Shortage of Geriatricians




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Shortage of Geriatricians May Hinder Healthcare for Elderly

By Laurie Barclay, MD, Medscape

September 12, 2006

A shortage of medical students entering the field of geriatric medicine (GM) foretells a shortage of geriatricians, which may compromise healthcare in the elderly, according to the results of a Canadian study reported in the September issue of the Journal of the American Geriatrics Society.

"Fewer and fewer people are entering into geriatric medicine training programs," lead author Susan J. Torrible, MSc, MD, from the Geriatric Assessment and Consultation Program at Windsor Regional Hospital in Ontario, Canada, told Medscape. "This situation coupled with a large number of physicians retiring from the specialty in the next decade will result in a crisis — too few geriatricians for an aging population.

Dr. Torrible explained, "The purpose of this study was to develop an understanding of the reasons for choosing or not choosing a career in GM from the perspective of medical students, internal medicine residents, trainees in GM, and practicing geriatricians."

Dr. Torrible estimates that there are currently just under 200 geriatricians working in Canada compared with an anticipated need for between 512 and 607 geriatricians in 2006. With 4 to 9 residents entering a GM specialty training program each year, coupled with growth in the Canadian population older than 65 years and the projected retirement of many practicing geriatricians, the shortage will continue to worsen.

"If the number of physicians trained in geriatric medicine does not increase, it will become increasingly difficult for frail, medically complex older patients to access medical care from a doctor trained specifically in addressing health issues of the older patient," Dr. Torrible said. "The bulk of the care is currently provided by family physicians whose numbers are also inadequate in many locations in Canada. It will be difficult for family physicians to continue to provide care to their older patients with less help from geriatric medicine specialists."

GRIST Study Surveyed the Community

The Geriatric Recruitment Issues Study (GRIST) therefore evaluated specific strategies that could improve recruitment into geriatrics in Canada. Using a survey, the investigators asked respondents about factors affecting their choice of medical career, their perceptions of the attractiveness of GM, and the anticipated effectiveness of potential recruitment strategies.

Between November 2002 and January 2003, 530 participants were invited to complete the GRIST survey, including 117 Canadian geriatricians, 12 GM trainees, 96 internal medicine residents, and 305 senior medical students. Of the 253 surveys (47.7%) that were completed and returned, 54 were from geriatricians, 9 from GM trainees, 50 from internal medicine residents, and 140 from senior medical students.

Despite differences in responses among the 4 groups, there were consistencies in feedback between medical students and residents and between GM trainees and geriatricians. All groups agreed that role modeling was effective, but that summer student research programs were ineffective as a recruitment strategy.

"Overall, medical students and residents indicated that GM was an attractive career because of the perception of the specialty by others, the opportunity to make a difference for patients, and the lifestyle associated with the specialty, [such as] hours of work, call schedule, ability to work part-time, and balance with family life," Dr. Torrible said. "Those already practicing or training in the field of geriatrics identified attractive features of geriatric medicine as the intellectual challenge, work with interdisciplinary teams, older patients, focus on the whole patient, and making a difference for patients."

Some Perceive Geriatrics as Unattractive

Features of GM perceived as unattractive by medical students and residents were management of chronic illness, working in long-term care, administration responsibilities, level of income, and lack of opportunities for procedural and technical skills. Those already committed to GM reported that unattractive features of GM were the perception of the specialty by others and level of income.

Of the 190 medical students and residents who completed the survey, 22 (15.7%) reported an interest in considering a career in GM. All but one of these reported a positive work or volunteer experience with seniors, which was a significantly higher proportion than for those students and residents who did not report an interest in pursuing a GM career.

Compared with their colleagues who reported no interest in a GM career, medical students interested in geriatrics were more likely to note the attractiveness of caring for older patients, a total patient focus, complex patients, intellectual challenge, part-time work, and dealing with chronic disease. Residents interested in GM were more likely to have had a geriatrics rotation during residency, and to report that GM is attractive because of its perception by other medical professionals, the opportunity to work in long-term care, and the opportunity to make a difference for patients.

Effective Recruiting Strategies

"Effective recruiting strategies identified by the respondents included positive role models, increased remuneration, the creation of high-priority training programs, and mandatory rotations in medical school and residency," Dr. Torrible said. "This information could help in the development of effective recruiting strategies aimed at increasing the interest in, and numbers of physicians practicing in, a GM career."

Based on the GRIST findings, the investigators proposed 6 recommendations for improving recruitment into Canadian GM training programs.

When formulating recruitment strategies, consider feedback from all participants in the career path (medical students, residents, currently practicing geriatricians, and GM trainees).

Implement and integrate local, provincial, and national mentorship programs to best utilize the influence of role modeling. This could include aggressive recruitment of geriatricians to participate in mentorship programs and encouraging geriatricians to participate in undergraduate medical school courses to increase the exposure of students and residents to geriatric specialists.

Implement local, provincial, and national advocacy campaigns to increase undergraduate exposure to GM and to the care of older people. This could include advocating for and promoting geriatrics curriculum at the national level.

To increase the perceived attractiveness of GM as a career choice, implement student incentive programs similar to rural or northern medicine recruitment initiatives.

Consider decreasing the duration of GM training to increase the appeal of the specialty to Canadian medical students and residents, while increasing GM training opportunities for international medical graduates.

Initiate recruitment campaigning by national medical organizations at all educational levels to simultaneously highlight the need for geriatricians and available training positions.

Limitations of the survey include low response rate; response by hard copy or online varying among groups; lack of data on French-speaking students, residents, trainees, and geriatricians; and possible lack of generalizability beyond Canada.

The Canadian Geriatric Society supported this study, and the authors report no conflict of interest.

The US Perspective

For additional insight regarding the implications of this study for geriatric care in the United States, Medscape interviewed Jane F. Potter, MD, president of the American Geriatrics Society, and Harris Professor of Geriatric Medicine and chief of geriatrics and gerontology at the University of Nebraska Medical Center in Omaha.

"There is an increasing shortage of geriatricians due to an increasing number of older persons in need of geriatric care and a declining number of geriatricians," Dr. Potter told Medscape. "Strategies to increase recruitment to the field need to include not only better reimbursement but also getting the word out about how satisfying and enjoyable careers in geriatrics really are. Physicians must see that this work is valued not only by the patients but also by society."

At present, there are 7600 certified geriatricians in the United States compared with an estimated need of 21,000 currently, or 36,000 by the year 2030. Although approximately 350 individuals enter GM training each year, the number of individuals in US training programs has declined related to federal cutbacks to Title VII programs, and more geriatricians are retiring than are completing training.

"There is also a misperception on the part of young physicians in medical school and residency about careers in geriatrics," Dr. Potter said. "Some of the misperceptions include the fact that work hours are onerous and that the field lacks rewards. In fact, in a survey of over 12,000 physicians done a few years ago, geriatricians were among the most satisfied specialties in both medicine and surgery."

Public Health Implications

There are several public health implications to the shortage of GM specialists, according to Dr. Potter. Most of these stem from the role of geriatricians in promoting function in older people, which is "the major determinant not only of quality of life but also of the cost of care." Other areas of expertise offered by geriatricians are management of complex and interacting diseases, and recognition of the effect of aging and other conditions on physical health and mental functioning and independence. Although frail older persons often have a cost of care among the highest of any segment of the population, geriatricians can provide cost-effective care in a variety of settings, from outpatient clinics and hospitals to nursing home and assisted living facilities.

"Pharmaceuticals are among the most costly aspect of care, and the role of the geriatrician is to minimize polypharmacy and simplify treatment regimens," Dr. Potter said. "Understanding the patient's preferences regarding goals of care helps to ensure that the care that is provided truly meets the patient's desires. More care than what the patient truly desires is unnecessary expense, while too little care violates the standards of our society."

To ensure a sufficient supply of geriatricians during this century, Dr. Potter recommends, first and foremost, that cognitive services receive fair and equitable reimbursement. Medicare reimbursement for cognitive evaluation and management has been losing ground compared with technological services. Reimbursement is also needed for telephone management, coordinating care in and across various settings, and communicating with family caregivers and with other health agencies.

"Too much of what is important for care of especially frail older people occurs outside of face-to-face contacts with those patients," Dr. Potter concluded. "Unless physicians and other healthcare providers are reimbursed for providing these essential services, there will be too few providers willing to perform these services."