Cover Story
Coming of Age
By Kim Kiser
With the number of geriatricians shrinking and few in training, who’s going to care for us in our old age?
It’s a balmy September Monday, and Fatima Nisar, M.D., is starting the third week of her month-long geriatric medicine rotation in the 44-bed transitional care unit at Walker Methodist Health Center in Minneapolis. Nisar, or “Dr. Fatima,” as some call her, begins her morning rounds by paying a follow-up visit to Mrs. S., a spirited 91-year-old who is recovering from a fall after blacking out in her home.
Dr. Fatima pulls a chair up next to her patient. “How are you feeling?” asks the soft-spoken physician, who is in her first rotation of her family medicine residency.
“I’m raring to go,” the diminutive woman says, explaining that she got up that morning, used the bathroom, and dressed herself—all without assistance.
Dr. Fatima continues: “Do you have pain?” “Have you been eating?” “How are you sleeping?” “Are you having shortness of breath?” The doctor and nurse practitioner, Karin Shurrer, take turns listening to Mrs. S’s heart and lungs. They notice that the irregular heart beats that might have contributed to her passing out are absent.
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"Patients are profoundly grateful. Most seem to recognize that this is difficult work and that there's a commitment to their care beyond this just being a job."
—Teresa McCarthy, M.D., pictured with patient Fred Doughty
Photo courtesy of Walker Methodist Health Center
"We will need a certain core number of geriatricians to do teaching, but the bulk of clinical care will be done by primary care physicians."
—Martha McCusker, M.D.
Photo by Janna Netland Lover
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The questions continue: “What day of the week is it?” “What is the date?” “What is the season?” “What is the year?” Mrs. S. answers all correctly and volunteers details about how she lives by herself and still likes to cook breakfast for her son when he comes by, how her granddaughter and great granddaughter had visited the previous day, how she hasn’t slept well since she lost her husband 12 years ago, how she once shook hands with the Rev. Billy Graham, and how she thinks she deserves an A-plus for improving her strength and balance in physical therapy.
The visit lasts nearly 45 minutes—more time than any primary care physician in private practice could possibly spend with one patient. And during that time, Nisar learns not just about her patient’s physical health and mental acuity but about her living situation, her family and social support system, and her values—all necessary ingredients in the recipe for a healthy geriatric patient.
As Nisar leaves, Mrs. S. tells her to come back any time.
Nisar remarks about Mrs. S. being particularly sweet and mentions how many of her patients take the time to ask her how she’s doing with her training or about her newborn baby.
Nisar, who did her medical training at King Edward Medical University in Lahore, Pakistan, and came to Minnesota for her residency, doesn’t yet know the direction her career will take. Teresa McCarthy, M.D., medical director for the transitional care unit and assistant professor of family medicine and community health at the University of Minnesota, is hoping experiences such as this one at Walker Methodist will convince at least a few family and internal medicine physicians to pursue geriatric medicine fellowships following their residencies—a feat that has proved more difficult than convincing the most stubborn patient he or she can no longer live independently.
“There was a vision when I was a fellow that there would be legions of training programs, and we would be turning out geriatricians to serve the aging population. That’s not the case,” McCarthy says. “In fact, there will never be enough geriatricians to take care of all the population.”
Adding Up the Numbers
McCarthy’s words echo the American Geriatrics Society’s warning about a shortage of geriatricians in the United States that’s only expected to worsen over the next 20 years. According to society figures, the United States currently has one geriatrician for every 5,000 adults age 65 and older. That ratio is expected to stretch to one for every 7,665 by 2030.
The fuel for this perfect storm in elder care is the warm wind of an aging population colliding with a cold front created by a shrinking pool of providers. According to the U.S. Census Bureau, the number of adults age 65 and older is expected to double from 35 million in 2000 to 70 million by 2030 as the baby boomers enter their seventh decade. People age 85 and older constitute the fastest-growing segment of the elderly population. Their numbers are likely to increase from 4.2 million in 2000 to nearly 21 million by 2050. “It’s what we call the demographic imperative,” says Martha McCusker, M.D., an assistant professor of geriatrics at the University of Minnesota and a staff physician in the division of geriatrics at Hennepin County Medical Center (HCMC). “The boomers are a big bulge in the numbers, but people tend to be living longer, too. We’ve done a better job of developing better treatments and management of chronic medical problems. As a result, people are not dying from heart attacks that might have felled them 30 years ago.”
At the same time, fewer providers are renewing their certification in geriatric medicine. In 1994, 8,824 family and internal medicine physicians held the certification. By 2006, that number had fallen to 7,128, according to a workforce study by the Association of Directors of Geriatric Academic Programs (ADGAP). Of those who were certified in 1996, only 40 percent of those in family medicine and 45 percent of those in internal medicine opted to renew.
The number of residents coming into geriatric medicine fellowship programs isn’t much better: According to the workforce study, one-third of the 442 first-year geriatric fellowship slots went unfilled in 2006. Of those positions that were filled, only 33 percent were taken by graduates of U.S. medical schools.
Minnesota has geriatric medicine fellowship programs at Mayo Clinic, HCMC, and Regions Hospital/HealthPartners’ clinics (see p. 34). Mayo has four slots and offers a one-year clinical training fellowship and two-year program that includes a research component. HCMC’s one-year clinical program has two slots. The Regions/HealthPartners program, which is sponsored by the University of Minnesota’s department of internal medicine, has one one-year slot. All positions are currently filled. “But the applicant pool has shrunk,” says Gregory Hanson, M.D., Mayo’s geriatric fellowship director.
Time is Money
Why the dearth of geriatricians at a time when they’ve never been needed more? Again, the answer lies in the numbers. In order to sit for board certification, physicians must complete a one-year fellowship following their three-year internal medicine or family medicine residencies. Often residents saddled with medical school debt topping $100,000 can’t justify another year of reduced earnings before going into practice.
In addition, the annual compensation for a geriatric medicine physician in private practice in 2004 at $160,000 was less than or about the same as those of general internal medicine physicians ($166,000) and family medicine physicians ($156,000) who do not practice obstetrics, according to the Medical Group Management Association. “Medical students and residents can figure out that this additional training isn’t going to generate additional compensation, and that’s been a chronic problem that has increased over time,” says Ed Ratner, M.D., an associate professor of medicine at the University of Minnesota and president of the Minnesota Medical Directors Association, a professional group for physicians who practice geriatric medicine.
One of the reasons for the lower salaries is the fact that practicing geriatric medicine takes time. Patients often have many medical issues—heart failure, high blood pressure, early Alzheimer’s disease, decreased muscle strength; in order to properly manage those issues, physicians need to look beyond what is simply happening to the body. They need to look at what medications patients are taking and whether they’re actually taking them; whether they’re eating properly, if at all; whether they have supportive family members nearby; whether they have friends with whom they visit or other social outlets; and whether they have the financial means to afford help, if they need it. Medicare doesn’t pay for such assessments. “The reimbursement structure is largely procedurally based. And with the reimbursement structure the way it is, there’s still a relative penalty for people doing cognitive medicine,” McCusker says.
Consequently, physicians can find themselves torn between being able to meet the needs of their patients and seeing enough patients to make a living. Hanson says he’s heard of some geriatricians who have had to change their practice mix and add younger patients. “Otherwise, they can’t survive,” he explains.
Geriatric medicine jobs have other downsides as well. McCarthy says medical groups often hire geriatricians to see patients in nursing homes—work the other physicians don’t want to do. “Doing nursing home rounds is a tough job. It doesn’t pay well, and you get isolated,” she says. “You’ve been hired to do work that loses money, and everyone else is bringing in the money.”
Graduates of internal medicine and family medicine programs who like working with the elderly want positions that not only offer better pay but also have more regular hours. They often find such jobs in hospitals. “There’s a tremendous call for hospitalists, and many people who otherwise would have elected [to do] an additional year of study of geriatric care issues have gone into the hospitalist track,” says Lawrence Kerzner, M.D., director of the geriatric medicine division at HCMC. “Their training in internal medicine is essentially the same, and they can jump right in and have a nice well-paying job with good work hours.”
The Gentle Side of Geriatrics
Ask geriatric medicine physicians why they chose the specialty and money (or lack of it) never muscles its way into the conversation. McCarthy’s decision to do a fellowship in geriatrics came while working in the wound clinic at the University of Minnesota Medical Center. There, she found herself working with elderly patients who had multiple chronic conditions such as diabetes and cardiovascular disease. “These were incredibly complex patients, and that’s what I liked. The medicine was so interesting compared with general internal medicine,” she recalls, enthusiasm resonating as she speaks. “And the patients are profoundly grateful. Most seem to recognize that this is difficult work and that there’s a commitment to their care beyond this just being a job.”
Training Geriatricians
Photo by Janna Netland Lover
When Lawrence Kerzner, M.D., began practicing geriatric medicine in the late 1970s, there weren’t many opportunities for formal training in the field. “Few were thinking about geriatrics at that time,” says the director of geriatric medicine for Hennepin County Medical Center (HCMC), who also oversees its geriatric medicine fellowship program.
Kerzner, who trained in internal medicine and infectious diseases, went on to develop a teaching program in geriatric medicine at Boston University, where he was practicing and teaching at the time.
Since then, he has watched geriatric medicine training evolve. Until the late 1990s, fellowships lasted two years. Then, the Accreditation Council for Graduate Medical Education changed the post-residency training requirement to one year. “They thought condensing it to one year would have the beneficial effect of attracting more people, the idea being that two years was a large commitment with no significant increase in salary or income,” Kerzner says. Medicare now funds geriatric medicine fellowships for 12 months, the amount of training needed for a physician to become eligible for board certification.
HCMC’s one-year program focuses on clinical care. Fellows spend their time working in the hospital and primary care clinics as well as in nursing facilities and hospice programs. They learn about rehabilitation medicine, bone metabolism, urology, geriatric psychiatry and dementia care, Parkinson’s disease, and other conditions common in the elderly, and about leadership in long-term care facilities.
The University of Minnesota’s department of internal medicine sponsors a similar one-year program at Regions Hospital and HealthPartners’ clinics. Mayo Clinic offers one- and two-year programs. Mayo’s one-year program focuses on clinical training. In the two-year program, fellows can do clinical research or earn a master’s degree in areas such as public health. “That gets them to the level of academic geriatrician who can go on and do research in their career in addition to care,” says Gregory Hanson, M.D., director of the geriatric medicine fellowship program at Mayo.
Kerzner says there has been discussion about changing the fellowship requirements back to two years in order to increase the number of geriatricians who can teach and do research and to provide more time for clinical training. “At the end, so many fellows say there’s so much more to learn, we could do another year of this.”—K.K.
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Such sentiments were reflected in a study of career satisfaction among physicians in 33 specialties that found those who practiced geriatric internal medicine were the most satisfied with their work. The findings were published in the July 22, 2002, Archives of Internal Medicine.
Educators are trying to show medical students the gentler side of geriatric medicine, hoping that they, too, might experience the rewards of working with such patients. “You have to expose medical trainees to the frail, complex, elderly patients in positive ways,” says the university’s Ratner, who has provided second-year medical students with the opportunity to do a visit with elderly patients in their homes. Mayo Medical School also offers the opportunity for home visits in the third year of training. Students at both schools take part in the Aging Game, a simulation in which they are transformed into elders with the help of leg splints, Vaseline covered glasses, and ear plugs and are asked to perform daily activities such as getting in and out of a car and grocery shopping in order to better understand what it’s like to live with arthritis, vision and hearing loss, and other conditions of the aged.
Neither school, however, requires a geriatric clerkship (only 23 percent of medical schools do, according to a 2005 survey of geriatric medicine program directors by ADGAP). Hanson says Mayo is planning to develop a unit that will be taught by geriatricians. “We’re hoping that will intensify their exposure a bit.”
Everyone’s a Geriatrician
Although such exposure may not increase the number of geriatric medicine physicians, it could be the first step toward helping future physicians of all types understand the needs and challenges of the elderly. “It’s acknowledged that we will need a certain core number of geriatricians to do teaching, but the bulk of clinical care will be done by primary care physicians,” McCusker says.
And that’s one reason why the university is having its family medicine residents do nursing home visits or rotations at transitional care units such as the one at Walker Methodist.
At the national level, the American Board of Internal Medicine has started a pilot project to integrate a set of quality indicators developed by UCLA and the Rand Corporation for the care of vulnerable elders (CoVE) into internal and family medicine residency programs in order to teach residents principles of geriatric medicine and quality improvement. Hennepin County Medical Center is one of the sites taking part in the project. “The experiment is to see whether the integration of these principles in a more formal teaching framework enhances not only the care shown by the CoVE indicators but also geriatric knowledge among residents,” Kerzner says.
But primary care physicians aren’t the only ones who need to be brought up to speed on the challenges of working with geriatric patients. “There’s been a move among the geriatrics profession to look at the education of specialists in relevant geriatric syndrome training—not just the medical specialties but also the surgical specialties,” says McCusker.
The Hartford Foundation has been a leader in promoting the idea. Through its Geriatrics for Specialists initiative, the foundation has funded grants to medical schools and residency programs in order to allow faculty to integrate geriatrics into surgical and related medical specialty training. This year, the grants, which were awarded by the American Geriatrics Society, went to 25 programs—more than twice as many as in previous years. (None went to Minnesota programs.)
At Walker Methodist, McCarthy is in her sixth year of leading a program that teaches not only family medicine residents but also Ph.D. pharmacy and nurse practitioner students to work as a team in caring for geriatric patients. The program involves faculty from the university’s school of pharmacy, school of nursing, and family medicine residency program teaching together, rounding together, and discussing patients and developing plans for care together. “It’s a very common-sense model,” McCarthy says. “And we have the data to show that this model of care on our unit alone has saved hundreds of thousands of dollars over a year to payers.” She says the savings come from shorter stays in the transitional care facility and fewer hospital readmissions.
McCarthy admits such comprehensive care won’t be provided for seniors until the baby boomers, who will want that kind of care for their parents and themselves, demand it. “A lot of providers believe that we in medicine provide high-quality care and that geriatric patients are just older middle-aged patients. They believe that the care of these patients doesn’t require any additional expertise or training,” she says. “But those of us who know this population and live and breathe geriatric care are convinced that this is not true.”
And that’s what residents such as Fatima Nisar are learning—that it’s not just treating the complex physical ailments but also managing the life issues that contribute to them so patients can live as fully as possible that is the challenge, and the reward, of geriatric medicine. MM
Kim Kiser is associate editor of Minnesota Medicine.