The New York Times recently asked, “Where are all the geriatricians?”
While there are 7,000 geriatricians practicing in the U.S. right now, there’s a larger issue. We will need many more in the coming years. According to the American Geriatrics Society, we’ll need approximately 30,000 by 2030.
Why? Older Americans over 65 will comprise 20 percent of the population by 2030, jumping from 35 million in 2000 to an estimated 70 million. This jump will be due in part to increased life expectancy.
At first glance this serves as a positive. Longer lives are among the blessings of living in the modern era. However, as people live longer, they are also susceptible to more chronic disease as they age.
The dramatic increase in chronic disease is a relatively recent phenomenon, driven by the rise in the older adult population, says Neil Resnick, M.D., the Thomas Detre Professor and Chief of the Division of Geriatric Medicine and Gerontology, and associate director of the Aging Institute of UPMC Senior Services at the University of Pittsburgh.
“Chronic illness now drives 85 percent of health costs,” says Resnick. “Until the last century, most conditions that brought people to the doctor and caused death were acute-care related. They’ve now been replaced by chronic conditions such as heart disease, stroke, cancer, and Alzheimer’s disease.”
So why do we need more geriatricians? What benefit do geriatricians offer that other doctors don’t?
For this, we turn to a geriatrician: Resnick.
“The value of a primary care physician cannot be overestimated. Better than anyone, the PCP knows the patient, his or her history, values, family, and the locally-available expertise,” says Resnick. “What the geriatrician adds is a complementary, but often critical, expertise, relevant to caring for older adults.”
Resnick explains older adults need an in-depth treatment program more than their younger counterparts, as they often take multiple medications, have more conditions, and require more time for consultations.
This can present treatment challenges, because evidence-based guidelines are generally designed for a younger adult with a single condition. But to an older adult facing changes related to aging, multiple diseases, and numerous drugs, these guidelines are often unfeasible, conflicting, inapplicable, or irrelevant.
Geriatricians can add expertise to help find answers to these treatment challenges.
“We are trained in differentiating how much of the patient’s problems reflect normal aging as opposed to diseases and the side effects of drugs used to treat the diseases,” says Resnick. “In addition, we’re experts in geriatric syndromes—conditions that are common in older adults.”
Geriatricians also know when and how to partner with experts in other disciplines, community resources, and the multitude of various settings and levels of care to devise and implement creative solutions to the particular care needs of older adults.
“This expertise helps us to peel back the layers and get to the root of the problem in ways that often differ from the approach that works so well in middle-aged patients who generally present with fewer conditions and in more classic ways,” explains Resnick.
The ultimate result of this knowledge is threefold. The geriatrician informs the patient on how their problems can be improved and additional problems prevented; he or she finds out the patient’s goals and what’s most important to them; and finally he or she partners with them to prioritize next steps in their treatment.
“As a result, it is rare for us to see a patient whom we can’t help and in whom we can’t improve their quality of life in a tangible and fundamental way,” notes Resnick.
Additional benefits accrue as well. Patients can remain in better health, more independent, and less likely to need hospitals and nursing care facilities. In turn, this can help reduce caregiver stress and costs to the patient, their family, and the health care system.
That’s also a positive because health care has undergone a metamorphosis. There’s now a pronounced focus on prevention. It’s all about keeping patients healthy, as opposed to keeping hospital beds full.
And because geriatricians are trained to identify risk, to understand the constraints posed by aging physiology, pathology, and pharmacotherapy, and to work with patients and the health system, they are well-positioned to address health risks before they can become a problem.
“In order to keep older patients healthy, you need to find the sweet spot,” says Resnick. “A geriatrician is trained to handle all of this. He or she is a good investment.”
Resnick has laid out a pretty good case for the value of geriatricians. And with so many more older adults, there will never be a lack of work.
According to Resnick, “Patients are often frustrated. But when they come to a geriatrician who makes them better without nursing homes, and with fewer doctor’s visits and less pills, they are immensely grateful.”
So, where exactly are all of the geriatricians?
Resnick has some explanations for why more medical students aren’t pursuing a career in this field.
The first has to do with ageism. There’s a stigma to being “older” both from the patients themselves and health professionals.
Many people think being called “geriatric” means they are in bad health, says Resnick. Ageism can afflict doctors as well, who might as a result dismiss a patient’s symptoms as a case of just being “old.”
Another reason has to do with the complexity of care it requires. “Taking care of older patients is not just complicated, but time-consuming. It requires a willingness to go through all of the diagnoses and explain them, the empathy to understand what the patient wants, and a willingness to deal with the system. It’s also about the ability to find joy in simply supporting patients, in helping to prevent or manage most of their conditions, since many can’t be reversed,” says Resnick.
Finally, it in some ways comes down to money. Geriatricians are as of yet not compensated on the level of their peers.
But all is not gloomy. Resnick also says there’s reason to be optimistic.
First, he notes studies have shown that geriatricians actually have a higher level of satisfaction in their profession compared to their peers. This belies the notion that taking care of older adults is an exercise in futility.
“Patients are often frustrated. But when they come to a geriatrician who makes them better without nursing homes, and with fewer doctor’s visits and less pills, they are immensely grateful,” explains Resnick.
Overcoming the stigma of ageism requires more education to show that older adults can be helped and are not just “old.”
At the University of Pittsburgh, the country’s first “major” in aging was created for medical students. In addition to enabling students to learn geriatric precepts, it also provides them with firsthand experience by pairing them with individual, community-dwelling older adults, with whom they meet over the course of their training. This also gives them a front-row seat into how a person’s health care problems are addressed by the system—from a patient’s point of view. This offers students valuable training and an increased understanding of the challenges these patients go through.
And as for the compensation, the law of supply and demand will eventually take care of that.
In general, Resnick remains an optimist. He has watched health care and his own profession change over the last couple of decades. And while the trends may change, the special place geriatricians have in the care of older adults never will.