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January 21, 2020

Why America faces a geriatrician shortage (and what to do about it)

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    The United States is facing a shortage of geriatricians as the number of older adults in the country outpaces the number of newly trained specialists in the field, Paula Span writes for the New York Times' "The New Old Age."

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    What geriatricians do

    Geriatricians are physicians who specialize in the care of older patients. These physicians help monitor and coordinate treatments for the various conditions and disabilities their patients have, help manage the medications they need, and assist them with decisions about what is best for their well-being and quality of life.

    Overall, a federal model estimates 30% of adults who are over the age of 65 need a geriatrician. Nancy Lundebjerg, CEO (?) of the American Geriatrics Society, said older adults who have at least three chronic conditions or are over age 85 are likely ideal candidates for a geriatrician.

    For example, when Linda Poskanzer, a therapist, was in her late 60s, she began experiencing shortness of breath when she walked short distances and had become disorganized and disengaged in her work. Poskanzer was taking antidepressants but they did not seem to help her symptoms.

    "I was not doing well emotionally," Poskanzer said. "Physically, I didn't have any stamina. I was sleeping a lot. I wasn't getting to work."

    Upon seeing her mother's distress, Poskanzer's daughter made an appointment for her mother with Manisha Parulekar, chief of geriatrics at Hackensack University Medical Center.

    Parulekar recommended Poskanzer take steps to improve her quality of life. Parulekar scheduled a sleep study for Poskanzer, which led to discovery that Poskanzer had sleep apnea. Parulekar also prescribed Poskanzer a new antidepressant and physical therapy in a pool to help Poskanzer regain her stamina, and eventually agreed that Poskanzer, who was overweight, was a good candidate for bariatric surgery. Today, Poskanzer is nearly 80 years old and continues to provide therapy 30 hours a week and feels "full of spirit."

    Poskanzer said she continues to see her geriatrician every four months, during which time they are able to sit and talk about how Poskanzer is doing. "I feel very well taken care of," Poskanzer said.

    Geriatrics is failing to attract new physicians

    But often older adults who could benefit from a geriatrician cannot readily find one because of a growing shortage, Span reports.

    According to Span, the federal model indicates the United States will need 33,200 geriatricians in 2025 to care for elderly patients. But currently there are about 7,000 U.S. geriatricians, of whom about 50% practice full time.

    As Span reports, the number of graduate fellowship programs training geriatricians, underwritten by Medicare, has not kept pace with demand as the nation's baby boomers age. For instance, a 2018 analysis found that, over a 16-year time period ending in the 2017-2018 academic year, the number of such graduate fellowship programs increased from 182 to just 210.

    Aldis Petriceks—the study's lead author, who is currently a medical student at Harvard—said, "It's basically stagnation." Petriceks said given the numbers, "We're not going to address this growing older population through some miraculous influx of specialized geriatricians."

    Why geriatrics isn't attracting new physicians 

    Part of the reason why the field has not grown significantly over the years is because the geriatrics doesn't attract enough residents, Spans explains. More than one third of 384 available slots for graduate fellowships in geriatrics—excluding geriatric psychiatry—went unfilled in 2019, according to data from the American Geriatrics Society.

    One reason why the field isn't attracting residents is because geriatricians are paid less than other specialists, Span reports. Total compensation for geriatricians in 2018 averaged $233,564, according to the Medical Group Management Association. In comparison, according to Span, anesthesiologists were paid twice as much, and cardiologists and radiologists had salaries topping $500,000.

    Mark Supiano, a geriatrician and researcher at VA Salt Lake City Health Care System, said, "These are smart people looking at economic reality." It is harder for physicians to pay back their medical school students loans when they are treating patients who are covered by Medicare, which reimburses doctors at lower rates than commercial insurers, Span writes.

    Another issue is the field does not "offer much glamour or the prospect of medical heroics," Span writes. However, a highly cited 2009 survey of 42 medical specialties found geriatricians reported greater career satisfaction than most other specialists. 

    What providers, pharmacists, and others can do to fill the care gaps for older patients

    As leaders in the field grapple with how to recruit more doctors, they're also looking at adopting other strategies to fill care gaps for older patients.

    For instance, Mary Tinetti, chief of geriatrics at the Yale School of Medicine, has called on geriatricians to serve as a "small, elite work force" who trains health systems and other institutions on how to care for older patients.

    "The most important thing geriatricians can do is make sure all their other colleagues"—including NPs, physician assistants, therapists, and pharmacists—understand older patients' needs, Lundebjerg said.

    According to Lundebjerg, this is already happening to an extent. For instance, the American College of Surgeons established a new verification program that sets standards hospitals should meet to improve outcomes for their older patients. Health systems also are adopting specialized EDs and other age-friendly approaches to meet the needs of older patients, as a growing number of internists and general surgeons, who are treating Medicare beneficiaries, have to know how to care for older patients, Span writes (Span, "The New Old Age," New York Times, 1/3).

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