Health
Gearing up for a graying America (AGS annual scientific meeting)
■ Release of a sentinel report on the future of geriatric medicine offers steps to take now to make a difference in the long run.
By Peggy Peck, amednews correspondent — Posted July 4, 2005
As a specialty, geriatrics is in critical -- but not terminal -- condition, according to "Caring for Older Americans: The Future of Geriatric Medicine," a long-anticipated report from the American Geriatrics Society.
Release of the report, which lays out the current work-force situation and puts forth a plan for future action, was the pivotal event at the AGS scientific meeting, held in Orlando, Fla., May 11-15.
Though there has been significant progress in the evolution of geriatric medicine, health care for older people is now at a crossroads, notes the report, which was published as a separate supplement to the June Journal of the American Geriatrics Society. "The clinical, educational and research approaches of the 20th century are unable to keep pace and require major revision," it states. The document also warns that maintaining the status quo will translate into falling further behind.
There was an initial burst of enthusiasm when geriatric training programs were established in the 1970s and the first examination in geriatric medicine was jointly administered in 1988 by the American Board of Family Practice and the American Board of Internal Medicine. But since then, geriatrics has run into a recruiting wall. According to a study accompanying the report, "fewer than 300 physicians entered geriatric medicine fellowships in 2003."
Thus, just as America is graying and baby boomers are turning into golden oldies, geriatrics has a shortfall of more than 7,000 geriatricians. There is only one trained geriatrician for every 5,000 Americans 65 and older. The AGS projects this number to reach a shortfall of 36,000 geriatricians by 2030.
That is the grim prediction in a report that sets an upbeat, can-do tone. A paradox? Yes, but that paradox is characteristic of geriatricians, who are consistently ranked as the lowest paid medical specialty and yet still usually ranked at the very top in job satisfaction surveys.
"As geriatricians we love our work, but, unfortunately, our work is not 'valued' in the same way as the work of procedure-oriented specialties," said AGS President David B. Reuben, MD, a professor of geriatrics at the David Geffen School of Medicine at the University of California, Los Angeles. For example, despite long struggles in the 1980s to have the so-called "cognitive" services reimbursed at a rate comparable to payment for procedures, Medicare continues to pay more for procedures than for "high-touch medicine, which is what geriatrics is," he said.
And the low pay spills over into meager funding for geriatrics research, Dr. Reuben added. So while geriatricians remain an underpaid minority in medicine, research and innovation aimed at improving care for the elderly has been "neglected by major federal agencies," the report states. The AGS document calls on those key agencies -- the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality -- to join together to finance pilot programs similar to the geriatric care programs provided by the Dept. of Veterans Affairs.
The VA, according to the AGS, "has been a leader in developing and evaluating new models of geriatric care that foster a multidisciplinary approach."
By contrast, Medicare has no mechanism to pay for "social services and other components of geriatric care that don't include a face-to-face encounter with a physician," said Meghan Gerety, MD, associate chief of staff at South Texas Veterans Health System and professor of medicine at the University of Texas Health Science Center, San Antonio. Dr. Gerety is immediate past president of AGS.
Geriatrics has evolved and developed as a team-based approach to care, and this model is the model that will go forward, she explained. "So we need to find a way to pay for these nonphysician services."
Moreover, it is unlikely that geriatric medicine can attract enough new geriatricians to meet the predicted shortfall 25 years from now, Dr. Gerety said. The AGS report also tacitly acknowledges this circumstance by suggesting all physicians receive more basic training in geriatrics.
But even this measure will be difficult to implement because "a paucity of academic geriatricians remains, and most educators in geriatric medicine are dependent upon clinical income, as academic institutions have generally been unable to provide adequate support for teaching geriatrics," the report states. To meet these training needs, "geriatricians will need to partner with other teachers. Most often, geriatricians will lead other faculty, including general internists, family physicians, surgeons and related specialists, to develop, implement and teach the geriatrics curriculum to medical students and residents."
Finally, the report suggests geriatricians mobilize patients into an effective health care lobby by forming coalitions of professional societies and community groups.