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As Population Grows Older, Geriatricians Grow Scarce
Officials, Schools Prod Doctors to Focus on Elderly Care

By Howard Kim
Special to The Washington Post
Tuesday, March 11, 2008

Mary Boland, 91, can consider herself fortunate. In 2006, the chronically ill former teacher from Cincinnati had a narrow brush with death when she came down with pneumonia. Within minutes, Boland's personal physician, Gregg Warshaw, was called.

"She was weak, confused and breathing abnormally," Warshaw recalls. "Her blood oxygen level was low, and she was suffering a low-grade fever."

In the elderly, pneumonia is often fatal. But instead of rushing Boland to the nearest hospital, as many family doctors might have done, Warshaw, a geriatrician, stabilized the condition and put his patient on antibiotics.

"Luckily, the pneumonia wasn't grave enough to warrant hospitalization," Warshaw says.

Geriatricians have provided specialized care to the elderly for decades, and until recently their numbers have been growing. But despite countless attempts to convince the medical profession and the public of their worth, the number of practicing geriatricians in the United States -- about 7,000 -- is falling seriously behind needed levels.

While the U.S. population age 55 and older is growing rapidly, according to a 2005 census report, the number of medical school grads going into geriatrics has been slow to keep up.

According to one estimate, the nation's teaching hospitals are producing one or two geriatricians for every nine cardiologists or orthopedic surgeons.

Low reimbursements and the allure of higher-paying specialties have been largely responsible. Then, too, the prospect of working long hours treating severely ill patients in their homes or at a hospital or nursing facility can be a turnoff, some physicians say.

"These are hard patients to treat because they're usually burdened with multiple complex disorders like Alzheimer's, dementia and congestive heart failure, and are often at the end of life," says Pittsburgh geriatrician Judith Black. Geriatrics isn't sexy, Black says, "but it can be extremely rewarding."

The rewards, geriatricians say, come from caring for a vulnerable, often misunderstood patient population and the strong relationships geriatricians develop with their families.

"Yes, they do die in the end; we all do," Black says. "But the effort is to bring dignity to those later stages of their lives."

That's not to say that primary care doctors aren't qualified to provide the same care. They are, says Kevin Grumbach, chief of the Department of Family and Community Medicine at San Francisco General Hospital. "What geriatricians are good at," Grumbach says, "is their coordinated team approach."

So it's all the more worrisome that the looming dearth of geriatricians is happening alongside another trend: a shortage of primary care doctors.

Most geriatricians are certified by either the American Board of Family Medicine or the American Board of Internal Medicine. To stave off the predicted deficit in the field's number of practitioners, geriatricians have pushed hard to encourage family doctors to get extra training in caring for the elderly.

But fewer physicians are going into primary care these days, and many are dropping out, tired of the hassles of low reimbursements and managed care.

Nevertheless, the American Geriatrics Society has lobbied aggressively for government support and more medical training:

¿ Last May, Sen. Blanche Lincoln (D-Ark.) introduced the Geriatric Assessment and Chronic Care Coordination Act of 2007, which codifies the coordinated team approach and requires that Medicare provide quality programs for older adults with multiple chronic illnesses.

¿ On March 4, Sen. Barbara Boxer (D-Calif.) introduced the Caring for an Aging America Act, which allows young physicians, nurses and other providers to work off all or part of their medical training debt by obtaining additional training in geriatrics or gerontology (the study of the aging process) and by working full time with the elderly for at least two years.

¿ In 2007, South Carolina established a loan-forgiveness program that offers physicians a free pass on their medical training if they go into geriatrics for five years. Five other states are looking at the plan.

Meanwhile:

¿ More than 50 medical schools have added elder care to their medical programs. The David Geffen School of Medicine at the University of California at Los Angeles recently revamped its curriculum to include geriatrics, and the University of Oklahoma College of Medicine in Oklahoma City requires a third-year rotation in geriatrics.

¿ Since 2001, the Donald W. Reynolds Foundation in Las Vegas has given $150 million to fund geriatrics training at 30 medical schools. The John A. Hartford Foundation in New York has doled out $40 million to 27 schools.

"There's still a ways to go," says AGS President Todd Semla.

At the same time, though, critics such as retired bioethicist Daniel Callahan wonder whether the investment in geriatrics is worth the social cost. "Are we going to continue funding programs for the elderly at a time when so many people have no health coverage?" Callahan asks. ¿

Howard Kim is a Los Angeles-based freelance reporter who covers the health-care field. Comments:health@washpost.com.

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