What Should Geriatricians Be Doing?

author affiliations:

Dr. Nusbaum is Professor Emeritus, University of Illinois.

Discussion about geriatrician workforce issues, such as a recent symposium of the Association of Directors of Geriatric Academic Programs,^1-5 routinely begins from the premise that the number of geriatricians is clearly inadequate to meet the needs of the expanding number of older Americans. A recent Institute of Medicine report notes that in 2007 there were 7128 doctors certified in geriatric medicine and 1596 certified in geriatric psychiatry. It cites projections that these numbers may increase less than 10% by the year 2030, and notes that these current low numbers in fact may even decrease.⁶

From a societal point of view, one might consider where these few thousand geriatricians nationally could have the highest impact on the care of the tens of millions of older Americans. A substantial fraction of the available pool of geriatricians would be required just to have a minimal presence of a few geriatricians at each of the medical schools nationwide, to inform the geriatric component of both undergraduate and residency medical education.

Efforts to increase the overall national supply of physicians by increasing medical school class size and/or opening new medical schools could create additional need for geriatrician faculty. Efforts to incorporate geriatric education into other disciplines such as surgery could involve additional geriatricians. Such an expanded geriatric role in each of 130 medical schools⁷ in the United States might collectively employ 1000 full-time equivalent employees (FTEEs) for teaching, or an average of about seven geriatricians per medical school. Others could be involved in leadership roles in federal geriatric-focused programs ranging from Medicare to Social Security.

In addition to the programs whose primary focus is geriatric, a broad range of other federal programs could also benefit from geriatric expertise in meeting the elements of their mission related to older Americans; examples would be workforce retirement concerns for the Department of Labor, or aging-in-place considerations for the Department of Housing and Urban Development. Many similar needs for geriatric expertise would also exist in each of the 50 states. Although no individual state would have the same workforce needs as the federal government, collectively the need among the 50 states might substantially exceed the need at the federal level.

The needs described above might well consume much of the available supply of geriatricians. It would also help to define career pathways for geriatricians that might be clearer and more attractive than one dependent on the vagaries of unknown future reimbursement under programs such as Medicare. One wonders if the acute hospital care institutional role for geriatricians may also expand as Medicare expands the range of medical events for which it does not provide reimbursement. Geriatricians might well be used as an institutional resource in the first instance to reduce the frequency of such events (such as encouraging early mobilization to reduce the incidence of decubiti), or in the second event to devise and implement programs to care for patients most effectively once such an event has occurred.

Such roles could readily absorb nearly 2000 FTEEs nationally, just to provide a 0.4 FTEE presence nationwide at each of 4897 community hospitals.⁸ An additional way in which the country might choose to use geriatricians would be to define a clearer role for their involvement in the administration of nursing homes (NHs). One might require, for example, as a condition for receipt of Medicare or Medicaid funding for a resident that a typical 100-bed NH have a 0.25 FTEE geriatrician on staff to support the quality of care in the facility.

Given that there are 1.6 million U.S. NH residents across 18,000 nursing homes,⁹ the modest geriatrician role proposed would require 4000 geriatrician nursing home medical director FTEEs nationwide. This could be quite analogous to the way in which an acute care hospital has an infection control officer and a blood bank director employed by the institution, each of whom may or may not be the infectious disease physician or the hematologist providing private practice care to the individual patient. One might also choose to create a stronger institutional role for a geriatric physician as part of the Medicare home care program, both at the home care agency and at the individual home site.

The Medicare home care program includes over 9000 Medicare-certified home health agencies, over 3 million beneficiaries, and over 100 million home visits per year.¹⁰ Many of the house calls are provided by nonphysicians, and less than 2% of the house calls are provided by geriatricians.¹¹ One way to increase geriatrician involvement in home care might be to set up requirements (and associated funding for reimbursement) for home care medical direction, and for recertification of the need for home care by periodic, actual face-to-face meetings of the certifying physician with the patient.

In the case of the patient who becomes truly homebound to the degree that he or she cannot reach the doctor's office for even a periodic visit, and where the prior physician does not wish to make house calls, this might be a logical point to transfer care to a geriatrician who is serving as the home care medical director. Fifteen hundred geriatrician FTEEs (assuming 2500 hours per FTEE) would allow enough manpower for at least one geriatrician home visit per year to each home care enrollee, as well as a very modest amount of time (perhaps a day a month) for a medical director role with each of the Medicare-certified home care agencies.

The one-year geriatric fellowship training experience is clinically focused, but a minority of geriatric fellows may still pursue careers in publicly funded research,¹² including health systems research and research on quality improvement. There might also be roles in pharmaceutical research, specifically in facilitating and helping to monitor evaluation of promising new agents for use in frail elderly persons. Geriatric research could engage perhaps 1000 geriatrician FTEEs.

The numbers presented here are only approximations, and one could certainly quibble about the details. The overall point, however, is that the national geriatrician workforce is scarcely adequate to address the missions of education, of research, of geriatric administrative leadership, and of clinical care in the institutional settings in which many frail elderly persons can greatly benefit from geriatric expertise. If geriatricians are applied to meet these several needs, it is hard to see much residual capacity for geriatricians to provide care to the independent-living but frail elderly, even though one of the major goals of geriatrics has been precisely to promote function and independence of elderly individuals.

In summary, the country has and will continue to have a shortage of geriatric physicians. Many individual geriatricians are likely to divide their time among multiple roles, such as service as both clinicians and as educators, but in net this will not expand the total geriatrician supply beyond 10,000 physicians. Steps to increase the supply by training more geriatricians would take many years to remedy this shortfall, and in any event it is unclear if, when, or how such a process will begin and be funded. Accordingly, it is prudent to consider how we as a society should triage the use of geriatric physicians to most improve the lot of older Americans.