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We Need More Geriatricians, Not More Primary Care Physicians

Article · June 28, 2017

What our country needs now is more geriatricians. Geriatricians specialize in the care of older adults, whether working as consultants or as primary care physicians. Their role in primary care is increasingly important because our current primary care system is ill-equipped, and in some cases, unwilling, to provide care for older adults. Ironically, the patients who need primary care the most — those with multiple chronic illnesses, or those with dementia or other aging-related syndromes — are usually the ones who cannot find accessible primary care physicians in family medicine or general internal medicine. This hit home recently when a former patient of mine was “fired” by his primary care physician (PCP) because he had missed “too many” appointments. He is 78 years old, lives alone with few social supports, has several chronic illnesses, multiple specialists are involved in his care, and he has a hard time with mobility and transportation. This was an emotionally devastating blow to him, and despite my help, finding a replacement PCP was challenging. It took a few months to get him in to see a new PCP, who told the patient that he would be seen once a year, but that he could see a nurse practitioner for any issues in between annual visits, and talk to a case manager once a month.

At a time when PCPs are often expected to see more patients and accomplish a lot of work during their brief visits, it’s becoming more common for PCPs to avoid older patients. A fellow geriatrician recently left his small panel of geriatric primary care patients to take a job at a different institution and transitioned his patients to a PCP in an affiliated practice. After a few referrals, he received a nice email from the PCP thanking him for the patients, but reminding him that he should refer to other physicians in the practice with open panels, since the PCP had limited bandwidth to see complex, time-consuming patients.

Who will take care of the increasing number of aging, more medically complex and frail people? If you think more geriatricians are being trained to meet the growing number of older patients with multiple chronic illnesses, think again. Many geriatrics fellowship programs fail to fill, and a budget proposal from the Trump administration eliminates the already limited funding for geriatrics training (along with slashing research into aging and aging-related conditions).

Geriatricians will never be top money-earners in a fee-for-volume world where doctors get paid for doing procedures or seeing as many patients as possible — geriatricians earn less than almost any other specialty. But their salaries would be better if they were compensated for the value and savings they generate for the Medicare program and/or Accountable Care Organizations (ACOs) that take financial risk. For example, geriatricians working with patients in post-acute care settings often can reduce costs by helping avoid unnecessary readmissions. Currently, there is a negative return on investment for completing an additional year of geriatrics training. Colleagues in Boston, where I live, tell me that starting salaries for geriatricians are lower than for entry-level PCPs. Entry-level and mid-career jobs for geriatricians seem to be disappearing; the outpatient geriatrics clinic at one of Boston’s best-known hospitals was recently closed, and I hear through the grapevine that geriatrics clinical services at other academic centers are also underfunded and in jeopardy.

Compounding the risk to geriatrics programs is the loss of geriatrics leadership, as retirements thin the ranks of the generation of geriatricians who trained me and built academic geriatrics training programs. Ironically, while lower-level positions are being eliminated, at one point last year, there were four academic hospitals in my community looking for new Chiefs of Geriatrics. Community geriatricians are also retiring and/or moving into other jobs.

It is time to rethink our approach to geriatrics, and to recognize that better care of older adults requires more geriatricians and their specialized skills in caring for older people. Of course, some non-geriatrician physicians do a wonderful job of managing older patients, using skills they have acquired through clinical experience. Family physicians, whose training emphasizes a holistic approach to patient care, may in fact be better equipped to manage older adults. But geriatricians have three important skill sets that many other physicians lack: training in aging-related physiological changes and clinical syndromes, as well as in team-based care and systems of care for older adults; a clinical focus that emphasizes functional status and a holistic approach to managing health; and a focus on shared decision-making guided by patient goals and preferences. They also have one more important trait: geriatricians enjoy taking care of older patients and their families, and they believe that a cure is not the only measure of success. As a group, geriatricians are one of the most satisfied specialties.

In the same way pediatricians understand that children aren’t just small adults, geriatricians know that older adults have different physiology, and that the prevalence of certain syndromes increases with aging. Geriatricians recognize that although each older adult ages differently based on genetics, environmental, and lifestyle factors, many older adults have common physiologic changes. A core concept in geriatrics is homeostenosis: the loss of the homeostatic mechanisms that enable systems to adapt to changes and stress. Many older adults have lost the physiologic reserve that buffers them from becoming ill when there is a perturbation in their health. Consider the impact of aging on medication metabolism: kidney function and drug elimination change, liver function and drug metabolism change, and even sensitivity to drugs changes due to aging-related shifts in tissue receptors. What this means is that smaller doses have a larger impact, and that’s why geriatricians practice the “start low and go slow” approach when prescribing new medications, and why in many cases the best intervention is to stop medications and simplify medication regimens. Geriatricians not only receive specialized training in this, but they also witness on a regular basis how much better patients feel when drugs are withdrawn.

Geriatricians are well versed in the practical management of older patients. This requires working in teams with others — not only specialist physicians, but also social workers, nurses, nurse practitioners, physical therapists, pharmacists, and nutritionists. They also understand how to assess functional status and address social determinants of health, such as transportation, nutrition, and housing. Geriatricians not only train in acute care hospitals and outpatient clinics, but they also train and work in skilled nursing facilities and long-term care facilities, assisted living facilities, inpatient rehabilitation facilities, and long-term acute care hospitals, and they have experience making house calls. Most importantly, geriatricians understand how these different settings of care can be used to meet the needs of their patients, and how to get patients and families help when they face challenging questions about issues like nursing home placement.

Many primary care physicians lack these experiences and the relevant knowledge — a point brought home to me a few years ago when a colleague from my primary care internal medicine training program told me how little he understood about managing dementia, despite 25 years of primary care practice. His mother had developed Alzheimer’s disease, and he realized he had no idea about how to find the right services to help her to stay home, or what nursing homes or assisted living facilities had special units to manage dementia patients.

Decision-making for older adults can also be complex and more challenging for all involved. For older adults with multiple chronic illnesses, or for those who are frail, making one health issue better can make other problems worse. One of my former patients was given a new medication for depression that worked, and his symptoms improved. Unfortunately, he developed nosebleeds. I reviewed his meds and determined that the new medication interfered with the blood thinner he was taking for his atrial fibrillation. Neither his cardiologist nor his psychiatrist felt that they could reduce the dose of either medicine, and my patient ultimately decided to live with the nosebleeds (and the risk of serious bleeding if he were to fall again) in exchange for not feeling so down and depressed. Geriatricians are used to working with complexity, accepting ambiguity, and, ultimately, letting patients decide how to define and achieve better quality of life.

It’s time to invest in geriatricians. Almost a decade ago the Institute of Medicine called for increasing the number of geriatricians and geriatrics specialists in allied fields, equipping all non-geriatricians and health care workers with geriatrics knowledge and skills, and educating patients, caregivers, and families about care of older adults. Despite consensus on these goals, little progress has been made. The first step in addressing these issues is advocating for more geriatricians and the resources to overcome the many barriers that have kept this from happening in the past. We need to make it easier and more desirable for doctors to choose careers in geriatrics. This may require incentivizing students and residents to choose geriatrics, increasing compensation for geriatricians, and supporting career development paths that reward experienced geriatrics clinicians with leadership roles and a voice in designing and implementing ACOs and systems of care for older people. Only then will we be able to develop clinical faculty as role models, and recruit and retain community-based geriatricians who are recognized for the value they bring to our health system. Older Americans need and deserve geriatricians — today and in the future.

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