By 2030, the last of the Baby Boomer generation will have turned 65 years old, putting the population of “senior boomers” in the United States at approximately 71 million. Currently, only about 7,000 certified geriatricians – physicians specializing in the care of older adults – are practicing in the US. That’s about one geriatrician for every 10,000 of these expected seniors, assuming that the number of geriatricians remains stable. However, the number of new trainees in the field of geriatrics is going down.
Geriatricians often act as primary care doctors, and at times as specialist consultants, for patients who are advancing in age and may require targeted, specialized care to maintain function and quality of life. Geriatricians are attuned to the specific needs of the patient at all stages of aging, regardless of what or how many chronic conditions that patient may have. As America’s population ages, these doctors will play a critical role in caring for senior citizens.
Many factors contribute to the declining number of geriatric specialists. Geriatrics fellowships require extra years of training. Despite their additional training, geriatricians are among the lowest paid physicians across all medical specialties. This is largely due to the fact that reimbursements for geriatrics services are lower, which translates to lower pay for the geriatrician. Further, the specialty also suffers from a general lack of prestige. These are all reasons why medical students aren’t as interested in pursuing geriatrics as a specialty.
Without a fundamental change in public policy, financial reimbursement, and training this is unlikely to change anytime soon. So, how can we care for an aging population while our pool of geriatricians is shrinking?
New models of care
The shortage of geriatricians does not necessarily condemn the elderly to poor medical care. New models of care are emerging that focus on better coordination of care for older adults that will help improve their likelihood of remaining healthy.
If we want care for older adults that is more than just “good enough,” we need more boots on the ground to provide that care. We don’t just need more geriatricians. We need more pharmacists, nurses, nurse practitioners and physician assistants trained in the special needs of the older patient. There are many examples of new care models that demonstrate the effectiveness of comprehensive, coordinated care for older adults.
In hospital settings for example, Acute Care for the Elderly (ACE) units use teams made up of nurses and nurse practitioners, physicians, social workers and other health-care professionals. These interdisciplinary teams use coordinated care principles to ensure better patient outcomes at a lower cost than traditional care, with a relatively small investment of geriatrician time.
Another program, Nurses Improving Care for Healthsystem Elders (NICHE) empowers nursing leaders to help health-care organizations improve the care of older adults by implementing principles designed to stimulate culture change within health-care systems that help make hospitals more senior-friendly. At present, over 575 hospitals have NICHE designation.
In outpatient settings, Program of All Inclusive Care for the Elderly (PACE) improves patient satisfaction while reducing use of institutional care and overall costs for poor, functionally impaired older adults by improving coordination between community and clinical services.
In each case, the geriatrician’s expertise is amplified throughout health-care organizations through care systems, better use of resources, technology, financial incentives and teamwork.
Responding to reality
The recruitment and training of geriatricians is an important part of the vision for excellent health care for elderly adults in the future. However, that is only part of the issue. Our health-care system needs to respond the realities of caring for older patients.
It takes more time to care for medically complex, often functionally or cognitively impaired older patients. This is an under-appreciated fact about geriatric care. Clinicians must be able to operate in a system that is conducive to coordinated, patient centered care. Ideal systems allow practitioners to take the additional time needed to provide the best possible care.
The extra time it takes to provide proper care for seniors also has to be accounted for in reimbursement mechanisms. If not, there is a risk that the services older patients need will only be available to those who can afford to pay extra for them.
What older adults need in order to optimize function and quality of life transcends simply the medical issues and extends to policies and infrastructure of our health-care systems and communities. Whether our society prioritizes these needs sufficiently to meet them remains an open question.