Story URL: http://news.medill.northwestern.edu/chicago/news.aspx?id=222236
Story Retrieval Date: 12/8/2013 11:13:33 AM CST
According to the U.S. Census Bureau, there were 40.3 million people age 65 or older in 2010, and by 2050 there will be up to 88.5 million. About 10,000 Americans turn 65 every day, according to the John A. Hartford Foundation, a non-profit focused on senior care.
There will be a shortage of 130,000 physicians across all specialties by 2025, according to the American Medical Association’s estimate. One reason is that Baby Boomers, who make up a large part of the physician workforce, are retiring, many of them earlier than earlier generations of physicians.
Additionally, there are only about 7,000 geriatricians nationwide, which is about half of the number needed currently and far less than what will be needed in the future, said Marcus Escobedo, program officer at the Hartford Foundation.
“We do not have enough providers and specifically geriatricians to provide care for these people,” Escobedo said.
Applications for geriatric fellowships nationwide fell 10 percent to 195 from 215 last year, according to a Hartford Foundation finding. Furthermore, fewer than 3 percent of medical students take a course in geriatrics, and there are no geriatric course requirements in most schools, according to the Hartford Foundation.
Treatment for diseases in older adults is different from that of younger people, necessitating the skill set of geriatricians, according to Richard Besdine, M.D., professor of medicine and Health Services Policy & Practice at Brown University.
“The reason there is a field is because these diseases that we know and hate in the middle ages present differently, need different evaluation, have different responses to treatment and the eventual outcome may be different,” Besdine said.
Furthermore, older patients present a wider array of medical complications and live longer with those conditions, said Mary Mulcahy, M.D., associate professor at Northwestern University’s Feinberg School of Medicine and a practicing oncologist.
A geriatrician takes a holistic look at the patient’s condition and discusses medications, lifestyle, nutrition and other needs. “A general geriatrician manages multiple complications within a population whereas a specialist comes in and looks at that one problem,” she said.
Internists are the doctors who mainly care for seniors, but the aging of Baby Boomers will affect other areas of medicine on which the elderly depend as well, said William Dale, chief of geriatrics and palliative medicine at the University of Chicago Pritzker School of Medicine.
“The most common person to get cancer is over the age of 65,” he said. “There are shortages in other specialties like oncology.”
The physician shortage is tangible already, Dale said, and is evident in the decreased time a physician can spend with patients. If a visit once took an hour, he said, it might now take 10 minutes.
“People are rushing to get things done quicker,” he said. “With older people, it just takes time.”
Unlike a specialist whose services generate large revenue for the care facility, like a gastroenterologist who performs costly colonoscopies, Mulcahy said, a geriatrician is paid less for his or her time.
“Because of that, the economics are skewed,” she said. “It’s time-intensive and they have no other source of billing.”
A geriatrician in Brown’s residency program makes around $125,000, Besdine said, after an internal medicine residency and a fellowship. A radiologist, who will have had fewer years of training, “can easily make double that,” he said.
The decision as to what specialty to enter often is therefore an economic one for medical students.
“A lot of students have a lot of debt and there is a lot of pressure against going into a lower paying field,” Dale said.
Psychological factors could also be exacerbating the shortage, according to Celia Berdes, Ph.D., director of the Social and Behavioral Sciences Program at the Buehler Center on Aging at Health and Society at the Feinberg School of Medicine.
“A lot of people haven’t had significant old people in their lives; they can’t imagine themselves as old people,” she said. “A lot of time in specialization it depends on the own interests of that person. It really is something that you have as opposed to something that you learn.”
Berdes pointed to gerontophobia, or a fear of aging and aversion to the elderly population, as a possible cause for health care professionals opting for specialties other than geriatric care.
“The specialization has always been problematic,” she said. “I think that’s because you really have to like old people in order to specialize in geriatrics.”
There is, however, hope for alleviating the shortage.
Some states, including South Carolina, incentivize geriatric care positions with loan forgiveness and reduction programs, Dale said. According to the Association of American Medical Colleges, the mean amount of debt 2012 medical school graduates carried exceeded $160,000 and 30 percent nationwide opted to enter a loan assistance program.
Illinois, with a state debt of $8.7 billion at the end of 2012, does not have such a program currently.
The Affordable Care Act, set to take effect in 2014, will afford many more seniors access to healthcare by strengthening Medicare and offering free preventive care services and wellness visits, thus further adding to the need for a robust healthcare workforce, according to HealthCare.gov, a website of the U.S. Department of Health and Human Services.
Escobedo said the new healthcare law could benefit geriatricians by changing the way billing works. It could mean a transition from the current fee-for-service system, in which a physician is paid for each service provided, instead of the time he or she spends with a patient.
“Trying to get as many patients in as possible doesn’t work very well for older adults,” Escobedo said.
One federal attempt at alleviating the problem is the Resident Physician Shortage Reduction Act of 2013, reintroduced by five members of Congress in March. It aims to increase the number of government-funded resident positions at teaching hospitals, by 3,000 each year between 2015 and 2019 for a total of 15,000.
While the legislation is a positive move, Dale said it is not entirely sufficient. “Not only does it sounds like it’s not enough but that it’s going to take a while for it to take effect,” he said.
Dale pointed to a growing number of medical school applications as a hopeful long-term solution for the strain. According to AAMC, applications were up to 45,266 in 2012, a 3.1 percent jump from 43,919 in 2011.
Furthermore, Dale said, younger doctors more often embrace new technology like electronic medical records, which could speed up data input and allow more time for a physician to spend with a patient.
The presence of geriatric nurse practitioners, who are trained to address the specific needs of older patients, could relieve the strain of doctors’ decreased time with a patient.
“I think the idea is fantastic and we’re trying to figure out how to make it work,” Mulcahy said.
Besdine is optimistic about an eventual solution to the shortage, even though it will not be immediate.
“It’s quite a challenge for physicians but I am absolutely confident as a profession we’re up to it,” Besdine said. “Geriatric education is getting more and more disseminated. We’ll eventually get it right. It’s just taking a long time.”