Ideally, the U.S. should have one certified geriatrician for every 300 citizens who are 85 or older. In 2013 this ratio is 1:870, and it is going to get a whole lot worse.
If the U.S. had a similar crisis looming for pediatricians you could be sure that the howls of protest would be loud and solutions quickly implemented. What is not widely known, even among a large segment of clinicians, is that geriatric medicine is as different from routine medicine as pediatrics is. Older patients often present symptoms differently, absorb drugs more slowly, respond differently to certain protocols and usually have multiple chronic conditions that overlap. Only a trained eye and mind can deal with these differences.
“The biggest difference is probably in the treating physician’s philosophy and approach to dealing with elderly patients,” said Dr. Jonathan M. Flacker, certified geriatrician and Medical Director of Emory’s Wesley Woods Outpatient Clinic. “It’s not beyond the internist’s ability to learn how to do it right, but doctors are notoriously hard to train.”
If you believe that your family doctor or specialist is ready to successfully handle your increasingly complex health care needs as you age, you are very likely wrong. The current notion, and it permeates the training of U.S. physicians, is that they will learn how to provide health care to the aged through contact with “old crocks” during their clinical teaching rounds in med school. This belief is more than naïve, it’s bogus. The great majority of the teaching physicians in U.S. medical schools don’t have any real expertise in geriatrics and, given the paltry number of trained geriatricians across the landscape, there certainly aren’t enough to teach or consult with all of the med-students, residents or practicing physicians who eventually have geriatric patients to treat.
In 2012 there were 7,356 certified geriatricians in the U.S. The country currently needs at least 20,000+ to effectively serve the 85+ population. The nation is getting older but the number of physicians trained to deal with that cohort is already too small and shrinking.
Even if we find a way to add a net of 200 or 300 geriatricians per year, the shortfall is going to widen because of the unprecedented growth in the aging population. In fact, it’s already too late for a solution that involves training enough certified geriatricians. The experts admit this and offer an alternative solution. This solution hinges on creating enough geriatric educators to insure that every new physician, of which there are over 16,000 per year, will have been sufficiently trained in geriatrics in medical school to know the differences between medical care for non-geriatrics and medicine for the oldest of us.
Currently there are about 1,300 geriatric educators and 400 geriatric medical researchers in the U.S. The magic number of needed geriatric educators and researchers was about 1,450 in 2009, according to the late Dr. Robert N. Butler of the International Longevity Center (ILC) in New York. So, on the positive side we likely have the necessary number of educators. However, the distribution of these teachers and researchers among the 145 U.S. medical colleges is dramatically uneven. Therefore, the opportunity for all medical students to get geriatric training is squelched.
In Great Britain, every medical school has a department of geriatrics, as do one half of Japanese medical schools. Of the 145 U.S. med schools, only eleven have geriatric departments. Eleven… that’s 7.6%! Plus, the geriatric curriculum at over three quarters of the U.S. med schools is an elective, not a required field of study. Currently, only 3% of med students at those 112 schools voluntarily choose to take the training. Fewer than half of U.S. med students report getting any training in geriatrics and of those, 25% report that their geriatric training was “inadequate”. In 2010, among all internal or family medicine residents, only 75 opted to enter a geriatric fellowship program and that is down from 112 in 2005. The production of geriatricians is going down while the number of aging Americans is going up. As statisticians observe, “When two lines on a graph cross, something important is occurring.”
There is ample evidence that the lack of professional geriatric training is already having a deleterious impact on America’s elderly. Many physicians, both family practitioners and specialists, lacking the information and training necessary to recognize the special needs of their oldest patients, simply dismiss their patient’s deepening confusion, unsteadiness, muscle weakness or odd gait as normal signs of aging. Without formal and reinforced training, these professionals will be unaware that such behaviors in the elderly could be signs of, in order of the above symptoms, depression, poorly maintained feet and toenails, low caloric intake or a urinary tract infection. These problems are readily treatable. But, as a result of misdiagnosis, the elderly patient continues to live a lowered quality of life. If we don’t press for solutions immediately the problem will metastasize to enormous proportions in the next 17 years.
Unfortunately, the current economics of medical care for the aged strongly augers against a significant increase in the number of certified geriatricians in the country. Geriatricians can expect to earn less than $200,000 per year once they have established a practice. Other specialists can expect something north of $400,000, once established and grinding out their procedure. If you were a med student, staring at a $150,000 or more in student loan debt, which career path would you prefer?
Then there is the problem of the way Medicare and private insurers have established the reimbursement caps for general practitioners, including geriatricians. In order to make a reasonable living, keep their malpractice insurance and staff paid, a family practitioner has to move through the daily load of patients at a brisk pace. “Old crocks” take too much time.
There are several suggested solutions for dealing with this dearth of geriatric professionals. First, student loan forgiveness programs for those who choose geriatrics, such as one in South Carolina, are a start. Even if widely adopted, however, such programs would not completely solve the national shortage.
Second, all U.S. medical schools should include a robust curriculum in geriatric medicine and make it a required course of study, not an elective. Every med student who takes the Step Two Board and Oral exams should show competency in understanding the basics of geriatric medicine regardless of their preferred specialty. Most of these future doctors will certainly have a large portion of their patients who age well beyond 65.
Third, we need to establish a payment policy for geriatric health care that doesn’t penalize physicians for spending the extra time required to effectively care for their elderly patients. In England, the reimbursement to general practitioners increases with the average age of their patient base. The English system recognizes the value of a doctor’s time and elders certainly require more time. The American health care payment system is just the opposite. Procedures it rewards, time and conversation it penalizes. Therefore, your routine face time with a doctor is likely 15 minutes or less per office visit. When you are 85 and dealing with multiple chronic conditions, a 15-minute visit with a physician, particularly one who has no significant geriatric health care training, is a recipe for quality of life problems not solutions.
Finally, the current cadre of 893,000+ practicing physicians in the U.S. must get re-schooled in the basics of geriatric medicine as part of their on-going professional development. As a future geriatric patient, I want to know that whatever ails me will not be misdiagnosed because my family doctor, cardiologist or gastroenterologist was not familiar with the basics of geriatric versus non-geriatric medicine. In fact, given the likely savings to Medicare of such required professional development, the government should make it mandatory.
To sum up the physician education problem, I quote Dr. Joseph G. Ouslander, Founding Director, Boca Institute for Quality Aging, Boca Raton, Florida: “I’ve worked with some truly outstanding physicians during my career but I’ve seen cases where they poison or misdiagnose their elderly patients due to ignorance of geriatric medicine.”
The U.S. needs the changes discussed, and soon, or it could be you or me who gets poisoned or misdiagnosed by some well-meaning and trusted physician.