Medical Education Feature - January 2008
By Ken Ortolon
In 1997, Austin internist-geriatrician Peggy Russell, DO, CMD, came to a monumental decision in her medical practice.
"I decided I needed to do internal medicine or geriatrics but not both because the office care of geriatrics is so different than that for non-Medicare patients," Dr. Russell said.
So, she accepted a position as chair of geriatrics at Seton Medical Center and helped establish two senior health centers in the Austin area.
Things seemed to be going well. She hired two physicians and two nurse practitioners, and by 1999 they were treating roughly 850 patients.
Then Seton pulled the plug. Dr. Russell tried to keep the centers going, leasing space from Seton on a time-share basis. She laid off the other two physicians and cut her patient population back to about 350 patients.
But in 2004, Seton informed her she could no longer have the time-share arrangement on her clinic space. That was the final straw.
"At that point, I had to consider relocating and outfitting a whole new office," Dr. Russell said. "It took me about five minutes to know I couldn't afford to do that. I closed the office, and I had to say goodbye to about 350 patients, some of whom I had taken care of for 20 years."
She now sees patients in Austin area nursing homes, which she says is financially viable because her overhead is about half what it was when she maintained an office-based practice.
Dr. Russell is one of many geriatric specialists who find themselves in a financial bind treating older patients. Geriatrics is one of the lowest paying specialties, and experts say low pay and other factors are driving new physicians away from geriatrics even as the aging baby-boom generation is creating a tremendous demand for physicians with expertise in caring for the elderly.
And if something is not done quickly to reverse the trend, some experts say the shortage of geriatric specialists will hit crisis proportions within the next 25 years as millions of baby boomers hit retirement age
Geriatricians are important, "because for some older patients, being cared for by doctors and others with little or no experience in the field of aging can have dangerous - even deadly - consequences," a November 2002 AARP online bulletin points out.
"In the realm of prescription medicines, for example, some doctors do not know that older people metabolize certain drugs differently from younger people and may face potentially hazardous interactions from drugs prescribed by different practitioners," AARP said.
"In other cases, doctors dismiss an older patient's symptoms as a 'natural' part of aging when in fact they're caused by an illness or medical condition," AARP said.
The Numbers Game
An April 2007 study by University of Cincinnati researchers estimated that 70 million Americans will be over 65 by 2030. But in the past decade, the number of physicians specializing in treating older patients has declined from 8,800 to 7,100.
To make matters worse, geriatric fellowships across the country are having trouble recruiting physicians. According to the American Geriatrics Society (AGS), there were 468 geriatric medicine first-year fellowships available for the 2006-07 academic year, but only 253, or 54 percent, were filled.
Craig Rubin, MD, professor of internal medicine at The University of Texas Southwestern Medical Center in Dallas, says the problem could be more acute in Texas.
A 2002 study by the Health Professions Resource Center at the Texas Department of State Health Services predicted the elderly population in Texas would triple from 2 million to 6 million within 30 years. Those numbers will fuel demand for trained geriatricians because of the number of patients needing care. In addition, the report cited several other factors, including increased longevity, higher utilization of preventive care services, and the fact that baby boomers in general are better educated than previous generations and the educated typically have high utilization rates.
But Dr. Rubin and others say the prospects of attracting significantly higher numbers of doctors into geriatrics are remote for a host of reasons.
"In part it's societal," said Dr. Rubin, director of UT Southwestern's Mildred Wyatt and Ivor P. Wold Center for Geriatric Care. "People in our society have a negative view of older individuals. It's not as glamorous. Just turn on the TV. It's not as sexy as the ERs."
Barry L. O'Neal, MD, president of the Texas Geriatrics Society (TGS), says physicians who care for older patients also may get less satisfaction from their practice because of the high number of chronic illnesses they treat. If you are treating younger patients with acute illnesses, most of those patients will be cured, but elderly patients with multiple chronic illnesses likely will not.
But the biggest problem in geriatrics continues to be reimbursement. Geriatrics is one of the lowest paid specialties, which TGS Board of Directors member Steven Levy, DO, of Houston, says is a big disincentive for doctors to go into the specialty.
"For me to visit with a patient with dementia and his or her family for 25 to 30 minutes, I'm going to get paid $75, maybe $90, if I'm lucky," Dr. Levy said. "Another physician doing a procedure such as a coronary angiogram and stent that takes maybe 15 minutes longer is going to get paid three times that amount."
Dr. Rubin says geriatrics requires a different body of knowledge and a different approach to care than treating younger people because those who treat the elderly frequently have to deal with multiple diseases, as well as social, economic, and family issues not usually present with other patients.
"So the whole approach becomes more time consuming and doesn't lend itself well to our current system of reimbursement," he said. "We have a medical system that really doesn't lend itself well to addressing some of the concerns of older people."
Like Dr. Russell, Dr. Levy tried to run a full-time geriatric practice in the 1990s, but found it just wasn't financially viable.
"I went into practice in 1992 or 1993 and had virtually a 100-percent geriatric practice at that time," said Dr. Levy, who says he chose geriatrics because of a love of older people that arose from growing up in a household that included four generations of his family.
"I was thrilled. I loved it and we had a good practice," he said. "And then Medicare started to chop away, chop away, chop away until finally I could not maintain my business based on 100-percent Medicare patients."
In an article [ PDF ] published in the October 2003 issue of the Annals of Internal Medicine , Dr. Rubin and colleagues from UT Southwestern said Medicare must increase reimbursement for the most time-intensive components of geriatric clinical encounters and support the interdisciplinary teams needed to care for older patients.
"This would increase the availability of clinical settings for the teaching of geriatrics," the authors wrote. A secondary benefit would be to attract more physicians to take care of elderly patients.
The authors also urged Medicare to provide funding for graduate medical education in nontraditional settings, such as nursing homes and house call programs.
Changing the Curriculum
But those measures may be too little, too late to provide enough geriatricians to meet the near-term demand, the experts say. The heaviest burden for caring for the aging population likely will fall on family physicians, internists, obstetrician-gynecologists, and other primary care physicians.
Because of that, Dr. Rubin and others say it is critical that all medical students and residents, with the possible exception of pediatricians, get some exposure to geriatrics in their undergraduate and graduate training.
"The only opportunity for the future in a sense is to have enough academic geriatricians and to instill geriatrics throughout curricula," Dr. Rubin said. "So whether you're going to be a surgeon or whether you're going to be an internist or whether you're going to be a family practitioner, you'll have core basic (geriatric) concepts throughout medical school, whether it's talking about medication issues or some of the syndromes that tend to get ignored, like falls, incontinence, dementia, and so forth."
In their 2003 article, Dr. Rubin and his coauthors recommended the Liaison Committee for Medical Education and the Accreditation Council for Graduate Medical Education require explicit geriatrics training for medical students and internal medicine residents at schools and programs they accredit. Dr. Rubin says UT Southwestern has introduced geriatrics training in their family practice and internal medicine programs but these are not yet required elements of training.
Carmel B. Dyer, MD, director of the Division of Geriatric and Palliative Medicine at The University of Texas Medical School at Houston, says the school has incorporated geriatrics into its general curriculum.
"Not everybody is going to become a geriatrician but, unless you're a pediatrician, you will have geriatric-aged patients," she said. "So we're trying to give everybody some degree of gerontologic training before they finish medical school and definitely in the residency."
Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .