we would pay significantly more for doctors who succeed to helping patients stop smoking. The chances are high that they have spared the patient a painful premature death from lung cancer or emphysema.
    And they have saved Medicare the cost of paying for lung cancer or emphysema treatment. . .
    By contrast, we might pay a lot less for PSA testing since, according to the National Cancer Institute, we have no evidence that early testing and treatment in any way alters the course of the disease . .

  8. What you allude to but don’t make explicit is that after doing an extra year-long fellowship in geriatrics at a fellow’s salary, geriatricians can look forward to making LESS than their colleagues who do not do a fellowship. According the the