With the number of Americans over the age of 65 expected to double by 2030, both the ageing of the baby boomer generation and the life-extending effects of modern medicine are becoming increasingly tangible. Yet, as Americans grow older, the number of physicians, nurses, and direct-care workers specifically trained in geriatrics is declining. From a healthcare perspective, this trend is especially troubling because the elderly require more specialized and a greater degree of care.
This emerging crisis in geriatric healthcare is a complex one; like the more general healthcare system, elder care evolves out of the relationship between patients and their families, healthcare providers, insurance companies, and the government through programs like Medicare and Medicaid. Due to the disproportionately large number of older patients on Medicare, however, geriatrics is one of the lowest paid specialties in medicine with a median income half that of a dermatologist. Perhaps it is no wonder, then, why there is a shortage of medical students entering the less glamorous field of geriatric field. Part of the solution to this growing problem involves increasing the incentives to make the field more enticing to young doctors. For instance, debt forgiveness to those who receive their specialty in geriatrics could be an effective policy. From a healthcare management perspective, however, there are additional solutions that may help make geriatric care more profitable and effective. By giving more responsibility to nurses and direct-care workers, overhauling the training process for all healthcare providers, and placing emphasis on keeping patients at home as long as possible, those in the healthcare field might succeed in keeping the emerging crisis at bay.
Geriatrics and the Elder Care Crisis
In his 2007 article in The New Yorker entitled “The Way We Age Now,” Atul Gawande described some of the issues that geriatricians must face in their work with older patients. Unlike younger patients, the elderly often harbor a number of chronic conditions that have been previously diagnosed, such as heart disease, high blood pressure, and diabetes. Office visits, then, require a degree of triage: what is the most important symptom to treat right now to make the patient more comfortable? (Often, the answer is subtle—a better diet, fewer medications, good hygiene.) Elderly patients are also more likely to experience memory loss, making the diagnosis and treatment of their symptoms more difficult for the healthcare provider. Similarly, the elderly are more prone to mental health issues such as depression, which might get overlooked by an untrained eye.
Yet, as a 2008 report by the Institute of Medicine found, those trained specifically in the field of geriatrics are becoming increasingly rare. Only a small percentage of physicians receive training in geriatrics, with the number of certified geriatricians in the U.S. at 7,100 and declining. The number of qualified nurses is equally small, representing around 1% of the workforce. Furthermore, the same story holds true for geriatric psychiatrists, dentists, social workers, pharmacists, and physician assistants.
The most obvious reason for the lack of trained professionals in the geriatric field is lack of compensation. Geriatricians receive some of the lowest salaries of any specialty, and new MDs needing to pay back mountains of student loans are looking elsewhere. Likewise, direct-care workers’ wages are not high enough to keep people at their jobs for any significant amount of time. Assisted living staff turnover, for instance, ranges from 21% to 135%, and 80-90% of home health aides leave their position after just two years. Wages might not be the only reason, either. Many people have negative stereotypes about working with the elderly, and dealing with ageing and death can be a source of stress that doesn’t warrant the relatively low pay.
Solutions for the Future
Much has been made of the expected need for nurses in the coming decades, and the geriatric field is no exception. One important way that care facilities might reduce costs in caring for the elderly is by transferring some of the care responsibilities from physicians to nurses—both registered nurses and nurse practitioners as they can provide adequate care for a fraction of the cost. While nurses are not able to perform all the duties of a physician, they can often manage symptoms and provide preventative care two things that can keep patients out of hospitals and nursing homes, thereby reducing the overall cost of care.
Training is another key component of preventing a shortage of care. Traditionally, certification in geriatrics has required a one- or two-year training program, but new models have streamlined the learning process into online courses and weekend boot camps, giving general practitioners and family doctors specialized information on how to treat the elderly without requiring them to give up a year of their practice. Training is equally important for nurses, direct-care workers, and even loved ones of patients, all of whom play a critical role in a patient’s overall well being.
Two somewhat novel approaches to care might offer a means of keeping patients at home as long as possible, which, along with reducing costs, is always a top priority of elderly patients. One is the use of telemedicine, which uses online technology and electronic monitoring to send patients reminders, perform diagnostic tests, and track patient progress. Another is the home visit, which has gained popularity in the last few years and even received funding in the recent federal healthcare overhaul. One study found that home treatment cost 30% less than hospital care because patients required fewer treatments and generally got well much sooner.
As we face the oncoming wave of older Americans who will require health care over the next few decades, finding enough doctors qualified to care for them seems like a daunting task. However, it’s not an impossible one. And it’s critical to continue to work toward closing the gap in geriatric care if we hope to ensure that our oldest citizens are not forgotten.
Further Reading:
Health Professionals Needed to Treat the Aging
Public Policy and Aging Report: The Geriatric Care Workforce Crisis
Nurse Practitioners: The Right Cure for Ailing Elder Care?
Eldercare Workforce Alliance: How America’s Solution to the Jobs Crisis Can Lead to Better Care for Older Adults
Experts Seek Ways To Handle Coming Boom of Aging Americans
Direct-Care Workers and Geriatric Care
Association of American Medical Colleges: Recent Studies and Reports on Physician Shortages in the US