Jeffrey Levine needed a specialty.
As he was nearing the end of his studies at the Albert Einstein College of Medicine at Yeshiva University in New York City more than 25 years ago, he thought of his grandmother, and, he says, "It struck me as odd that I had almost finished my medical training, I had this 100-year-old grandmother, and no one ever talked to me about aging."
Almost all physicians leave medical school knowing enough about obstetrics, for example, to be able to deliver a baby in a taxi, but they get little or no exposure to geriatrics, the branch of medicine that focuses on the prevention and treatment of illnesses related to aging, and on improving the health and quality of life for older people. Yet while most physicians will have elderly patients, very few will ever deliver a baby in a cab.
Generally, geriatricians are primary-care physicians who have received additional training to qualify for certification in geriatrics. The scarcity of new doctors who receive such training today has created a crisis, says Dr. Levine, a geriatrician who practices in New York City. To make matters worse, many medical schools have phased out geriatric certification for nurse-practitioners. If you’re seeking a geriatric specialist today, Levine says, "I have two words for you: Good luck."
Where Are the Geriatricians?
According to Dr. Sharon Brangman, who chairs the board of the American Geriatrics Society, the United States currently has 7,100 physicians trained in geriatric medicine. But, she says, the country really needs about 16,000. And as baby boomers age, the demand will only rise. By 2030, Brangman estimates that the United States will need 36,000 geriatricians.
Medical schools produce about 200 new geriatricians each year.
To fill the gap, a lot of medical students will need to get interested in the specialty very quickly, says Levine, who maintains a blog on issues in the field. But that’s not likely to happen, for several reasons.
For one thing, geriatrics is not sexy, Levine says, because geriatricians don't cure people — aging is not a disease. But there’s another key reason he believes medical students overlook the field: The pay. "If you are a practicing geriatrician you will not make a lot of money," he says, at least in comparison to other specialties. Relying as they do on Medicare reimbursements, geriatric physicians earned an average of $183,523 in 2010. In comparison, dermatologists averaged $392,885 in the same year, according to the Physician Compensation and Production Survey. Medical students who leave school with six-figure debt, Levine says, "are not going to look at specialties that don't make money."
Geriatrics doesn’t pay as well as other specialties in part because patient appointments tend to be longer. A young patient may take 20 minutes of a physician's time for a checkup or diagnosis, while a visit with a geriatric patient requiring complex counseling can occupy as much as three hours.
Ageism in the Medical Field?
When Levine decided to become a geriatrician, he took one of the few geriatric fellowships available at the time, under Dr. Robert Butler, then chairman of the Geriatrics Department at Mount Sinai Medical Center in Manhattan. "Butler liked to say we live in a Peter Pan Society where we never grow old," Levine says.
Brangman agrees that in a society that's obsessed with avoiding old age, ageism is a factor in the shortage of geriatricians. Television medical dramas can have an especially powerful influence on the fields that young doctors choose as specialties, she says, but those programs "don't tend to portray old people in a very nice way." Too often, they are presented as whiners, cranks or manipulators, Brangman says, or worse, “they're infantilized. They're cute but no longer truly human." A more positive reflection of older patients on TV could make the field more appealing to young doctors.
Brangman's organization is doing its best to change the stereotypes, but it lacks the power of broadcast television. "We're trying to get the message out there," she says. "Maybe it's being heard, but it's not being acted upon."
Training the Next Generation
The coming geriatrics shortage "has to be addressed on a governmental and societal level," Levine says. He recommends a program of loan forgiveness for medical students who commit to the specialty, but believes students also need role models who can show them the rewards of practicing in the field. "The role models people have now are researchers, or doctors who perform specific procedures," he says.
An exception to the rule is the Iowa Geriatric Education Center at the University of Iowa, which incorporates geriatric care lessons into the university's medical, dental, pharmacy and nursing programs, as well as its Palmer College of Chiropractic. Iowa’s approach is rare, and that’s a shame, Brangman says. "Nurses, therapists, everyone in the health-care system should have a background in geriatrics," she says. "It is important to know what is normal aging and what is a disease. Aging is not a disease. It is a normal part of life."
A report issued by the Committee on the Future Health Care Workforce for Older Americans has called for immediate action to train health-care providers in basic geriatric care, and to offer similar training to relatives and other informal caregivers. The report, Retooling for an Aging America: Building the Health Care Workforce, further recommends that Medicare, Medicaid and other health plans pay higher reimbursement rates as a better incentive to recruit and retain geriatric specialists.