In this second of a two-part interview, Dr. Suvi Neukam addresses ways to grow the geriatric profession, improve its care delivery system, and thus provide even better outcomes for older patients.
In this continued conversation, Suvi Neukam, D.O., assistant professor of internal medicine and geriatrics at Oregon Health & Science University in Portland, Oregon, explains why It is has been difficult to enlist more geriatricians and what can be done to increase their numbers. (The interview has been edited for clarity and length.)
Given the fact that the size of the older population is growing, why do we continue to have such a shortage of geriatricians?
This is such a good question, and as the associate program director of [OHSU’s] geriatric medicine fellowship, one that I have thought a lot about. It is actually deeply baffling to me that medical trainees don’t want to go into geriatrics. Geriatricians are typically ranked as having very high job satisfaction.
Suvi Neukam, D.O.
Anecdotally, I have not seen a high level of turnover amongst my geriatric colleagues (especially compared to peers I know who have “burnout of” hospital medicine or general primary care). More so, there is a need –– a real need! –– in our country for geriatricians. And who doesn’t love some good job satisfaction?
Yet there are not enough of us. So, why?
Geriatricians have, on average, lower pay than their generalist colleagues. In addition, the extra year (or two) of fellowship further delays their earning potential and ability to pay back their often large medical school debts.
Geriatricians also typically take care of the most complex patients. I rarely, if ever, address only one problem, and typically the number is closer to double digits. And every “problem” we manage is in the context of all of the other health conditions and social considerations that a patient carries.
Patient complexity also relates to the reality that caring for geriatric patients often requires caring for their support system as well: partners/spouses, adult children, caregivers, and even the retirement communities or care facilities they live in. We do not get sufficient training in medical school and residency for how to navigate things like caregiver support, transitions to higher level of care, spending down to Medicaid, Medicare benefits, transportation resources after driving retirement, and working with nursing facilities. These things are complicated!
But not only are they complicated, they are not glamorous. And this is actually a very big problem –– arguably one of the biggest. Geriatrics is not prestigious. Is this a reflection of a lack of intergenerational respect in our society? Or perhaps an anti-aging mindset? Or a belief that medicine is only about “fixing” and “curing”? I’m not sure. But it is common that when I say I am a geriatrician, people respond with “Thank you. I’m glad someone wants to do that.”
What can and should be done to increase geriatricians’ numbers?
Efforts are being made to improve exposure to geriatrics in medical school, both in classroom learning and clinical experiences. Additionally, providing more mentors in geriatrics early on in medical training can be very effective. I am also working on increasing interest even at younger ages, prior to medical school. Through the Portland Public School System, I have joined career panels and am hoping to mentor high schoolers with an interest in the health sciences.
We are also working on local recruitment of actively practicing primary care doctors or hospitalists. And every year or so, our fellowship attracts applicants who have been in practice for several years and then realized the benefit of this additional training. I think sharing these stories can be very powerful and help others consider going back for fellowship training regardless of how far into their careers they are.
But these are all grassroots efforts. At a national level, we need to re-brand. Our professional societies or, gosh, maybe even the federal government and Centers for Medicare & Medicaid Services need new marketing campaigns to show that we need geriatricians and that it is worth the extra training. But to that point, we need to actually make it worth the training. The government also must improve the financial incentives to go into geriatric medicine. Perhaps this means a change in reimbursement or new loan forgiveness programs. But on the whole, the country and medical profession need to help geriatrics change its image, improve the financial incentives, and build more prestige.
What should the medical profession and society in general be doing to improve health care for older adults?
Strong efforts are underway to improve how well the healthcare system itself is set up to provide elder care. The Age Friendly Health System model is an approach to care delivery that focuses on the “4Ms” of aging: mentation, medications, mobility, and what matters. The Age Friendly approach is being used in clinics, hospitals, and even skilled and long-term care. Applying this model helps ensure that even if there are not geriatricians directly providing care, the system is set up to practice with a geriatric mindset.
I would also suggest that there is room to improve how older adult care is funded. I would advocate for expanded Medicare coverage –– inclusion of in-home care, caregiver support, long-term and memory care, nonpharmacologic treatment options, geropsychology, and (goodness!) hearing aids.
Clearly there is a wish list here, but I am somewhat of a serial optimist, so I view the field of geriatrics as ripe with opportunity. It is an exciting time to care about how we, as a society, will age and work to ensure we age well.
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