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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