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The Geriatrician Shortage: Who will care for our seniors?

Posted Nov 29 2008 12:21pm

9CATYD5USCAZDRI7GCARKA1LHCA25HHJBCAQ4EUGUCAEIW3HACABQTPFLCAOV83Q7CAWCRSAICARIZOY9CAZYG32JCAH8AALLCA0KIJWYCA4YMGTJCAP4JUBXCA211THRCAWW5GF2CA8522MZCAAYAY5BCAQXGM8T.jpg A sweeping change is occurring at the basic structure of our society. We once were proud of the fact that we had a culture of caring for the aged. But the scenario is slowly moving towards growing neglect and isolation of elders on the one hand and lack of capacity and will of the government to reach out to them on the other.

Last week, Beth Israel Hospital in New Jersey, all but decimated it's geriatric department. Employees were unceremoniously terminated without any notice going out to the hundreds of elderly patients, advising them to make other arrangements. Not that these elderly really have other choices. Beth Israel serves a huge population of indigent elderly.

Theresa Redling, Beth Israel's Chief of Geriatrics, said she received her notice Wednesday. Ms. Redling, who also served as Hospice Medical Director at Beth Israel, was awarded the 2008 Humanism in Healthcare Award. This honor is bestowed, by The Healthcare Foundation of New Jersey, on individuals in the trenches of patient care who have consistently demonstrated the principles of caring and compassion in their work in hospitals and in nursing education programs in the Essex, Union and Morris region served by The Foundation.

"I think this will be devastating to the senior community that Beth Israel serves," Redling said.

Just as the United States is going grayer than ever, with baby boomers heading for retirement and adults age 85 and older making up the fastest-growing segment of the population, the shortage of qualified elder care specialists is expected to grow more acute.

According to the American Geriatrics Society, there are now approximately 7,600 certified geriatricians in the United States, and another 14,000 are needed to care for the elderly population adequately. By 2030, the nation will need 36,000 trained geriatricians to serve some 70 million adults age 65 and older—the largest Medicare generation in history.

Only one in 5,000 adults age 65 and older are under a geriatrician's care, according to the American Geriatrics Society.

Geriatricians are family or internal medicine physicians who have taken extra training in the area of aging and the special needs of seniors. In the words of Cheryl Phillips MD, a Sacramento geriatrician, “the particular focus of geriatrics training is the care of frail elders—where understanding how to assess and determine the individual’s ability to function is oftentimes every bit as important as understanding their diseases.” Thus geriatrics deals with coordinating long-term care for chronic conditions or helping seniors to manage their day-to-day life. Geriatricians tackle issues like confusion, dementia, incontinence, falls, depression, and the special effects that medications can have on the elderly.

As the New York Times explains, “caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying non-medical solutions, like timed trips to the bathroom to improve bladder control.”

We have a number of superb general internists and physicians in our community, and many of them do have the necessary skills to care for the frail elderly population. But many more believe they have those skills, and simply don’t. Geriatricians say that they routinely see patients who are overmedicated and/or given inappropriate medication and aren’t receiving proper treatment for incontinence, memory disorders, and other age-related issues. “The physicians who are treating them are fine, compassionate physicians,” they say. “But like the vast majority of American physicians, most of them did not have a single hour of geriatric training in medical school.”

In most cases, doctors are simply learning as they go, notes John Howard, M.D., an internist with Mercy Medical Group who also does rounds at two skilled nursing facilities. “I’m not trained as a geriatrician per se, but I think you can get a good sense of how to provide quality care to the geriatrics population by simply doing it on a regular basis,” says Howard, who feels fortunate to have received some training in geriatrics while in residency at UC Davis. “But there does seem to be a general shortage of folks who are able to treat the elders.”

Michael GuntherMaher, M.D., a geriatrician and medical director of Elder Care Services for Kaiser Permanente, takes a slightly more optimistic view. “The vast majority of patients will get adequate care from general medical practitioners,” he says. “They have for decades, they will for decades.” The larger issue, he says, is that appropriate care for the more vulnerable elderly requires a team of health professionals, “and that mostly doesn’t happen. Where do you find social workers, psychiatrists, nurses, and pharmacists and integrate them with doctors? Providing more geriatricians alone will not likely solve this problem.” Critical shortages in nursing and other allied health professions are also complicating the issue.

Unfortunately, our fee-for-service system, set by Medicare and mimicked by most private insurers, places a greater value on procedures than it does on the type of care geriatricians provide. As Dr. Laura Mosqueda, a geriatrician from the University of California-Irvine, told MSNBC in 2006, “you’ll get reimbursed better if you remove a wart than if you take the time to talk about how somebody’s doing after their husband passed away.” Working with patients is seen as having less worth than working on patients.

Experts see little hope that the geriatrician shortage will be resolved any time soon, largely because so few doctors elect elder care as a specialty. Geriatrics fellowships produce only about 300 new practitioners a year nationwide—a problem partly blamed on Medicare. “Almost all of the reimbursement for geriatricians is defined by very specific payments under Medicare,” says Sutter’s Phillips. “Geriatrics is probably the only area in medicine where the physician can spend a year or two in additional training and end up making less than if they had never done so.”

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