Baby boomer time bomb: Too many aging patients, too few geriatricians

An IOM study predicts severe work force shortages, fueled in part by low reimbursements.

By Myrle Croasdale — Posted May 5, 2008

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Elizabeth Eckstrom, MD, had been a general internist for 10 years when she did a geriatrics fellowship, after research into fall prevention piqued her interest in older adults. Now that she is a geriatrician, she earns less than she did before.

But she thinks the change is still worth it.

"For me, it's about the rewards I see in caring for these patients, even though we aren't paid very well," said Dr. Eckstrom, associate professor at the Oregon Health & Science University School of Medicine.

She is one of a shrinking number of doctors who specialize in treating older patients. Today, there are about 7,100 geriatricians in the U.S. -- a 22% decline from 2000.

There will not be enough geriatricians when the 78 million baby boomers begin to turn 65 in 2011, according to a new Institute of Medicine report. By 2030, there will be an estimated 8,000 geriatricians, but the nation will need 36,000, according to the Assn. of Directors of Geriatric Academic Programs.

"The supply side is really scary," said John W. Rowe, MD, the IOM report's committee chair and former CEO of Aetna.

The IOM report, released last month, recommended an increase in geriatric competency throughout the health care work force to offset a shortage in geriatric specialists. It also called for the adoption of interdisciplinary care models and a fundamental change in how health care is reimbursed.

Low reimbursement was cited as the biggest barrier to building the geriatrician supply. In 2005, average geriatrician income was $163,000, compared with $175,000 for a general internist.

In addition to raising reimbursement for senior citizens' care, the IOM study recommended establishing a National Geriatric Service Corps to create financial incentives for geriatric specialists.

The impending surge of seniors and their health care needs has focused attention on Medicare's solvency, but Dr. Rowe said the health care work force needs addressing, too.

"Even if there is enough money, there isn't going to be anybody there to provide the care," said Dr. Rowe, a professor of health policy at Columbia University Mailman School of Public Health in New York.

Pushing for more training

The AMA is one of several medical organizations supporting greater training in geriatrics.

"With approximately 7,000 geriatricians currently in the United States, all physicians caring for aging patients need to become proficient in geriatric care to help meet the increasing health care needs of seniors," AMA Board of Trustees member Cecil B. Wilson, MD, said in a statement.

Preventing cuts in Medicare payments is also an important step, Dr. Wilson said, so physicians can continue to accept new Medicare patients.

"Reimbursement is a huge barrier," said American College of Physicians President David Dale, MD. "We get relatively low rates for the substantial time it takes to be a good doctor for an older person."

Another problem, said James King, MD, American Academy of Family Physicians president, is the decline in U.S. medical graduates interested in family and general internal medicine.

"We need to push harder on increasing the number of primary care physicians," he said, because they will be the ones to treat older patients.

Efforts are under way to improve geriatrics training for medical students and residents. But not as much is taking place for practicing physicians, said John B. Murphy, MD, president-elect of the American Geriatrics Society.

"We need a big push to get primary care physicians up to speed, but also to change the health care system to allow them to practice properly," said Dr. Murphy, professor of internal and family medicine at Warren Alpert Medical School of Brown University in Rhode Island.

Physicians caring for frail older patients need support from other professionals, such as social workers and pharmacists, he said, but the current pay structure does not fund that team approach. "This is not something even large group practices can afford to do."

The lack of reimbursement also discourages debt-burdened medical graduates from spending an extra year in training to learn about the physiological and psychosocial changes that affect how older adults manifest illness and respond to medications, said Rosanne M. Leipzig, MD, PhD, vice chair of medical education for the department of geriatrics and adult development at Mount Sinai School of Medicine in New York.

A fragmented care system also makes it difficult to practice geriatrics outside an academic setting, she said.

In Oregon, Dr. Eckstrom has been researching what primary care physicians know about geriatrics. Issues such as incontinence, falls and when to consider assisted living or long-term care frustrate them, she said.

"Internists are great at taking care of disease," she said, but they tend to undervalue day-to-day functionality and can feel overwhelmed by the needs of older patients.

Dr. Murphy of the AGS acknowledged that barriers to providing quality geriatrics care are high, but he is optimistic the situation will improve.

"We can make headway on this, but we can only do it if we get all the voices in the choir singing together -- the professional organizations, the employers, the lay groups," he said. "We have to put our proprietary interests aside and solve this issue."

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Treating an aging population

Few physicians pursue a career in geriatrics, and as the number of older adults nearly doubles between 2000 and 2030, access to geriatricians is expected to be strained. A February report from the Government Accountability Office said there were 264,086 primary care physicians in 2005, or about one for every 1,111 Americans. Here are the IOM's numbers and projections for geriatricians:

2007 2030
Geriatricians 7,128 7,750
Geriatricians per older adult 1 for every 2,546 1 for every 4,254
Geriatric psychiatrists 1,596 1,659
Geriatric psychiatrists per older adult 1 for every 11,372 1 for every 20,195

Source: "Retooling for an Aging America: Building the Health Care Workforce," Institute of Medicine, April

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Geriatrics training

Most medical schools offer coursework in geriatrics, though the depth of this education varies.

Academic leadership: Less than 1% of faculty specialize in geriatrics. However, all programs have an identified leader in geriatrics.

Exposure to geriatrics in medical school: Required by 98% of schools.

Advanced geriatric training programs: Internal medicine has 139 fellowship programs with 468 first-year positions. Psychiatry has 58 fellowship programs with 142 first-year positions.

Advanced geriatric trainees: Internal medicine has 253 trainees in their first year and 34 in their second year. Psychiatry has 72 trainees.

Source: "Retooling for an Aging America: Building the Health Care Workforce," Institute of Medicine, April

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