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We Need Geriatric Competence

Posted on | May 17, 2008 | No Comments

Will there be enough caregivers for our aging population?

The long-expected upsurge in the number of older Americans is almost here. The first baby boomers will turn 65 in 2011. By 2030, there will be more than 70 million adults over 65, nearly double the number today. Oftentimes, older age requires more frequent and regular health care; those over 65 today use a greater percentage of health care services than other segments of the population. In the next two decades, with numbers increasing so that approximately 20 percent of Americans are over 65, their use of health care services—and the national Medicare bill—will grow.

As documented by a recent Institute of Medicine report, far too few health care providers have the adequate knowledge and skills to care for these older patients. Today there is only 1 certified geriatrician for every 2,500 older adults, and if current rates of attrition continue, this number will fall sharply in the next 20 years to 1 for every 4,200 older Americans. The numbers don’t get any better when we look beyond doctors: only 4 percent of social workers specialize in geriatric care, and only 1 percent of nurses, physician assistants, and pharmacists specialize in geriatrics. Yet these health care providers are often the very people who spend the most time taking care of older patients. We are facing a crisis: who will take care of our parents and relatives, our friends—and us?

We need more specialists in geriatric care, and we need every health care professional to receive education and training in geriatrics. The answer is deceptively simple since it will require significant change in the way we train health care workers for practice. All licensure and certifications, not just for doctors but for all health care professionals, should require demonstration of geriatric competence, and this means that our education infrastructure and health care reimbursement systems will have to change.

Currently, specialties like dermatology, emergency medicine, ophthalmology, and general surgery have no geriatric training requirements—even though these doctors treat large numbers of older patients. Yet these same programs have requirements for pediatrics. The American Dental Association doesn’t recognize geriatrics as a specialty. For students hoping to focus on geriatric care, the barriers are numerous: there are too few faculty members, inadequate curricula, and little opportunity for training outside the hospital. Although we have known for some time that the health care system will need to accommodate the aging of our population, this knowledge has not spurred significant change. Only 5 of 144 U.S. medical schools have a full geriatric department today. In contrast, all UK medical schools have one, and their largest specialty is, coincidentally, geriatrics.

But simply changing the educational opportunities won’t be enough: an increasing number of geriatric training slots have not been filled—why not? Importantly, there are often financial disincentives to additional training in geriatrics. For example, geriatricians train as general internists plus spend an extra year to specialize—yet, on average, they make thousands of dollars less per year than a general internist. We need more inducements and loan forgiveness programs to encourage students and trainees to choose geriatrics, and we must restructure the compensation scale so pay is not only commensurate but an incentive.

In addition to the financial deterrent, the negative stereotypes of caring for older people often contribute to decisions by professionals-in-training to pursue other specialties. These beliefs are not supported by fact: science has demonstrated that aging and poor health are not one and the same, and a full 20 percent of those over 65 have no chronic disease and need only preventive and episodic care. Yet the stigma remains even though geriatricians rate their job satisfaction higher than any other medical specialty. In order to dispel this myth, we need to find ways to provide more opportunities for younger people to interact with healthy older adults.

The facts are inescapable: the population of older people is growing, and we must make sure that the health care provider population grows both in size and skill.  It is not just a societal obligation but in our own self-interest. After all, we are all aging, and at some point, we will all need someone to take care of us.

(Judith A. Salerno, MD, is Executive Director of the Institute of Medicine of the National Academies. She recently served as Deputy Director of the National Institute on Aging at the National Institutes of Health. She can be reached at JSalerno@nas.edu. Opinions expressed by Health Commentary guest bloggers do not necessarily represent the views of Health Commentary.)

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