Comments of a California Geriatrician on the Road Less Traveled

I naively assumed when I began my journey in the field of Geriatric Medicine, that I would be followed over time by hordes of other physicians, given the impending increase in aging populations.  While the population of seniors has nearly doubled, the number of physicians with Geriatric Medicine training has diminished. Less than 5% of the current California healthcare workforce is certified in geriatrics.  Moreover, the California Census Bureau projects a rate of growth of the age 65 plus population that far exceeds the other age groups, particularly among the 85 plus group, and among the non-White populations. The percentage of filled first year geriatric fellow positions dropped from 91% in 1998 to 45% in 2017. Currently, the American Geriatric Society estimates that there are 3,590 full-time practicing geriatricians, out of a total pool of less than 7,000 board-certified geriatricians. A professional colleague recently commented that if things continue to progress as they are, American geriatricians will become a historical footnote. 

Is there demand for physicians with training in Geriatric Medicine? My experience has been that older adults and their families are very motivated to find a geriatrician. Moreover, there is ample evidence that jobs are available, and often unfilled. There is no doubt that lack of available training opportunities is an important factor.  There are inadequate training opportunities because there are not enough training programs, or incentives to develop training programs. Although Medicare is the single largest source of graduate medical education funding in California teaching institutions, little effort is devoted to recruiting and training physicians specializing in the care of older adults, for whom Medicare was established.

Another important deterrent relates to income. Geriatrics is the only medical specialty in which an additional year of training results in lower salaries. My guess is that most of my geriatric medicine colleagues do not earn a living providing direct care to older adults. Their income comes from other sources: income from universities for teaching, income from hospitals and nursing homes for medical leadership, consultant fees from law firms or insurance companies for expert witness testimony, and monies from grants and foundations for research. 

Perhaps the most important reason for the lack of geriatricians is based on the attitudes of medical students and residents toward the elderly. From the time I began my training, I was often asked by medical colleagues why I wanted to waste my time in the care of elders.  I concluded over time that within the medical world, many (but not all) had negative, stereotypical attitudes about aging. A brief internet search will reveal ample evidence that my conclusion bears weight. 

What motivated me to take this journey? Long before I encountered training opportunities, my life experiences had opened my heart to the value of aging. I had numerous positive experiences with older persons that shaped my perception of aging.  Yet my original plan in medical school was to serve all ages as a family physician. The events that motivated me to alter my career trajectory toward serving an aging population and to direct my efforts toward training other medical professionals in Geriatric Medicine occurred later, when I actually started seeing patients. Direct contact with older patients changed my perspective. My personal discovery was that older patients were more likely to express gratitude for care, and more often open to listening to medical advice. I also observed that seniors are often accompanied by loving family members or caregivers who were appreciative of my efforts. I was fortunate that my medical mentors at the time presented me with ample educational opportunities in Geriatric Medicine. Such education taught me that older patients often have conditions that are manageable, which in turn reinforced my satisfaction in practice. 

Upon completion of my training, I discovered that primary care reimbursement was not optimal. Comprehensive geriatric assessment; a tool emphasized in most academic geriatric training programs, was not reimbursed by Medicare. I adapted by organizing my practice, training staff to help me in patient evaluation, hiring and training nurse practitioners to be practice partners, and streamlining my approach to geriatric assessment. I explored other things I could do besides my individual delivery of primary care. Caring for older adults requires that one utilize numerous health care services such as acute hospital, skilled nursing, hospice, and home health. I learned early on that most of those services require some type of medical leadership, and that frequently those leaders had no understanding of geriatric medicine. So I acquired medical direction skills so that I could diversify my revenue streams. 

I used my practice as a center of operations for ventures into graduate medical education. Over time I had medical students and residents shadowing me. Eventually I became a Geriatric Medicine Fellowship Director. My program emphasized the importance of learning how to provide adequate clinical care for seniors. I urged trainees to look beyond the traditional reimbursement model, and to develop skills in other areas. I provided training on roles in graduate medical education, medical direction in hospitals, clinics, and skilled nursing facilities, forensic consultation, and practice management. I promoted the importance of team development, and augmentation of a geriatric practice nurse specialists and nurse practitioners. I helped many graduating fellows navigate contracts for both small and large jobs in the field. 

It may be futile to contemplate solutions to the under-recognition of the importance of geriatric medicine professionals in California.  Yet I believe that it is critical to convince legislators, teaching institutions, and other professionals that Geriatric Medicine education has value so they will offer it. Also of paramount importance, we must encourage medical students and resident physicians to view a career in Geriatric Medicine as fulfilling, emotionally and professionally. We must also urge legislators to improve the current medical and long term care system so that the skills learned in geriatric training can be more easily implemented. Geriatric training programs must anticipate the kinds of experiences and skills that young geriatricians need. I share the opinion with many other leaders in long term care that geriatricians must have substantial leadership skills to be successful in the 21st century, and to avoid becoming a historical footnote.
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Comments on "Comments of a California Geriatrician on the Road Less Traveled"

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Timothy L. Gieseke - Friday, July 15, 2022

Frank, thank you for writing this piece encouraging physicians to develop geriatric expertise and use that expertise to improve the care of elders in their health system. It's unfortunate that the fees in private practice don't support a physician whose main source of income is from direct patient care. This is a flaw in our payment system that fails to support the care of complex seniors. My default was to take on leadership roles in systems of care which paid much better then direct patient care, but meant I took care of less patients then I would have like to have seen.

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