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Confronting a patient explosion

The New Physician January-February 2007
This month, The New Physician inaugurates a new regular department, “Specialty Close-up.” In each issue, we will examine a medical specialty in depth to give readers facts and perspectives as they weigh their specialty choices.

Geriatrics at a glance

  • Median salary: $155,000
  • First-year fellowship slots: 442 in 131 programs
  • Number of U.S. practitioners: 7,000
  • Patient population: one geriatrician for every 5,000 Americans over 65

Over the next 20 years, a tsunami of aging baby boomers will sweep the United States, and it’s an event for which our medical system may not be prepared. Geriatricians say that, like it or not, all physicians will have to incorporate more care for elderly patients into their practices, and more specialties will likely add certifications in geriatric care.

And while the over-65 population is about to explode, the supply of geriatricians isn’t growing much at all—in 2004, fewer than 300 physicians entered geriatric medicine fellowships, a number that has remained virtually unchanged for years. Over half of the fellows were international medical graduates, and the number of fellowship slots remaining unfilled hovered around 31 percent, according to a workforce study by the Association of Directors of Geriatric Academic Programs.

The number of geriatric psychiatry fellows is actually declining: There were just 79 in 2004–05, down 16 percent from three years earlier.

Most geriatricians have internal or family medicine backgrounds. They either serve as the primary care physician for patients over 65, or consult as a specialist when another physician has found that age has made a case too complex. Some geriatricians travel around several assisted living facilities or nursing homes to see patients.

Though the current pathway to board certification in geriatrics leads through either a family or internal medicine residency, followed by a one-year fellowship, geriatrics isn’t necessarily just family practice for the elderly. Other specialties may soon be picking up the certificate as well.

Dr. Germaine Odenheimer is both a geriatrician and neurologist, a twist the Oklahoma City academic physician believes we’ll see a lot more of in the coming years. A geriatrics certificate for neurologists might be available in the next year or two, she believes. Odenheimer spends about one-third of her time doing clinical work, primarily seeing patients with dementia.

At Dr. Wayne Chen’s private practice in Southern California, around 70 percent of patients are seniors. His other job as director of the University of Southern California’s Home Visit Program takes him into the community to treat hundreds of home-bound elderly. The care is far more involved than treating acute conditions, he explains. “For new patients, I’ll try to assess what their social support system is.” For example, a patient might need help taking medications.

Though some of the home-bound patients live with family, many are alone, and some are seniors taking care of even older people. Chen mentions a household with a 100-year-old woman living with her daughter and granddaughter—all of whom are seniors.

He follows up with patients about once a month, depending on their particular needs. His work also requires coordinating a network of home-based medical services such as equipment suppliers and caregivers.

Such home visit programs help keep hospitalizations of seniors and associated costs down. Providers can also keep an eye out for Medicare fraud—or elder abuse.

There’s also plenty of research opportunities for improving the care of a delicate patient population. “As I went through my residency, I found out that the people I liked taking care of, the sorts of issues that I liked dealing with, were the complex [ones],” says Dr. Jacob Blumenthal, a geriatrician who spends most of his time doing research at a federal Geriatric Research Education and Clinical Center in Baltimore, Maryland, one of 21 developed by the Veterans Health Administration. Geriatrics is full of complex patients, so the choice was a “no-brainer” for Blumenthal. His fellowship consisted of one clinical year and two in research. “There are lots of unanswered questions that someone like me can break into.”

Currently, his work focuses on fat tissue as an endocrine organ. “The cocktail-party answer is that we’re finding now that fat isn’t just a repository for excess energy; it is also an organ that secretes mediators,” he explains. On top of the possibility that the fat’s specific region affects those mediators, the age of the patient may also play a role.

Harvard Medical School second-year Elizabeth Kwo cites her grandparents as stimulating her interest in geriatrics; the broader social issues of aging also appeal to her.

“This country is very youth-focused, and I feel like the elderly are often overlooked. And oftentimes, I think this idea of aging seems to scare a lot of people,” she says. “I could really see myself helping people to embrace aging to a point where...they look at it like a natural process, rather than a process to avoid.”

Kwo hopes to set up a concierge-style practice that will help finance her work in the community. She is developing an idea she calls an “aged manpower bank,” in which seniors take their skills and experience to the community, such as in a library, while also staying active.

Though no one has discouraged her plans to follow an internal medicine residency with a career in geriatrics, many of her peers are surprised. Her classmates say things like, “That’s very admirable.”

“Geriatrics is just not the glamorous, sexy fellowship that people talk about,” she says. “But [that] has never been a deterrent.”

One concern voiced by students interested in geriatrics is the compensation, which is more comparable to family practice than surgery. The median salary for an internal-medicine-trained geriatrician was $155,000 in 2003, up 2.3 percent from 2000. Meanwhile, the median salary for a urologist was up 14 percent over the same period, to $344,000.

“I’m sure my classmates will be making about twice as much as I will going into primary care. I do think about that, but ultimately I can’t see myself doing anything else,” Kwo says.

Which is probably a good thing: According to workforce studies, the number of geriatricians needs to start climbing, and soon—the wave of aging baby boomers is on its way, and people aren’t dying any younger.

Simha Ravven, on a one-year research fellowship at the University of Iowa between her second and third years at Tulane University School of Medicine, is concerned about funding for geriatrics training, and whether there will be enough fellowship slots. Currently, there are—but only because they aren’t being filled.

The American Geriatrics Society’s May 2006 position paper for the American Board of Medical Specialties outlined potential changes to training requirements for a specialty that, according to Census projections, may have 70 million patients in its demographic in just over two decades. The authors could not reach a consensus on whether to keep the one-year fellowship model, or extend it to a required two years and risk losing recruits even while improving the quality of training.

Ravven points out that some medical schools have started incorporating geriatrics into the curriculum during the first two years. “That engenders an interest in it,” she says.

Odenheimer agrees, and from personal experience. In addition to seeing patients, she teaches at the University of Oklahoma Health Sciences Center, the first school to require geriatrics training. During the second year, for example, students learn about the personal challenges of aging by wearing diapers during a two-hour session. Some are given “arthritis,” and everybody has to count pills at the pill station. And they have the pleasure of “paying” for it all at the bill station when they are done. Even for those students who might not be driven to the specialty by the experience, there is a tangible benefit.

“One of the things that I see, from my perspective, is the need for geriatrics to become part of lots of other specialties,” Odenheimer says. “I think a lot of students may or may not think of doing geriatrics up front, but clearly the population demographics are going to absolutely demand geriatricians.... Whether people go into geriatrics directly, or whether they go into it through another specialty, I think that most physicians are going to have to have a substantial amount of geriatric training in the next 10 years or so.”
Pete Thomson is associate editor of The New Physician.