January 19, 2020

Where Have All the Doctors Gone?

The New York Times began the new year with a spate of bad news, including a column with the imploring title “Older People Need Geriatricians” and the despairing subtitle, “Where Will They Come From?” The author, Paula Span, who has for years written insightful and informative articles about aging, made a number of valid points about the shortage of geriatricians: projections are that the US will need over 33,000 geriatricians in just five years, but there are only about 7000 in practice today; and one-third of training slots in geriatric fellowship programs went unfilled last year. 

What struck me about the article is that I recall the NY Times running a very similar piece a few years ago. A quick search revealed that indeed, exactly 4 years ago, the Times had a piece called “As the Population Ages, Where Are the Geriatricians?” This essay pointed out that geriatricians are just about the lowest paying subspecialists in the US, earning less than half of what a cardiologist typically makes. They even make significantly less than a general internist—though geriatricians have more training.

The Times is not the only major newspaper to bring the issue to public attention. As far back as 2013, the Wall Street Journal had a column “Desperately Needed: More Geriatricians.” A year later the same paper ran another piece with the same theme but a possible fix. Entitled “A Remedy for the Looming Geriatrician Shortage,” it reported on a consortium involving four medical schools, Icahn, Johns Hopkins, Duke, and UCLA, that focuses on training medical school teachers. Instead of aspiring to develop full-fledged geriatricians, they offer 3-5 day, intensive training modules to medical school faculty members to enable them to transmit expertise in falls, dementia, incontinence, delirium, and other geriatric topics to their students. Funded by the Reynolds Foundation, the program had managed to train 430 physicians over the course of 10 years. The “Program for Advancing Geriatrics Education” (PAGE) ended in 2017.

The real problem, as implicitly acknowledged by PAGE, is not so much the shortage of geriatricians as the lack of geriatric medical expertise. So why has it been so difficult to remedy the situation—the gap between supply and demand has been growing, not shrinking? And what are we going to do about it?

Several explanations have been advanced, each with a corresponding solution. Since compensation for geriatricians is comparatively poor, economists argue, just improve salaries. This means modifying the Medicare fee schedule since the patients under discussion are almost all on Medicare. Since it’s going to be very hard to increase the size of the total pie, giving a larger share to physicians who see geriatric patients will mean giving a smaller share to cardiologists and orthopedists. That won’t go over well with the cardiologists and the orthopedists, not to mention the gastroenterologists, ophthalmologists and other procedure-oriented specialists, who are all well-paid under the current system. Pervasive ageism is another probable cause. More physicians are likely to want to care for older patients if the society as a whole values older people. Society doesn’t and physicians, who are after all members of society, tend not to either. In fact, the reason that so many of the young physicians who accept geriatric fellowship residency slots are from other countries is that ageism is perhaps not so endemic in the developing world. Changing attitudes is going to be even more difficult than modifying the Medicare fee schedule. 

In light of the obstacles faced by each of the proposed solutions, we need to turn to a quintessentially geriatric way of looking at the world: instead of seeking a magic bullet, instead of expecting that there is one root problem and therefore just one problem that needs fixing, we should accept that the problem is multifactorial. Poor reimbursement, ageism, the absence of procedures, insufficient role models all contribute to the shortage of geriatricians and the lack of geriatric expertise among generalist physicians (both internists and surgeons). The fix will likewise have to be multifactorial. Build on pioneering strategies that involve co-management by a geriatrician and an orthopedist for hip fracture patients. Develop screening tools for frailty and refer the frailest of the frail to geriatricians. Maybe we can’t make a great deal of headway in any of these arenas, but perhaps we can improve things a little bit in each of them. And that would be a good start.