The medical profession has been troubled
for years by a persistent shortage of doctors who treat the oldest and sickest
patients.
By Paula Span Jan. 3, 2020
Linda Poskanzer was
having a tough time in her late 60s.
“I was not doing well
emotionally,” she recalled. “Physically, I didn’t have any stamina. I was
sleeping a lot. I wasn’t getting to work.”
A therapist in
Hackensack, N.J., Ms. Poskanzer was severely overweight and grew short of
breath after walking even short distances. Her house had become disorganized,
buried in unsorted paperwork. The antidepressant she was taking didn’t seem to
help.
Her son, visiting
from Florida, called his sisters and said, “Mommy needs an intervention.”
One of her daughters
made an appointment with a geriatrician — a physician who specializes in the
care of older adults. Dr. Manisha Parulekar, now chief of geriatrics at
Hackensack University Medical Center, suggested her new patient take action on
several fronts. She arranged for a sleep study, which found that Ms. Poskanzer
suffered from apnea. She prescribed a different antidepressant, and physical
therapy in a pool to help rebuild her stamina.
And weight loss. Eventually,
the geriatrician agreed that bariatric surgery made sense. Over nine months,
Ms. Poskanzer lost 75 pounds; she has shed another 15 since.
Now about to turn 80,
Ms. Poskanzer is still providing therapy, 30 hours each week, feels “full of
spirit” and continues to see her geriatrician every four months. “She sits and
talks, which a lot of doctors don’t do anymore,” Ms. Poskanzer said. “And she
knows me. I feel very well taken care of.”
Testimonials like
this spotlight the rising need for geriatricians. These doctors not only
monitor and coordinate treatment for the many ailments, disabilities and
medications their patients contend with, but also help them determine what’s
most important for their well-being and quality of life.
Patients like Ms.
Poskanzer often can’t easily find geriatricians like Dr. Parulekar, however. As
the nation’s older population surges, the gap between need and supply has
steadily widened, and a persistent shortage of geriatricians has troubled the
medical profession for years.
Geriatrics became a
board-certified medical specialty only in 1988. An analysis published in 2018 showed
that over 16 years, through academic year 2017-18, the number of graduate
fellowship programs that train geriatricians, underwritten by Medicare,
increased to 210 from 182. That represents virtually no growth when adjusted
for the rising United States population.
“It’s basically
stagnation,” said Aldis Petriceks, the study’s lead author, now a medical
student at Harvard.
Moreover, geriatrics
fails to attract enough young doctors to the graduate fellowships it does
offer. Leaving aside geriatric psychiatry, more than a third of 384 slots went
unfilled last year, the American Geriatrics Society
reports.
If one geriatrician
can care for 700 patients with complicated medical needs, as a federal model estimates,
then the nation will need 33,200 such doctors in 2025. It has about 7,000, only
half of them practicing full time. (They’re sometimes confused with
gerontologists, who study aging, and may work with older adults, but are not
health care providers.)
Why do so few
residents choose to specialize in geriatrics? Though salaries are rising, total
compensation (wages plus certain benefits) for geriatricians in 2018 averaged
$233,564, according to the Medical Group Management Association.
Anesthesiologists
earned twice as much; radiologists and cardiologists topped $500,000.
“These are smart
people looking at economic reality,” said Dr. Mark Supiano, a geriatrician and
researcher at VA Salt Lake City Health Care System. Treating patients covered
by Medicare, which pays less than commercial insurance, is a slow way to repay
medical school loans.
Nor does the field
offer much glamour or the prospect of medical heroics. “Having patience, having
good communication skills, it’s a different personality than being a surgeon,”
Dr. Supiano acknowledged. Yet a much-cited 2009 survey of 42 medical
specialties found that geriatricians reported higher career
satisfaction than most.
Not every older
person needs a geriatrician, but the federal model estimates that 30 percent of
the over-65 population does. This is especially true “when someone has three or
more chronic conditions and is over 85,” said Nancy Lundebjerg, chief executive
of the American Geriatrics Society.
That describes
Dorothy Lakin, 93, whose recent medical history includes heart failure, macular
degeneration, falls, colon cancer and heart valve surgeries, and a stroke.
“She’s had a zillion
trips to the E.R., one after another,” said her daughter Mary Ellen Lakin, 70,
who lives in Newton, Mass. “I thought, let’s see if there’s a way to make her
life easier.”
Mary Ellen Lakin
found her way to Dr. Laura Nelson Frain, a geriatrician at Brigham and Women’s
Hospital in Boston, who has gently steered mother and daughter through the past
year. She reduced the number of medications Dorothy Lakin took and the
specialists she saw, stayed in touch with Mary Ellen and sent a geriatric
nurse-practitioner to make house calls.
“It’s less of ‘Let’s
order this med, let’s order that procedure,’ more of a holistic approach,” Mary
Ellen Lakin said. Her mother recently entered hospice care.
Nevertheless, given
the numbers, “we’re not going to address this growing older population through
some miraculous influx of specialized geriatricians,” Mr. Petriceks said.
Leaders in geriatrics
agree, and while they continue working to bolster their numbers, they’re also
adopting other strategies. Dr. Mary Tinetti, chief of geriatrics at the Yale
School of Medicine, has called for geriatricians to
serve as “a small, elite work force” who help train whole
institutions in the specifics of care for older adults.
“The most important
thing geriatricians can do is make sure all their other colleagues” understand
these patients’ needs, she said, including nurse-practitioners, physician
assistants, therapists and pharmacists.
To some extent, this
is already happening. Medical associations representing cardiologists and
oncologists have begun focusing on older patients, Ms. Lundebjerg pointed out.
Health systems are
adopting age-friendly approaches,
like specialized emergency rooms. The American College of
Surgeons’ new verification program sets standards hospitals
should meet to improve results for older patients.
Last month the Senate
Committee on Health, Education, Labor and Pensions voted to reauthorize a $41
million program that educates health professionals in geriatrics; it
awaits a floor vote. A companion bill has already passed the House of
Representatives. “It’s money very well spent,” Dr. Tinetti said.
Health professionals
increasingly recognize that if they’re not in pediatrics, they will be seeing
lots of seniors, whatever their specialty. A 2016 American Medical
Association survey, for example, found that close to 40 percent of
patients treated by internists and general surgeons were Medicare
beneficiaries.
“Our medical students
are living and breathing this,” said Dr. Supiano, who also teaches at the
University of Utah School of Medicine. He warns them, “If you don’t like taking
care of older people, find another career.”
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