Thirty-five years ago, Jerry Gurwitz was among the first doctors in the United States to be certified as a geriatrician — a doctor who specializes in the care of older adults.
“I understand the demographics and the issues facing older patients,” Gurwitz, 67 and chief of geriatric medicine at the University of Massachusetts Chan Medical School, told me. “I felt that this field presented tremendous opportunities.”
But today, Gurvitz fears geriatric medicine is declining. Despite a growing elderly population, there are fewer geriatricians now (just 7,400) than there were in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and over grew by more than 60%.) Research suggests that each geriatrician should care for no more than 700 patients; The current ratio of providers to elderly patients is 1 in 10,000.
What’s more, medical schools do not require students to be taught about geriatrics, and less than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors completing the one-year fellowship required to specialize in geriatrics is narrow. 30% of 411 geriatric fellowship positions remain unfilled in 2022-23.
The implications are stark: Geriatricians will be unable to meet the growing demand for their services as the elderly US population continues to grow over the next few decades. There are very few of them. “Tragically, our health system and its workforce are completely unprepared to deal with the coming wave of multimorbidity, functional impairment, dementia, and frailty,” Gurvitz warned in his JAMA piece.
This is far from a new concern. Fifteen years ago, a report by the National Academies of Sciences, Engineering, and Medicine concluded: “Unless immediate action is taken, the health care workforce will lack the capacity (both in size and capacity) to meet the needs of older patients. Future.” According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.
This target is unlikely to be met.
What is impeding progress? Gurwitz and co-physicians cite a number of factors: low Medicare reimbursement for services, low earnings compared to other medical specialties, lack of prestige, and the belief that older patients are unlovable, too difficult, or not worth the effort.
“There is still tremendous ageism in the health care system and in society,” said University of North Carolina professor Greg Warsh.
But this negative view is not the whole story. In some cases, aging has been remarkably successful in disseminating policies and practices to improve care for older adults.
“What we’re really trying to do is expand the tent and train a health care workforce where everyone has some degree of geriatrics expertise,” said Michael Harper, board chair of the American Geriatrics Society and professor of medicine at the University of California, Berkeley. -San Francisco.
Among the principles geriatricians champion: Older adults’ priorities should guide plans for their care. Clinicians should consider how treatment will affect the senior’s function and independence. Regardless of age, frailty affects how older patients respond to illness and therapy. Interdisciplinary teams are best suited to meet the often complex medical, social, and emotional needs of older adults.
Medications need to be regularly re-evaluated, and de-prescribing is often warranted. It is important to maintain mobility after an illness. Non-medical interventions such as paid assistance at home or training of family caregivers are often as important or more important than medical interventions. A comprehensive understanding of the physical and social conditions of older adults is essential.
The list of innovations led by geriatricians is long. A few notable examples:
Hospital-home. Elderly people often suffer setbacks during hospital stays because they stay in bed, lose sleep, and eat poorly. Under this model, older adults with acute but non-life-threatening illnesses receive care at home, closely managed by nurses and doctors. At the end of August, 296 hospitals and 125 health systems — a fraction of the total — were approved to offer hospital-at-home programs in 37 states.
Age-friendly health systems. Focus on four key priorities (known as the “4Ms”) are key to this broader effort: protecting brain health (Mrentation), careful management Mredications, save or advance Mrpower, and what care MrOlder adults get the most attention. More than 3,400 hospitals, nursing homes and urgent care clinics are part of the age-friendly health care movement.
Geriatrics-focused surgery standards. In July 2019, the American College of Surgeons developed a program with 32 standards designed to improve the care of older adults. Hampered by the Covid-19 pandemic, it has started at a slow pace and only five hospitals have been accredited. But as many as 20 are expected to apply next year, said Thomas Robinson, co-chair of the American Geriatrics Society’s Geriatrics for Specialists Initiative.
Geriatric Emergency Department. The bright lights, noise, and harsh environment of a hospital emergency room can disorient older adults. Geriatric emergency departments deal with this with staff trained to care for seniors and in a calm environment. More than 400 geriatric emergency departments are accredited by the American College of Emergency Physicians.
New dementia care models. This summer, the Centers for Medicare and Medicaid Services announced plans to test a new model of care for people with dementia. It builds on programs developed over the past several decades by geriatricians at UCLA, Indiana University, Johns Hopkins University, and UCSF.
A new frontier is artificial intelligence, with geriatricians consulted by entrepreneurs and engineers to help older adults live independently at home. “For me, it’s a great opportunity,” said Lisa Wocke, chief of geriatric medicine at Penn Medicine, which is affiliated with the University of Pennsylvania.
The bottom line: After decades of geriatrics-focused research and innovation, “we now have a very good understanding of what works to improve care for older adults,” says the American Geriatrics Society’s Harper. The challenge is to build on this and invest significant resources in expanding the program’s reach. Given competing priorities in medical education and practice, there is no guarantee that this will happen.
But this is where geriatrics and the rest of the health care system must go.
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