On May 12th, 2022, I posted a blog regarding our nation’s cockamamie physician reimbursement policies (“Physician Reimbursement Askew).  I pointed out that primary care physicians average net incomes about two-thirds that of subspecialists.  The difference lies in procedures—interventions such as colonoscopies are valued way out of proportion to the cognitive work of diagnosis and care for chronic conditions such as hypertension and diabetes.  Geriatricians are in the “cognitive” category. 

A recent article in the Journal of the Medical Association about geriatricians amplifies the problem of training physicians with expertise in the care of the aged.

Geriatricians 

Geriatricians, typically graduates of residency programs (i.e., the training medical school undergraduates undertake after medical school) in Internal Medicine and Family Medicine, undergo further training in the field of geriatrics.  This discipline involves care for the elderly, with emphasis on the care of patients with multiple medical problems, unwieldy pharmaceutical regimens, functional debility, cognitive decline, and much more.  Crucially, geriatricians gain expertise in discerning whether symptoms betray disease or whether they are a normal part of aging. Training in interdisciplinary team care is also a crucial part of the curriculum.

The number of board certified geriatricians in the US is declining.  In 2000, there were 10,270, and in 2022, the number was 7,413.  The number of young physicians engaging in advanced training in geriatrics in 2022 fell to 177.  In the most recent census, 16.9 percent of the US population was 65 years of age or older, a figure expected to increase to 22 percent in 2050.

Family doctors and internists currently supply most of the primary care for the elderly.  They need to develop their expertise on their own, as neither medical schools nor residency training programs have geriatric specific curriculum requirements.  Many argue that, rather than worry about the lack of physicians specifically trained in geriatrics, there should be greater emphasis on clinical training in primary care residencies specifically aimed at care of the elderly.  On the other hand, there is plenty of data that demonstrates the superiority of geriatricians’ care of the elderly.

At any rate, it is clear there is not, nor will there be, a sufficient number of geriatricians to meet the need of a burgeoning elderly population.  They will continue to fill a crucial role in advocacy for old patients, training of primary care physicians in the clinical care of the elderly, and research.  But they make a financial sacrifice for their efforts–compared to general internists and family doctors, geriatricians earn less than if they had simply gone into practice without another year of training.

Reality

Of course a sensible doctor person power policy would target the increasing lack of physicians who can provide great care for the elderly.  The need for doctors who prioritize care of the elderly is currently marked and will only get bigger.  But there are obstacles to plugging the gap.  One, taking care of the elderly is hard.  Patients typically have an array of problems that require much more time to address than corporate medicine typically allots.  In fifteen minutes, primary care doctors and geriatricians are supposed to address problems like hypertension, diabetes, sleep disorders, arthritis, and the possibility of cognitive decline.  And these only scratch the surface of problems.  A gastroenterologist  can make make three times the amount of a primary care doctor in a morning of performing colonoscopies–without concern for all of the other problems a patient may have. 

In a rational physician person power policy, money would be poured into compensating primary care doctors and geriatricians.  This is not going to happen.  Our nation has no overarching physician person power policy.  The market drives the amount of subspecialty doctors, and medical school graduates continue to flock to these highly paid, procedure-oriented specialties. A physician advisory commission, an influential body that advises Congress on physician reimbursement policies, is composed of two-thirds procedure oriented doctors.  Guess what it prioritizes in terms of physician compensation.

The US has a looming crisis in care for the elderly.  What are we doing about it?  Nothing.