Overlooking older patients

NEW YORK

Lisa Skinner, a chief resident at UCLA School of Medicine, thought about specializing in the treatment of old people, and even got a master's degree in geriatric social work. In the end, she opted to pursue general internal medicine.

"I hated to give up the younger patients, even though I enjoy the older patients," she said.

Across the country, thousands of new doctors like Skinner have decided to pursue specialties other than geriatrics, a trend that has created a vast shortage of elder care doctors.

Experts who worry about the depth of the problem say it's going to become extreme when baby boomers start hitting old age -- creating a "senior boom" -- and start needing special care.

"It's going to be enormous," said Dr. David Reuben, chief of geriatrics at the University of California at Los Angeles, School of Medicine. "You can't imagine how big this is going to be."

Reuben is one of the 76 million Americans born between 1946 and 1964, known collectively as baby boomers. "In 2011, we're going to start hitting 65. One of out every five people in the country," he said.

He and other experts say baby boomers probably aren't worrying about geriatric issues right now -- unless they have sick parents.

"It's a problem that the baby boomer generation is seeing now as they see the quality of care for their parents," said Daniel Perry, executive director of the Alliance for Aging Research. "They're coming away from that experience confused, seeing their parents passed from one physician to another."

At least 20,000 gerontologists are currently needed to care for the 35 million Americans over the age of 65, according to the alliance, a nonprofit advocacy group. But only 9,000 out of the 650,000 doctors in this country are certified in geriatric medicine. "It's one of the great disconnects in American health care," Perry said.

And future gerontologists aren't coming down the pipeline. Of the 126 accredited medical schools in the United States, only three have a geriatrics department, says the Association of American Medical Colleges. The rest cover elder care within broader classes.

Every year, about 16,000 students graduate from U.S. medical schools, with another 7,500 coming from abroad. Out of those 23,500 newly minted doctors, only about 500 -- or 2 percent -- go into geriatrics.

Dr. Susan Kline, executive vice dean of academic affairs at New York Medical College, said students aren't interested in treating old people exclusively, despite the opportunity to tap into a guaranteed patient flow.

"It's very difficult to take care of geriatric patients because they have chronic multi-system degenerative diseases that are progressive, not curable," Dr. Kline said. "It's kind of fighting a losing battle and it's not fun, especially if the patient is at all difficult, which many of these patients can be."

Two years ago, the Association of American Medical Colleges and the John A. Hartford Foundation began awarding 20 medical schools $100,000 grants to enhance their geriatric curriculum.

"Some people have a perception that, 'Yuck, I don't want to take care of all these old people,'" said Brownell Anderson of the AAMC, a physician education advocacy group. "That's the perception we're trying to change. But there are so many other factors that go into the decision."

Among the other factors, med students don't find geriatrics as glamorous as other specialties. "They're not held in the esteem that the cardiac surgeon or the brain surgeon is," Anderson said.

On top of that, geriatrics is one of the lowest paying medical specialties, and doctors leave med school with massive debt, anywhere from $75,000 to $150,000.

"It takes a lot longer to do a comprehensive geriatric assessment. If they're being reimbursed the same as a seven-minute visit, they're going to avoid this field," Perry said. His Alliance for Aging Research advocates higher Medicare reimbursements, partial loan forgiveness and an awareness campaign about the shortage of gerontologists.

"The baby boomers ought to be upset about this and they ought to be calling for change. They are the next generation to bat," Perry said.

"We're not saying every older patient needs to be seen by a geriatrician, but they certainly need to know that their physician has had some exposure to geriatrics as part of their training," he added. "Far too few of them have even a single course in geriatrics."

Skinner, who completed four years of medical school and is now doing a fourth year of residency, agreed.

"In residency, we have a strong geriatrics division here at UCLA. In medical school, I don't think we had as much exposure as I would have liked to have in the study of geriatrics," she said.

Many experts believe the best -- and possibly only -- solution may be to train all physicians, regardless of their specialty, in the aspects of gerontology related to their field.

"Attracting people to exclusively practice geriatrics has not been a success, by and large, and the best hope is to train general internists and family physicians well in those aspects of medicine that are unique to geriatrics," Kline said.

"When somebody gets to be 80 years old, they can still find a doctor to take care of them," she said. "The doctor just won't be a gerontologist. It'll be a doctor who will know something about older people and will be able to take care of them."