AS AMERICA’S VAST BABY-BOOMER GENERATION AGES, WILL ENOUGH SPECIALIZED DOCTORS BE TRAINED TO CARE FOR THEM IN THEIR GOLDEN YEARS? - By Jeanne Wright
BY 2030, MORE THAN 70 MILLION AMERICANS WILL BE OVER THE AGE OF 65 – twice the number counted in the 2000 Census. But even as the baby-boomer generation grays, there already are too few doctors who are specially trained to treat the elderly and their complex healthcare needs, portending a potentially crippling shortage in the years to come.
For a variety of reasons, medical students historically have shown little interest in geriatric medicine. In an era of high-tech healthcare, geriatricians rarely are hailed as stars. And the pay is poor compared to most other specialties. But to their aging and frail patients, these doctors – trained in family practice or internal medicine with at least one additional year of fellowship training in geriatrics – are unsung heroes who treat them with kindness and respect. Their roles as geriatricians have led to tremendous strides in the way some doctors and families view the aged and how they care for them. It is a specialty that requires a holistic approach; besides providing direct medical care to their patients, geriatricians often spend much of their time coordinating care among different physicians treating their patients for a variety of overlapping chronic physical or mental conditions such as heart failure, diabetes, arthritis, depression and dementia. “Being a geriatrician,” says UCLA geriatric specialist Dr. Deborah Kado, “allows for constant intellectual challenges in diagnosing and treating some of the most complicated cases.”
In fact, some in the field consider geriatrics much broader than a specialty or subspecialty. Dr. William R. Hazzard, a professor of medicine at the University of Washington and co-author of Principles of Geriatric Medicine and Gerontology, the top text in the field, defines geriatrics as a “supraspecialty … embracing all of the breadth and complexity germane to optimal health and social care of elderly people and necessitating our multidisciplinary, team-oriented modus operandi.”
HOWEVER ONE DEFINES IT, the crying need for more geriatricians is clearly evident. According to a report from the American Geriatrics Society (AGS), the very elderly – people age 85 and older – is now the fastest-growing segment of the entire population. “Unfortunately, we may not be equipped to give them the care and dignity they deserve,” says Dr. David B. Reuben, chief of the Multicampus Program in Geriatric Medicine and Gerontology at UCLA. The Multicampus Program, within the Division of Geriatrics, was established in 1979 and, with more than 50 full-time faculty representing many disciplines, is one of the largest academic geriatrics programs in the world and has been recognized as a national leader in the field.
Along with Dr. Gary Small, director of the UCLA Center on Aging, Dr. Reuben has been on the frontline of the effort to recruit and train more medical students to care for the growing number of seniors who now, and in the future, will need significant medical care and attention. Both say the medical community must address the growing demand for more geriatricians and geriatric psychiatrists. If the demand is not met, “we will be on a course to disaster,” warns Dr. Reuben. Estimates of the number of geriatricians needed to care for the growing population of elderly ranges from 20,000 to 36,000, according to The Alliance for Aging Research. Currently, there is one geriatrician for every 5,000 adults age 65 and older, reports the AGS, a nationwide, non-profit association of geriatric-healthcare professionals, and statistics indicate that the number of physicians entering the field is shrinking. According to one set of measures, about 9,000 geriatricians practiced in the United States in 1998; in 2006, that number had dropped to 6,700. By 2030, it is estimated that there will be only one geriatrician for every 7,665 older adults – a 50-percent decline over the next 25 years, says the AGS.
The situation appears just as dire for geriatric psychiatry. With increased longevity, risk for many neuropsychiatric illnesses increases, generating a growing need for specialists with expertise in diagnosis and treatment of geriatric mental illness. The AGS and Alliance for Aging Research forecast a “severe and worsening” shortage of geriatric psychiatrists, noting that more than half of available geriatric psychiatry slots go unfilled. There were just 2,100 geriatric psychiatrists in the United States in 2005 to treat older adults. The President’s New Freedom Commission on Mental Health Subcommittee on Older Adults predicts that by 2030, there will be about 2,600 geriatric psychiatrists – a numerical increase, perhaps, but still too few to care for the 70 million older adults projected for 2030. “If we conservatively estimate that 15 percent of those people will have such major psychiatric illnesses as dementia and depression, then each geriatric psychiatrist would be caring for more than 4,000 patients, spending less than 30 minutes per year with each of them,” Dr. Small notes.
UCLA is working to address this need with a one-year subspecialty program for geriatricians and geriatric psychiatrists, and additional fellowship years for geriatricians and geriatric psychiatrists interested in academic-career paths. This additional training is enhanced by individual research projects, collaboration with faculty in ongoing investigations, and supervised teaching and administrative experience. In addition, a two-year postdoctoral fellowship for psychologists provides specialized clinical and research training. UCLA also provides significant exposure to geriatrics during the four years of M.D. training, says Dr. Bruce Ferrell, associate chief for education in the Division of Geriatrics. While the requirements are sprinkled throughout the first- and second-year curriculum with lectures in such subjects as the physiology of aging and molecular biology of aging, there also are required lectures in the third and fourth years, as well as seminars and elective clerkships in the field. All told, Dr. Ferrell says, students can receive up to 80 hours of exposure to geriatrics during their four years of training at UCLA.
ATTRACTING MEDICAL STUDENTS TO CAREERS in the field of gerontology has been a hard sell, Drs. Reuben and Small say, despite the fact that geriatricians report the highest job satisfaction of any specialty, according to a 2002 survey in the journal Archives of Internal Medicine. Other medical centers and universities have had similar experiences. “It is a troubling issue for us,” Dr. Leo M. Cooney, the founder of the geriatrics program at Yale University School of Medicine, told The New York Times last year. In a good year, he said, perhaps one out of 45 residents in internal medicine might decide to be a geriatrician.
To boost interest in the specialty, some states are initiating programs that offer loan forgiveness as an incentive to pursue geriatrics. UCLA and other schools offer grants, fellowships and research opportunities in the field. The federal government also has gotten involved, with a bill introduced in May, the Geriatricians Loan Forgiveness Act of 2007, to extend the National Health Service Corps Loan Repayment Program to training in geriatric medicine or geriatric psychiatry. If passed, the program would forgive $35,000 in educational debt incurred by medical students for each year of fellowship training in geriatric medicine or geriatric psychiatry. The bill, which is now in committee, would require an individual to provide services in geriatric medicine or psychiatry during a period of obligated service.
Geriatrics is a “noble profession” that should attract students who are passionate about providing patient-centered care to the elderly, as well as enhancing their quality of life, says Dr. Reuben. Yet, he reports statistics similar to those cited by Dr. Cooney of Yale: “If we get one or two new students a year, it is a resounding success,” Dr. Reuben says. For many young physicians deciding what career path to take, compensation is a major consideration, “particularly for those students who may be staring at $150,000 or more in school debt,” says Dr. Reuben. And geriatrics, as important a field as it may be, just does not enjoy the prestige or pay of other specialties. According to a report in The New York Times, radiologists and orthopaedic surgeons – procedure-intensive specialties – top the compensation ladder with average annual incomes of $400,000 or more; geriatricians linger near the bottom, at about $150,000 a year.
One reason behind the disparity is that geriatricians depend almost entirely on Medicare revenues, states a report from the AGS and the Association of Geriatric Academic Programs. The report states that Medicare does not factor the time it takes to spend with older patients and their families, visiting patients in nursing homes and coordinating care with other physicians. Often, doctors also must spend considerable time working with agencies and departments to assist their elderly patients, as well as assessing cognitive and mental issues. As a result, they do not receive proper reimbursement for the time they put in, according to the group.
CERTAINLY, MEDICAL PRACTICES AND SKILLS VARY, yet geriatricians may argue that their role in caring for older adults is profound and continues to shape the way society treats its elderly. Dr. Small points out that doctors who have not been trained specifically to treat the elderly may incorrectly diagnose older patients or are at risk for not recognizing certain diseases or drug interactions that might affect the elderly. (The National Center for Health Statistics estimates that medication problems may be involved in up to 17 percent of all hospitalizations of older persons.)
“If doctors are out of touch with caring for older patients, they could end up treating an 85-year-old the same way they would care for a 50-year-old,” Dr. Small notes. “The healthcare system tends to limit the time doctors spend with patients, and they can miss critical mental and physical problems if they are unfamiliar with symptoms that are expressed in the aged.” The University of Washington’s Dr. Hazzard is among those who point to a lack of “respect and support for those who care for the elderly,” seeing in the shortage of geriatricians and limited interest in the field a refl ection of what he calls “society-wide denial of aging.” Ageism, Dr. Small says, also is a factor in why some students avoid working with the elderly. Some find it uncomfortable or depressing to treat those who have multiple and often highly debilitating health problems, which may include dementia or Alzheimer’s disease. Treating elderly patients often is as much, if not more, about managing their conditions rather than curing them, and many young doctors selecting a specialty prefer to work with patients they feel they have a chance of curing.
But there are some students for whom the challenge of treating elderly patients is a powerful magnet. Consider Navid Ezra, a second-year medical student at the David Geffen School of Medicine at UCLA, who decided, after working with a geriatrician during an internship at an adult day healthcare center, to focus on geriatrics as a specialty. Geriatricians “seem to have more patience than some of the other specialists,” he says. “They spend more time with their patients, and really listen and empathize with them.” Having the opportunity to talk and listen to the elderly patients before and after surgery was invaluable, he says. “They allowed me to have a part in their healing process. No science. No drugs. Just concern and conversation. It fortified my desire to work with the elderly … and motivated me to learn about diseases of aging.”
Medical professionals are banking on the hope that, with incentives, more students like Ezra will embrace the specialty. Toward that end, the Association of American Medical Colleges has offered a program, sponsored by the John A. Hartford Foundation, to grant awards to U.S. medical schools to enhance their gerontology and geriatrics curriculum. The Donald W. Reynolds Foundation, through its Aging and Quality of Life program, also has made significant grants to support comprehensive projects in academic health centers to train medical students, residents and practicing physicians in geriatrics. In 2004, UCLA was among four academic health centers – including Duke University, Johns Hopkins University and New York’s Mount Sinai Medical School – to receive a total of $12 million, $3 million each, over six years to establish the Donald W. Reynolds Consortium to Strengthen Faculty Expertise in Geriatrics in U.S. Academic Health Centers.
Still, authorities in the field are concerned that, even with incentives, not enough geriatricians can be trained to meet the need. Uneasy about what the future may hold for the aging population, Dr. Kado suggests a universal approach, arguing that to meet the oncoming tsunami of aging baby boomers, medical schools “need to teach all medical students about the sensitive needs of the geriatric population, regardless of what specialty the students might ultimately choose.” It is unrealistic, she says, to think that, even if more students were to rush to gerontology, schools will be able to train enough geriatricians to fill the need.
FOR PATIENTS AND THEIR FAMILIES, a skilled and caring geriatrician can make all the difference. Juliet Kendriek was one such patient. Before coming to the UCLA geriatric center, the retired nurse bounced from one doctor to another seeking help for a variety of health problems. At one facility, she was treated like a child. At another, she was told to stop complaining, she was just getting old. The experience, recalls her daughter, left the elderly woman frustrated and angry. “It was very hard on my mother, especially when she was treated with disrespect,” says Helga Scow Sterns.
At UCLA, which U.S.News & World Report ranked No. 1 in the country in 2007 for its clinical geriatrics program, Kendriek came under the care of Dr. Kado and other physicians in the Multicampus Program in Geriatric Medicine and Gerontology. “My mother felt very loved and cared for,” Scow Sterns recalls. When doctors diagnosed Kendriek with a virulent form of cancer, Dr. Kado spent extra time to reassure her, and made sure she was sent to all the right doctors, her daughter says. When her condition worsened, the center doctors did everything they could to make sure she was comfortable. And when Kendriek died, at the age of 86, Dr. Kado went to her memorial service.
Without such caring, Scow Sterns says, her mother would not have had the quality of life she enjoyed up to her final days. “These doctors seem to truly love their work,” the daughter says. “They are a special breed.”