Geriatrician Shortage Bodes Ill for Care of Elderly

BY JOYCE FRIEDEN

WASHINGTON — The number of
physicians choosing to specialize in geriatrics
will not be anywhere near enough
to meet the needs of the elderly patients
of the future, Dr. Christine Cassel said at
a meeting jointly sponsored by the American
Thyroid Association and Johns Hopkins
University.
In 1987, the American Board of Internal
Medicine (ABIM) and the American Board
of Family Medicine created a certificate of
added qualification (CAQ) in geriatric
medicine. To date, 7,422 such CAQs have
been issued, including 263 in 2006, said Dr.
Cassel, ABIM president. “That rate is not
nearly enough to keep up with the predictions”
of the number of geriatric specialists
needed, she said.
Geriatrics is challenging because “it’s
not about mastering one area in great
depth, but being comfortable enough dealing
with a wide range of specialties—not
just subspecialties of internal medicine,
but other specialties [such as] ... orthopedics,
urology, and psychiatry—that you
will be referring to,” she noted.
The physician must also understand
the difference between disease and aging,
and know how to evaluate physiologic
age.
In addition, “no geriatrician thinks you
can be a solo practitioner in an office by
yourself.” Instead, geriatric medicine specialists
need to know how to integrate advanced
practice professionals, social workers,
pharmacists, and others into the practice
team, Dr. Cassel said. In effect, what
elderly patients will need are generalist
physicians.
“That generalist discipline, which is
rapidly disappearing from American medicine,
is necessary to solve this problem of
coordination of care and reduced costs
and better quality,” she said.
Dr. Cassel quoted ABIM data that
showed that in 1997, only 43% of internal
medicine residents went into subspecialties;
by 2005, that figure was 60%. The
data that the board is seeing today suggest
that only 15% of internists are becoming
general internists, “and of that 15%, more
than half are [becoming] hospitalists,” she
said. “It really is the very rare person who
wants to do [generalist] practice in the
community.”
Dr. Cassel pointed out that “our health
care payment system has made it virtually
impossible to do that [kind of medicine].
It has put huge barriers in the way
of people who want to [go into general
practice], and created great incentives for
people who want to do more procedural,
more highly specialized work.”
Internists who specialize in procedures
will often argue that specialists “are pushing
innovation. [They say], ‘That’s why
America has the best health care in the
world, because we have all these specialists,’”
she continued. “But the evidence is
quite to the contrary. ...The United States
is somewhere between 15th and 20th in
the world in terms of numbers of older
people and higher life expectancy.”
Dr. Cassel noted that Japan, Germany,
and Sweden—countries where life expectancy
for both males and females is
higher than in the United States—not
only provide universal health insurance
for the entire population, but also, within
the last 10 years, have enacted universal,
government-funded long-term care
insurance.
“Somehow they managed to do this
and still spend less money than we do,”
she said. “This idea that the United States
provides the best quality of care is getting
less and less defensible.”
The lesson to be learned from these
other countries “is not that we should, in
a wholesale way, adopt one or another of
these systems; the message is that there
has to be a way to figure out how to provide
comprehensive, affordable, good
care with an aging population,” Dr. Cassel
said. “Germany, Sweden, and Japan
are probably where we’re going to be 15-
20 years from now, so as we look ahead,
we can probably learn some lessons from
them.” ■
‘It really is the
very rare person
who wants to do
[generalist]
practice in the
community.’
DR. CASSEL