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The Case for Geriatricians

Our views about this little understood and much underappreciated medical specialty must change in order to improve older adults’ health and quality of life.

 


Imagine that you have recently bought a vintage house, built in the early 1940s. A distinguished residence, filled with original architectural elements, the home was never renovated but kept in its original condition. And while the structure continues to retain its charm, it requires updating of its plumbing, electrical wiring, and roof. Of course, you want to make these renovations with care in order to maintain the character and integrity of the dwelling. So which contractor will you hire to do the work: someone who creates and assembles prefabricated units, a builder of commercial structures, or a specialist in historic homes?


Our bodies are our most essential “homes.” However, most of us know so little about the aging body that we assume an older one is just like a middle-aged one…only existing much longer. And for many elders who are in absolute tiptop condition, such a comparison may appear to be quite valid. But in general, an 80-year-old is unlikely to be as muscular, flexible, and free of chronic disease as a 40-year-old.


And just as we don’t assume that children are merely physically and cognitively small adults (hence the need for pediatricians), we should likewise have a different understanding of the special requirements of older bodies. More importantly, we must value older people enough to make sure that there are plenty of well-trained physicians, known as geriatricians, who can give them the best personalized care possible.


But the unfortunate reality is that the U.S. has a serious shortage of geriatricians. One assessment from March 2023 estimated that a total of 7,300 physicians --- fewer than 1% of all doctors --- were board certified in geriatrics. Compare this with a May 2022 U.S. Bureau of Labor Statistics report citing the employment of 33,430 pediatricians. Given the fact that in 2022 there were about 25% more children ages 0-17 than adults 65 and older, our current healthcare system should have more than 25,000 geriatricians to meet an equivalent need. In addition to this total, to keep pace with the growing older population, we’ll need at least 5,000 more by 2030.


In a keynote address in mid-March 2023, Age Wave CEO Ken Dychtwald bemoaned the dire state of U.S. geriatric education. “As of last week,” he said, “…we have 183 medical schools in America, only 11 full departments of geriatrics. Like, excuse me?”


Why the huge discrepancy between the supply and the demand? Geriatrician Michael Wasserman, chair of the Public Policy Committee of the California Association of Long Term Care Medicine, puts it succinctly: “There are a few primary reasons. First, lack of geriatric medicine training. Hence, few role models. Second, poor reimbursement. Geriatrics is the lowest paid specialty. Third, most experiences with older adults occur in hospitals, where patients are generally at their worst. There is a need for positive primary care experiences.”


Let’s consider these reasons one by one.


Lack of geriatric training. To what kind of specialized training is Wasserman referring? “Classic internal medicine is about diagnosis, treatment and cure,” he says. “Geriatric medicine is about function and quality of life.”


To be sure, simultaneously addressing function and quality of life can be a challenging endeavor, nevertheless it’s crucial to the treatment of older people. In a recent article published by the American Society on Aging, geriatric physician assistant Steven D. Johnson explained his work in the context of the relationship he has with his patients: “The care of the older adult tasks us with the responsibility to consider all the physical, medical, emotional and social relationships and offers us the opportunity to transcend the clinician/patient roles and find in that relationship our shared humanity.”


The American Geriatrics Society adds another dimension:


In getting to know older adults and caregivers in a more personal way, geriatrics healthcare professionals learn about the connections between overall well-being and what individuals ultimately want and need from their own care. Geriatrics bridges an important connection between clinical best practices and the recognition that an older person may have unique care preferences and expectations that warrant adjusting individual plans.


The dearth of geriatric training didn’t suddenly appear on the national scene. It’s always existed. However, with the continuous growth of the older population, it’s become more obvious and urgent. In 2019, a bill known as The Geriatrics Workforce Improvement Act, authorizing funds to train more geriatricians, was introduced in the U.S. Senate but was never voted on and died in 2020. Tragically, the government’s response to this state of urgency has been to do nothing.


Poor reimbursement. Because of its holistic approach to the diagnosis and treatment of older patients who often present with multiple complex chronic conditions, the very nature of geriatric care requires longer and more involved office visits than the average 15 to 20 minutes most internists spend with younger adult patients. One 2021 analysis puts the dilemma succinctly:


A major driver of persistently low physician recruitment into geriatrics is compensation. In addition to incremental debt associated with geriatric fellowship training, a board-certified geriatrician can expect to make US$20,000 yr less than an internist largely because all geriatric patients are on Medicare, which pays less than the commercial insurance common in a general internist’s practice.


Not exactly the kind of incentive that would attract healthcare practitioners to that specialty.


Lack of broader interaction with older patients. If medical school students encounter patients of advanced age primarily in hospital settings under highly stressful, acute circumstances, it’s unlikely that they will be inspired to specialize in geriatrics. They may assume that there is little upside in treating people who don’t have much longer to live and therefore it’s futile to try.


Ironically, such negative assumptions keep potential practitioners from discovering the psychological and professional rewards of working with older adults that make geriatrics one of the highest personally satisfying medical specialties. Or, as the American Geriatrics Society explains:


In several studies, geriatrics ranks among the most satisfying health professions. In fact, one study reported that geriatricians had the highest job satisfaction of physicians practicing in any subspecialty. Geriatrics healthcare professionals cite their encounters with inspirational older adults, the deep and meaningful relationships they develop, and the typically steady work hours as significant factors adding to their job satisfaction.


Wasserman would agree. “I’ve always loved being around older adults and was very close to my grandparents,” he says. “My greatest satisfaction has always been getting to know my patients. Older adults appreciate a clinician who hears their concerns and is honest in focusing on their function and quality of life.”


There may be an even deeper reason why geriatricians are in short supply. Maybe, just maybe, it’s because our society doesn’t value old people enough. As we discovered during the COVID pandemic, widespread cultural ageism based on the fear and dread of getting old and dying leads many of us to believe that elders are less “productive” in midlife economic terms and thus pose a great financial burden on the healthcare system.


What we fail to recognize is the immense social contribution of older adults to maintaining economic and emotional stability in their families, purchasing consumer products and services, volunteering at nonprofits, and safeguarding businesses’ institutional knowledge and practices.


Older adults, like people of all other ages, deserve the best healthcare, one that is tailored to their needs and desires for a quality life. And just like vintage buildings, their bodies and minds house treasures worthy of being cherished and protected.


Who's better than a most-highly-trained specialist to handle the job?

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