Past, present and future: Geriatrics in American health care
Before COVID-19, geriatricians across the country found themselves significantly outnumbered by the growing senior population and their complex chronic conditions. Projections in the United States showed that if one geriatrician could care for 700 patients, the country would need 33,200 doctors by 2025.
At the current rate of increase in new geriatricians entering the field, this could result in a national shortage of 26,980 full-time equivalents. There are also estimates that half of available doctors only work part-time. While regions like the District of Columbia are making ends meet with 47 geriatric doctors per 100,000 citizens, at least 10 states have fewer than eight.
This uphill battle becomes compounded by the significant impact of COVID-19 on nursing homes and seniors across the country. There’s also the cost associated with senior care — 5% of the population is responsible for 50% of all health care spending.
Dr. Marc Arenas, a board certified geriatrician and family physician, believes that people in the specialty have known of the shortage for the senior population for quite some time; however, there are several major hurdles in recruiting young professionals to geriatrics including salary opportunities.
“After spending 10 years engrossed in your studies, coming out of that in significant debt is a difficult proposition for a lot of physicians, especially those who are sole providers for their family,” said Arenas. “Even if they’re passionate about geriatrics, the economics just don’t make sense. And in major cities, it’s a harsh reality that even those who are very talented physicians might have to choose a different specialty due to a significant gap in possible income.”
According to the Association of American Medical Colleges, around 20,000 students enroll in medical school each year and just 0.57% end up specializing in geriatric medicine. Even if the U.S. could attract 10 times more residents to geriatrics, the number needed would still fall short.
A specialty ready for change
While there isn’t a one-size-fits-all approach to addressing the shortage of geriatricians in the country, many potential solutions have been discussed within the medical community. The one agreeable point is that change needs to happen sooner rather than later. David Grabowski, a professor at Harvard Medical School and healthcare policy researcher, believes that the current tenuous business model for the nursing home industry will need to be dramatically changed or there will be pushed beyond the brink of return.
Here are a few areas that will need the most focus in order to create positive change for geriatrics.
1. The salary gap
It may sound like a very simple fix but increasing the overall pay would clearly attract more young professionals to geriatrics. According to the New York Times, geriatrics is among the lowest-paying specialties in medicine. In 2014, the median yearly salary of a private practice geriatrician was less than half a cardiologist’s income.
But where would this “extra money” for an increase in salaries come from?
Unfortunately, that is where this “simple” fix becomes quite complex. While there may be a growing senior population equating to potentially more nursing home residents, COVID-19 may force a shift away from long-term care facilities in favor of family caregivers. These facilities are already navigating tight margins, and a further reduction in revenue (i.e., depending on how long the coronavirus impacts nursing homes) can be disastrous.
2. The knowledge gap
Prior to COVID-19, caring for seniors with multiple chronic conditions typically led geriatricians down paths filled with nuances. Arenas believes that older adults are often excluded from studies due to their high number of comorbidities and tendencies to become chronically ill — regardless of preventative measures taken.
“Historically, adults over the age of 85 are excluded from studies, especially those who have multiple chronic conditions. While that is usually appropriate for adult medicine, it leaves a knowledge gap in geriatric medicine,” said Arenas. “As a geriatric practitioner, it feels like the Wild West. Incomplete case studies leave us frustrated and can’t properly estimate what is going to happen with a specific patient because we have incomplete data. The wealth of knowledge around senior care simply isn’t there yet.”
As COVID-19 studies and vaccines progress, there is some concern that seniors may be disqualified despite 80% of deaths in the country having occurred in people over the age of 65.
“A year from now, when these trials are published, I don’t want to see that there’s no one in them over 75,” Dr. Sharon K. Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, told the New York Times. “If they create a drug that works really well in healthy 50- and 60-year-olds, they’ve missed the boat.”
3. Rebranding geriatrics
Geriatric medicine is often viewed negatively by medical students. In terms of training, geriatricians need an extra one to four years compared to their internist colleagues. The media has also created a negative portrayal of what it means to work in a nursing home — especially during a pandemic.
Physicians in training seek opportunities that are both intellectually engaging and emotionally appealing, according to a study published in BMC Medical Education. It’s important to highlight that geriatricians report greater satisfaction with their careers than doctors in other specialties. The same study suggests merely exposing students to geriatrics, especially earlier in their academic careers, could help.
4. Taking a different approach
Given the pressing need in the U.S. for geriatric health specialists, the issue must be analyzed from all angles. The best way to do so may be to adopt an interdisciplinary geriatric care team model.
Geriatricians would step into an advisory role — consulting on the most complex and severe cases. Geriatric social workers, pharmacists, psychologists and psychiatrists would play similar but less holistic roles; contributing their expertise to those cases most relevant to their training. In this model, gerontological nurse practitioners would replace geriatric doctors as seniors’ primary healthcare providers, and other geriatric specialists — from home health aides and family caregivers to physician assistants and medical technicians — would continue doing much of the heavy lifting while receiving more support and better compensation for their efforts.
By strengthening the geriatric interdisciplinary team, the U.S. could bridge the gap between geriatrician supply and demand and also achieve better health outcomes at scale. Increased quality of care, enhanced patient safety, better management of chronic health issues, more adherence to medication and treatment regiments, fewer adverse reactions to incompatible drug cocktails, longer-lasting function and mobility, fewer hospital readmissions and lower costs are just a few benefits we can look forward to.
COVID-19 will forever change senior care and how the country views nursing homes. And while the future of geriatric medicine may seem to be up in the air, there is hope for the growing number of seniors who are in desperate need for it. It just may take on a different look or feel to it.