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More Elderly, Fewer Doctors
By Angela Stewart, Star Ledger
October 24, 2008
A looming shortage of doctors who specialize in caring for the elderly means these physicians should focus on the oldest, frailest and most vulnerable patients who need them most, according to a national survey of leaders in geriatrics.
The crunch will worsen as Baby Boomers age and the number of older Americans doubles over the next two decades, while the number of geriatricians is expected to remain steady at about 7,500, according to a survey and report in a special October issue of The American Geriatrics Society.
The national survey of leaders of academic programs in geriatrics found that the great majority -- 75 percent or more -- believed that geriatricians should center their efforts on patients who are 85 or older, who have trouble with day-to-day functioning or who suffer from multiple medical problems.
Those surveyed contend that younger and healthier elderly patients can be cared for effectively by general physicians, such as internists or family physicians.
The geriatrics journal aims to start a conversation among doctors and families about the future role of geriatricians -- and how to make the best use of these specialists since there are not nearly enough to go around.
"We're only training about 300 a year and we're losing people at the same time," said Gregg Warshaw, director of geriatric medicine at the University of Cincinnati College of Medicine and lead author of the article that detailed the survey results.
Geriatricians, like other primary care doctors, do not make as much money on average as specialists, who perform more lucrative tests and procedures. In 2006, the average geriatrician had an annual income of $162,000, while the average gastroenterologist earned $406,000, according to Warshaw.
"We can't respond to all the calls," Warshaw said. "So we need to communicate to the family doctor when it's okay to refer someone to a geriatrician."
The lack of doctors specializing in the frail elderly means that many such patients end up seeing multiple specialists, such as a cardiologist for the heart, a rheumatologist for arthritis and a nephrologist for kidney problems. The result is that no single physician coordinates the care and takes charge of the "whole person," said Knight Steel, chief of geriatrics at Hackensack University Medical Center. Even at his own hospital, where roughly a third of the beds on any given day are occupied by people on Medicare, there are not enough geriatricians to go around, he said.
"Seeing these patients takes a lot of time," Steel said. "Unfortunately, the American health care system is a disaster if you are trying to provide comprehensive care. The reimbursement rate for geriatricians compared to a specialist like an orthopedist or ophthalmologist is staggering."
By 2030, one in five Americans will be 65 and older, the journal article said. This means approximately 36,000 geriatricians will be needed, with Warshaw predicting a significant shortfall. He said trying to find a geriatrician in the community is already difficult.
Some trends in health care for the aging are nonetheless emerging.
Bruce Leff, an associate professor of medicine at Johns Hopkins University School of Medicine in Baltimore, has developed a model for treating elderly patients with common emergency room conditions like congestive heart failure in their homes, using the services of both geriatricians and nurses. An independent study found this "home hospital" model saved money and that patients had less mental confusion and reported greater overall satisfaction. Leff said there are ways to harness the knowledge and experience of geriatricians so that other health care professionals can benefit.
"I think any health system interested in the care of older people should be pulling geriatricians into their leadership systems to infuse those systems with geriatric principles," he said.
An editorial accompanying the journal study suggested that geriatricians should be involved in the training of internists and family physicians, as well as nurses, to ensure they have a basic competency in geriatrics care.
Theresa Redling, head of geriatrics at Newark Beth Israel Medical Center, said calling in a geriatrician, even as a consultant, can help all seniors "age better."
"The idea is not to wait to involve a geriatrician in a senior's care until they get frail," she said. "Small changes can make a huge, positive impact on the quality of an older person's life."
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