More geriatricians needed for baby boomers’ care

Ailing baby boomers hoping to get an appointment with a geriatrician to help oversee their increasingly complex medical needs may find themselves waiting in a long line.

The need for doctors to help manage the care of older patients with chronic conditions being treated by multiple specialists is expected to grow exponentially over the next two decades. But fewer medical school graduates -- often deterred by the prospects of relatively low pay -- are choosing to become geriatricians.

By the year 2030, people 65 and older will be 20 percent of the population -- up from 12 percent now. And though many will be in better health than older people are now, a growing share will be 85 and over. By then, it's hard to escape some manifestations of chronic illness.

"Eighty-five is when they start to get interesting in their complexity," said Dr. Diane G. Snustad, an associate professor and geriatrician at the University of Virginia. "Those are the ones who need me. Every doctor should have a sense of the spectrum of aging and be able to take care of older people. People who really need the intensive therapy and attention and the multidisciplinary attention, that's usually 80 and above."

Snustad is board-certified in geriatrics. To get those credentials usually means that after completing four years of medical school, doctors undertake a three-year paid residency in internal medicine or family practice. They then train for another one to two years in geriatrics.

The prospect of more years of training with no real financial benefit makes it difficult for geriatrics to attract young doctors. That's especially the case for students burdened with loans.

"Most fellowships you go to . . . you get paid more because you are a specialist," said Scott Abedi, 27, a second-year medical student at Virginia Commonwealth University who has an interest in geriatrics.

"You go into geriatrics, you get out, and you get paid less," Abedi said. "Most of your reimbursements are from Medicaid and Medicare, and they don't reimburse very well. . . . It doesn't attract people."

According to the American Geriatrics Society, the average salary for private-practice geriatricians in 2006 was $161,888 -- $2,133 less than family physicians and $15,171 less than internists.

In 2007-2008, just over half the 498 geriatrics fellowship training slots in the United States were filled. Data from the Association of American Medical Colleges show 2008 medical school graduates accumulated an average of $140,000 in debt. About 17 percent of medical students graduate without any debt.

"There is no real incentive like you see in other areas of medicine," said Danielle S. Avula, 25, also a second-year medical student at VCU. "There is this huge need, and it's growing bigger and bigger."

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For the summer, Abedi and Avula are shadowing Dr. Peter Boling, head of geriatric medicine at VCU.

As Boling and the students saw patients, the difference from a typical 15-minute visit was apparent.

The visits were longer. There was a caregiver in the room. One patient, Woodrow Page, 91, had been to the emergency room recently, and Boling called up the records from that visit on a computer. Page's daughter-in-law and caregiver, Gloria Page, filled in other details.

"I'm feeling fine right now, but when I left the house I was feeling kind of woozy," Woodrow Page said. His daughter-in-law, herself a health-care professional, thinks the shortness of breath he has complained about is a side effect of his medications. His weight is also going down because he's not eating.

"I've made his food as mechanically soft as possible," said Gloria Page. "He said if he tries to swallow, it won't stay down."

Boling looks through the medical records and notes there has been a consultation with a speech therapist to see if there is a swallowing problem. He goes over the medication, worrying aloud about how much fluid the patient can lose and still maintain good kidney function.

"How many older patients really need to have a geriatrician?" Boling asked. "I think most of us in the field feel that the folks who really need a geriatrician are the ones who are really complex and unhealthy. Those are the ones where the unique knowledge of the geriatrician is most beneficial." Patients like Page -- frail, taking a number of medications and with some disability -- benefit most from specialized care of geriatricians.

Boling said there are about 40 million Medicare beneficiaries. Of that number about 4 million to 8 million are having a rough time, coping with multiple chronic conditions. They are the ones responsible for a big chunk of health-care spending.

Boling believes dollars could be saved if experts in geriatrics were available to help oversee the care of patients who need multiple specialists and who take multiple medications. He would also like to see more of that care provided to patients at home, and is working with others to get support for the Independence at Home Act, introduced in Congress this year.

Geriatricians typically work as part of a health-care team that may include nurses, social workers, pharmacists, rehabilitation therapists, psychiatrists and others who often also have training in caring for older people.

An April 2008 Institute of Medicine report calls for more geriatricians but also a "fundamental reform in the way the work force is trained and used to care for older adults." Not only are there not enough doctors trained in caring for older people, but also there should be more nurses, pharmacists, physician assistants and social workers who have some training in geriatric care. The report also recommends better training of nurse aides, home health aides and personal-care aides who do much of the hands-on care of elderly people.

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David Sadowski, executive director for the Crater District Area Agency on Aging, thinks the pay issue is not the only thing that dissuades students from pursuing geriatrics. As families have scattered, there is not the sense that there used to be that older people are part of the family continuum.

"It's a different world and a different family situation," said Sadowski, a gerontologist. "In my generation, we were involved very closely with grandparents. Younger people may not have that same appreciation that older generations have. A lot of them are separated by miles."

Julia Siegel, 25, is one young person who sought out such contact. She started volunteering at a long-term care facility at age 12. She would spend summers and weekends there, and her interest continued when she got to undergraduate school at the University of Virginia. There she did research on cognitive aging and later worked for a senior services organization.

"Years ago, one of the residents on the Alzheimer's and dementia unit said, 'I don't remember your name, but I remember your heart.' I hope to be remembered in this way as a physician," Siegel said. "By my last year of college, I decided that medicine would be the most effective way for me to serve the elderly."

She, too, wishes geriatricians were compensated better.

"I'm sure it will be frustrating to watch my classmates make double, triple, and even higher salaries despite having trained the same amount of time for our specialties. I'm surprised there aren't more scholarships or loan-repayment programs for those interested in geriatrics."

By their sheer numbers, baby boomers will be in a position to force change.

"They want good medical care, but they also want medical care in an environment that is not institutional. They want a doctor to come to their home," Sadowski said. He shares caregiving duties for his mother. Torn on what to do as his mother's health declined, he was told about a medical group, New Era Physicians, that does home visits. It has worked for them.

"We got her psychological status much better," Sadowski said. "I have heard that same story from other people. You get them home, get them in their environment and they thrive."

Damien Howell, caregiver for his sister Patrice Howell, 66, can relate. His sister, who has early onset Alzheimer's disease, is one of Boling's patients. At a recent visit, she was able to answer when Boling asked how she was doing.

"Not too good," she replied. It may not seem a big deal but months ago she was in hospice care and not expected to live much longer after contracting an infection that led to delirium. She was unable to speak.

"She did Lazarus coming out of the dead. She really did make a remarkable recovery," Damien Howell said. Under Boling's care, Howell said, his sister has flourished.

"It's a multi-system disease. She needs someone who can manage all the specialists. Dr. Boling really fills those needs and has really helped in her care and her quality of life."

Contact Tammie Smith at (804) 649-6572 or .