How can we train more geriatricians?

In 2003, authors Warshaw and Bragg published a paper that reported on three decades of progress in creating a workforce to care for our aging population.

They noted that, as of academic year 2001-2002, 120 geriatric medicine fellowships were training 338 fellows. U.S. medical schools had 869 full-time equivalent (FTE) geriatrics faculty members teaching in IM residency programs and FP residency programs. From 1988-2002, more than ten thousand Certificates of Added Qualifications in Geriatrics were awarded. But, as Warshaw and Bragg pointed out, that growth was not producing enough geriatricians to care for the increasing elderly population.

I have a 90-year-old father and an 86-year-old mother who are still living independently but are very frail. Thirty years ago, when I graduated from medical school, they were sprightly at ages 60 and 56. Back then, I didn’t appreciate the importance of geriatrics. Boy, I do now.

I have learned some valuable lessons while helping to manage their care.

A great doctor knows what not to do as well as what to do. My parents are lucky to have a great internist who has been their physician for 35 years. He knows the importance of not doing everything. He has tried to find the right balance between intervention and observation. Not everything needs to be fixed.

Avoiding hospital stays is critical. After age 85, people don’t get better when they are admitted to the hospital; they get worse. They get loss of muscle strength from prolonged bed rest with no PT, pressure sores, new confusing medications, and antibiotic destruction of their gut flora that results in embarrassing diarrhea. I tell my dad that he is like a shark: “If you are not moving, you are dying.” Continued activity is the key to independence. Until nine months ago, even though he is blind, my dad walked on his treadmill for 20 minutes a day. Although only 1.2 miles an hour, he was moving.

Nurses in most community hospitals don’t really know how to care for elderly people. Seeing an untouched meal tray, they say, “I guess you weren’t hungry,” and take it away. It doesn’t occur to them that elderly people often can’t hear or see well enough to navigate the complexities of feeding themselves when hospitalized. My family makes sure one of us is parked in my father’s room most of the day; we schedule family members to be present at every meal to help my father eat.

Medicare is a fabulous safety net that allows many older people to age in place in their homes. It provides hospital beds, lifts, oxygen concentrators, and weekly home health nurse visits. This is why my parents have been able to stay independent.

There are angels out there. There is a wonderful lady who comes in three times a day to help bathe and feed my father. She has no formal training, but she could teach nursing students how to prevent pressure sores. She cares for a number of older people and keeps them engaged and connected. Her assistance and expertise are priceless.

So how does this relate to the geriatrician workforce challenges we are facing in academic medicine?

We should focus on older students. Because their own parents are probably close to needing geriatric care, it’s easier for them to “get it.”

We need a fast-track retraining program in geriatrics for licensed physicians. I appreciate trained geriatricians so much more now than I did 30 years ago, when I opted to specialize in anesthesiology. Retraining could provide a way for experienced physicians to add to their qualifications and give back to society.

We need a residency/fellowship experience that is community-based and patient-centric. We must teach practitioners to help seniors age in place and create networks of community care.

Academic medicine has a wonderful opportunity to develop a commitment outside of our acute-care facilities, leveraging provider training programs and population-based research to create a sustainable pipeline of geriatricians.

Joanne Conroy is Chief Health Care Officer at the Association of American Medical Colleges. She blogs at Wing of Zock.

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  • Anonymous

    Sorry, but if you honestly think your proposals will correct the dearth of geriatricians, you are so deeply ensconsed in your ivory tower as to be totally clueless.

  • http://www.facebook.com/people/Josh-Small/823514767 Josh Small

    We can train more geritricians by making sure geriatricians get paid more.  Simple as that…

  • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

    ” I opted to specialize in anesthesiology.”

    Says it all right there.

    • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

      haha so true. i’m so glad that, just once in a while, we see some honest opinion on this board, and not just mindless pc dribble

    • Anonymous

      Amen.  I was one of those who specialized in geriatrics.  Not something I choose to make known these days.

  • Peter Cutri

    Agree. Free market would work great in medicine.

  • http://twitter.com/Hootsbudy John Ballard

    The level of professional cynicism in this forum is breath-taking. 

    • Anonymous

      The three certified geriatricians in my town have all closed their practices during the past five years due to financial distress.

      Geriatrics is not a low-income specialty, it is a no-income specialty. The combination of long training and deferment of income, lengthy appointments, high overhead (all staffing needs go up when dealing with old patients), and low Medicare payments is not financially viable at this time.

      To point that out is factual, not cynical.

      What is cynical in the extreme is, as the author did, to make your bundle and then piously attempt to con others into a career path that you had no interest in.

      • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

        “…..What is cynical in the extreme is, as the author did, to make your
        bundle and then piously attempt to con others into a career path that
        you had no interest in…..”

        You said it.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      Matched only by your ignorance Ballard.

      Every doc on this forum……EVERY ONE…..knows geriatrics-trained specialists who have ceased to hold themselves out to the public as geriatricians. They do not advertise their training because they find themselves facing bankruptcy if they limit their practice to geriatrics.

      Southerndoc has it right. What’s being pointed out are FACTS, not cynicism. If you have a problem with facts, too bad. Go back to your cafeteria.

      • http://twitter.com/Hootsbudy John Ballard

        Hit a nerve, I see. I took early retirement from the food business ten years ago and have worked during my post-retirement life in the senior care environment, first with a facility with 80 independent and forty assisted living residents, then as a non-medical caregiver through an agency. My ignorance has been tempered by a continuing ed. course in gerontology at a local university and caring for my mother during her final years.  

        At the end of thirty years in the food business I had reached the point where I was ready to work less and earn less. Unfortunately the company where I worked, like most companies, didn’t have a position for someone who would willingly do any job in the building but was experienced enough to be a floating cook, chef or manager as needed. When I think how little it would have taken to retain me it scares me; I’m glad to have left. My life since has been much richer than it would have been otherwise. My income, of course, is not impressive, but my quality of life taking care of (other) old people has never been better. I’ve learned a lot. And I’m taking notes. 

        I’m also naive enough to imagine that there could be a few aging physicians who are either tired of the pace of whatever their specialty may be who would be candidates for geriatric medical care for (other) old people. I probably should have more sympathy for physicians, lawyers, engineers, CPAs and a whole population of other well-paid professionals when they grouse about how little money they earn, but I have spent too many years among working poor and blue collar workers. 

        And I have to say that slogging through the doc blogs for the last few years has not done much for my sensitivity to their complaints. I don’t dispute the facts. But I have a problem with the attitudes. I think it has to do with money. In the food business one knows quickly and in no uncertain terms whether those being served are pleased. I’m slowly coming around to a better appreciation for concierge medicine, an old-fashioned cottage industry model, something along the lines of “All Creatures Great and Small.”

        • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

          Yawn. How’s the air up on your high horse. I came from the same poor blue-collar background, shoveled shit and was motivated to go to medical school…..frankly, because I worked enough food service jobs to know I didn’t want to do that the rest of my life. Translated for enough of my non-English-speaking relatives in hospitals. They were proud of the first kid in a large family to graduate college, ever. I’ve done medical missions on two continents. Had an African orphan adopted into a local family, mother couldn’t believe I could talk with the kid in the Swahili I learned when I was in Africa. The kid was Medicaid, I suppose I should dump my Medicaid kids…….but I like the children. I’m cynical that way.

          The fact is, like it or not, doctors walk away from geriatrics. They walk in idealistic, they walk away disillusioned. They take down any public mention of training in geriatrics.

          In fact, a great way to do geriatrics would be a retainer “concierge” model. Medicare makes it extremely difficult to do it. Massachusetts regulates your fees for Medicare patients, even if you’re not in Medicare, as a condition of licensure.

          I’ve also been around long enough to know there USED to be aging physicians willing to do the nursing home work, and all sorts of volunteer work. They staffed free clinics all over the place. They gave up and just plain retired. I was a medical association delegate for ten years, trying to find ways to make it easier for retired physicians to volunteer. Too many roadblocks, the docs just give up.

          The dollars going through the hospice and home health agencies is actually quite impressive, not that it goes to the caregivers. The docs are used to sign off orders and take responsibility, for free.

          • http://twitter.com/Hootsbudy John Ballard

            Thanks for your reply.
            I apologize for having offended you and I stand corrected.

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

            Fine.

            The person who wrote the thread article is an anesthesiologist. That’s about the highest-paid of the medical specialties. She went from there, to an even higher-paid administrative job with the American Association of Medical Colleges. In other words, about as far away from hands-on care of the elderly as you can go.

            A few docs on this thread…..docs who actually go into the nursing homes and actually care for these elderly…..have commented on that.

            And that’s our “leadership”. You wonder why there’s cynicism.

            southerndoc1: “What is cynical in the extreme is, as the author did, to make your bundle and then piously attempt to con others into a career path that you had no interest in.”

            ……….read it until it sinks in…………

          • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

            “……She went from there, to an even higher-paid administrative job with the American Association of Medical Colleges…….”

            That high-paid administrative job with the American Association of Medical Colleges, by the way, pays $582,000, over half a million dollars a year.

            Source: Guidestar-dot-org, any nonprofit organization has to file a Form 990 with the IRS, and the IRS filing is a public document. I’m revealing no secrets, anybody can look it up.

            I’m citing the 2009 tax year IRS filing Form 990 (filed in 2010). The head of the form reads, in big letters, “Open to public inspection”.

            The organization has to list salary of their highest-paid employees. The person who wrote this pompous article could hire a full-time geriatrician out of petty cash. She went for the big bucks and lectures docs like me, who actually take care of these elderly people for a fraction of what she makes to offer this useless advice.

            Medical students pay astronomical tuition, go into incredible debt, to support this bloat. Remember, she’s one of many people making these astronomical salaries off of medical student fees (MCAT, AMCAS, etc.). The students go into debt, they realize geriatrics pays poorly, they do the same as she did. Go into anesthesia. Then they wonder why they can’t find doctors for their aging parents.

          • Anonymous

            Turns out she came to this position from hospital administration. No telling when this pompous twit actually last passed gas.

  • http://pulse.yahoo.com/_UQ52N63EO5UL7JQE7RLBOG3YRU kumud

    Gee, there are so many reactions i have to this post i don’t know where to begin:

    1- you are right, there is a need for doctors that want to care for the elderly

    2- everyone outside primary care (doctors and otherwise) love to point that out but aren’t willing to give up the big bucks paid for e.g.regional blocks to compensate us fairly.  Hence, specialties like “pain management” (what a waste)

    3- when medicare rates are stagnant or declining, and they discourage high-level billing codes for the 1-hr housecall for the elderly man with 10 meds who feels “weak” whose family is totally uninvolved and whose visiting nurses are both unavailable and useless even when available, but produce endless documentation for me to sign so they can be paid, it is far from a viable business model

    4- why do we need geriatrics fellowship training programs? most of internal medicine training (caring for those with chronic conditions) is geriatrics by default.  tacking on another 3 yrs to learn and practice the “get-up-and-go” test is just about pointless, and even counterproductive by taking roughly 10% of the worklife away from a potentially productive physician, which leads me to…

    5- taking students who are older??? absurd. that is just a recipe for worsening the projected physician shortage, especially when many of those will likely NOT go into primary care anyway.  Same is true for young women – my class of about 50% women has hardly any that actually continued to work after residency. The ones that did certainly didn’t choose any primary care field. it was derm, radiology, anesthesia, ophthalmology etc.

    6- your “angels” visiting nurses are making something like $2500 for every 2 month block of care that the physician signs off for.  That is why the doctor (who gets like $100/visit for a housecall) must “re-certify” their orders every 60 days.  So if they’re coming in every week,well you can do the math.  Not everything is as it seems, but most things ARE primarily about money.  Same is true of hospice.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      You get a hundred bucks for a house call? I’m jealous.

      The hospice in my area is a twenty-five million-dollar business.

      Nice fat salaries easy enough to see from guidestar. Not that any of that money is reaching the “angels”, they go to suits that never see the inside of a nursing home. One can only imagine what’s hidden in the subsidiaries and captive insurance companies.

      Lots of room for fraud, just Google “hospice” AND “fraud”, or similar.

  • Anonymous

    I truly enjoyed my 26 years of practice because the majority of my patients were geriatric and lived in retirement communities. They were a wonderful group of patients, and I have many fond memories of the time I spent with them. But the practice of geriatrics is financially untenable at this point and I don’t foresee any changes that would be favorable to this specialty in the future.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I have a geriatric practice for years and love the hands on long term care you get to provide. You are severely undercompensated for the time and thought you put into the developing care plan of each individual. You need longer appointments. You need to develop different communication skills for patients who are hearing and sight challenged. Medical students are a diverse but different breed today. They want a balanced professional and personal life and they need income to pay off the extraordinary cost of their medical education and training. Until primary care physicians are compensated for their evaluation and management and cognitive efforts it will be impossible to recruit doctors for geriatrics in large numbers.
    For years I have advocated a National Health Service Program for senior care in which all physicians in training and all nurses in training must spend a year or two before specialty training and before going out into practice providing elder care.They can staff senior centers, community centers, do home visits and keep seniors out of acute care hospitals in many instances.It would provide an elder care perspective and experience that they would take to their specialty training. At the same time it would put young idealistic caregivers out in the field before they have a chance to burn out or become jaded. 
    The article by Dr. Conroy is excellent and says it all.

    • Anonymous

      Sorry, but I don’t see how it’s at all possible to say Dr. Conroy “says it all.”

      She completely ignores, either intentionally (due to political reasons) or unintentionally (due to a disconnect from reality), the root problem: low pay.

      To promote this career path for today’s young physicians is completely irresponsible.

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        I agree with you that Dr Conroy didnt discuss pay. I am not sure it is irresponsible to promote this career path. Students should know what the payscale is and the pros and cons. I can see the problems in this specialty if you are the primary bread winner in a family. As a second income in a family it may work. I think Dr Conroy presented several excellent ideas which clarify the need for geriatric trained physicians. 

        • Anonymous

          As a second income for a family? That is like saying as a second car you couldn’t trust to drive any farther that you would otherwise walk. Either the work pays enough to support the person doing it and meets their family’s needs, or it doesn’t. If it doesn’t, then call it what it is, volunteer unpaid work. For professionals who must first work to support themselves and pay their bills, as well as save for retirement and all the other things wise and responsible people ought to do, suggesting taking this kind of work on under conditions of inadequate pay is not just irresponsible it is unjust and wrongful.

  • Anonymous

    Wanted:  Slave to work for less than the cost of doing business for an out of control hyper-regulated hateful bureaucracy which offers the ultimate in user unfriendliness, which mandates sub-standard care for frail profoundly disabled individuals in an environment of extreme malpractice lawsuit risk.

  • Jim Richardson

    Wow.  This is all so sad.  I’m a hospital based geriatrician.  It’s a great field and I love my practice and patients, but I agree that we will not see more physicians practice geriatric medicine until the specialty is recognized as having something to add to the care of the frail elderly.  And that recognition has to come via an improvement in the Medicare fee schedule.  But, like others here, I don’t see that happening.  I first certified in geriatric medicine in 1988.  I wonder if there will be any geriatricians to care for me by the time I retire.

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