A chasm of need in geriatrics field

Dr. Jim Ericson is torn.

As a third-year resident in internal medicine, he knows his skills are desperately needed in geriatrics. But he would be poorly reimbursed for long hours working through the multiple health problems of older patients, and he needs to repay large medical school loans. If he headed into cardiology or gastroenterology, he says, he’d be “fantastically paid.”

Thousands of young doctors like Ericson face the same dilemma. And most of them are choosing to bypass geriatrics, even as the field’s need for specialists increases.

By 2030, 20% of the U.S. population will be 65 and older; up from 12.4% in 2000. Yet the number of certified geriatricians in this country -- internists or family practice doctors with additional certification in geriatrics -- will fall from 9,256 in 1998 to fewer than 6,200 by 2004, according to authors of a study that appeared last week in the Journal of the American Medical Assn.

The study, conducted by researchers at the University of Cincinnati Medical Center, included a survey of geriatrics program directors at U.S. medical schools. It was prepared for the Assn. of Directors of Geriatric Academic Programs, which seeks to improve geriatrics training.

Geriatricians provide more comprehensive care to older patients with complicated conditions than most primary care doctors and specialists. That kind of care translates into better physical functioning and better survival for elderly patients, some studies have shown. In addition, geriatricians are trained not just to seek cures but also to manage chronic disease, and they tend to be the doctors who deal with patients and families in the last years before death.

But several major obstacles stand in the way of young doctors who might otherwise choose geriatrics.

“There’s no financial incentive,” said Ericson, 37, who attended medical school after an eight-year engineering career. Doctors are paid to spend just a few minutes with patients, yet geriatrics patients need more time.

“Nobody can get to know an 80-year-old patient in eight to 10 minutes, even in an hour,” said Ericson, who is instead considering general internal medicine. He said he might specialize in geriatrics later if it becomes more financially feasible.

Geriatricians rely in large part on Medicare payments because most seniors are covered only through the federal health insurance program for those 65 and older and the disabled. Medicare payments to doctors, which were reduced in 2002, are slated to be cut further in coming years, deterring young doctors like Ericson, the journal report said. Even some veteran geriatricians have stopped taking Medicare patients, said Dr. David B. Reuben, director of UCLA’s multi-campus program in geriatric medicine and gerontology. That’s especially true with geriatric psychiatrists, who are reimbursed at a lower rate than other physicians participating in Medicare.

Another problem is the basic difficulty of dealing with very sick patients, often suffering from Alzheimer’s disease.

“Older people, particularly those who are frail or have cognitive impairment, are tough,” Reuben said. “I was with a resident about two weeks ago. I had this very sweet lady in her 80s who was incredibly demented and kept asking me the same things over and over again. The resident said, ‘I can cross geriatrics off the list. It’s too much work and it’s too difficult.’ ”

In addition, Reuben said, doctors trained to make patients better may not feel comfortable with patients they’re unlikely to cure.

“It’s very difficult compared to taking out a cataract or repairing a broken hip,” Reuben said. “It’s the lack of a quick fix.”

Geriatrics combines internal medicine, family practice, neurology, psychiatry and rehabilitation. Practitioners deal with problems common in later years, including confusion and dementia, depression, falls and physical instability, incontinence, chronic pain and end-of-life care. While other specialists may do their work in the office or a hospital, geriatricians also see patients in their houses, retirement and nursing homes, day care and hospices.

Medical centers are the key places to teach geriatrics. More than 60% of the heads of academic geriatric programs at U.S. medical schools who responded to a survey cited too few geriatrics researchers on their faculties, too few doctors pursuing advanced geriatrics training, poor reimbursement and a lack of institutional support as barriers to establishing stronger programs in geriatric medicine.

Academic geriatricians not only have a key role in contributing to the standards of care for seniors, they also should serve as role models for younger doctors, said Reuben, who was part of a national oversight panel for the study.

At Loma Linda University School of Medicine, where Ericson is in his third year, Dr. James P. Larsen not only works with the residents, he also lectures third-year medical students about evaluating memory loss, preventing bed sores and determining when a patient can be taken care of at home.

Such early instruction is one of many opportunities to build expertise among future doctors who most likely will not choose the specialty. Because primary care doctors and specialists without geriatric certification treat the vast majority of senior citizens, academic geriatricians like Larsen, along with the study authors, stressed the importance of making every med student, resident and practicing doctor, regardless of their specialty, better able to handle the unique problems of seniors.

“I do think that education and getting at them at an early stage does make a difference because it filters out to the community,” Larsen said. “You get the medical students involved, the residents involved and when residents graduate, many practice in the local community and continue some of those habits they’ve learned.”

The field of geriatrics will never be like pediatrics, where everyone of a certain age automatically goes to a geriatrician, Reuben said. However, there are patients who could benefit from the perspective and skills of a geriatrician. But they often can’t find one. Reuben cited the example of his own mother-in-law, one of the 25,000 seniors living at Leisure World in Laguna Woods, an Orange County community with few geriatricians.

Ericson said he recognizes the need for more geriatricians, but that would require an extra year of fellowship before he can get back on his financial feet. Right now, he said, “I’m wrestling with it.”