Lillian Brown didn’t think much of it when she noticed one of her feet was darker than the other. Her doctor, though, recognized it as a sign of poor circulation.
When she turned a little forgetful, Brown, 62, figured she’d be told, “That’s just part of aging.” But her doctor ordered an MRI and found a cyst on her brain.
Brown’s doctor, Ugochi Ohuabunwa, is a geriatrician — specially trained to care for the elderly. A doctor who is not a geriatrician, Brown believes, might not have discovered her problems.
“They’re more in tune as to what to watch for. They’re more able to catch things,” she says.
As the number of elderly Georgians soars, however, the number of geriatricians is not keeping pace.
There are only 127 certified geriatricians in the state now, against a need for 442 based on the elderly population and a doctor’s ability to care for 700 older adults each.
Georgia is projected to have 1.9 million residents over 65 by 2030, up from about 1 million now, and an estimated half-million will need to be cared for by a geriatrician, according to the American Geriatrics Society.
The problem is nationwide. It’s estimated 30,000 geriatricians will be needed by 2030 to care for 21 million elderly. There are just over 7,000 now.
Older adults account for one-quarter of all doctor’s office visits, one-third of all hospital stays, and more than one-third of emergency medical responses. Four in five need care for chronic conditions like heart disease, hypertension and arthritis.
While other doctors provide care for the aged, geriatricians get an extra year of specialized training.
Geriatricians like Ohuabunwa, an assistant professor at the Emory School of Medicine, typically spend more time with patients and view their care holistically. They commonly work with other specialists including social workers, physical therapist, pharmacists and nurses, and deal with the multiple, intertwined physiological, psychiatric, social and economic needs of older adults.
Geriatricians, says Ted Johnson, a geriatrician and chief of the division of general medicine and geriatrics at Emory, “manage the outlook for a patient.”
Emory University and its affiliates, which employ 24 geriatricians, offers one of two geriatric medicine fellowship programs in Georgia. The Medical Center of Central Georgia/Mercer University School of Medicine offers the other program. Internal and family medicine residents can enter the year-long program after completing their residencies.
During their fellowships, doctors learn about the physiology of aging, common illnesses in the elderly and their effects, and issues such as patients taking multiple prescription medications. They also learn about non-medical aspects of elderly patient care that may be needed, like legal matters including durable powers of attorney and living wills. And they learn how to practice medicine in different settings including the patient’s home and long-term care facilities, as well as how to work in a team.
Richard Ackerman, geriatrics fellowship director at the Mercer program, said, “There is a critical need for geriatricians. Georgia is a fast-growing state and the number of elderly people is growing. Even if we doubled or tripled the number of fellowship programs it wouldn’t meet demand. There’s way too many old people.”
Emory had three fellows last year, and will have three more this year. Mercer had two last year and only one this coming year.
More physicians aren’t becoming geriatricians for several reasons.
First, there is the financial. The required extra year of training adds to the hefty tab many medical students ring up over the course of their education. That can leave a newly-minted doctor with hundreds of thousands of dollars in debt. Many would rather get out as soon as possible and start earning income to pay off the loans.
Second, geriatrics does not pay as well as other areas of medicine. Treating the elderly, because of the complexity of an older person’s condition, requires that a doctor spend more time with each patient, reducing patient volume and total compensation.
In addition, their bills are generally covered by Medicare which pays providers less than private insurance.
The median salary for a geriatrician in private practice in 2010 was $183,523, according to the American Geriatrics Society, $21,856 less than the median salary for a general internist.
Compounding the problem is that fewer medical school graduates have gone into internal medicine and family medicine in recent years. Those are the two fields that provide applicants to the geriatric fellowship programs. Doctors in those two areas make less money and have more unpredictable work schedules than physicians in areas such as dermatology, radiation oncology and emergency medicine.
Some teaching hospitals like Emory, Grady and the Department of Veterans Affairs have committed to hiring geriatricians because of the value and potential cost savings. Those providers see geriatric care as essential because of the needs of their elderly patient base. But the number of positions available at each is limited.
Other reasons for the lack of geriatricians are more subtle.
For example, doctors in other areas of medicine can look forward to curing a patient of whatever illness the patient has — the ultimate success story for many physicians. Geriatricians, on the other hand, may have to settle for managing their patient’s illness and improving their quality of life. There may be no cure, or available cures might cause the elderly patient more suffering.
Nothing dissuaded Ohuabunwa who, on her recent examination of Brown, spent plenty of time with her, going through all of her prescription medicines, one by one, to make sure there were no drug interaction issues, and watching her walk the hospital hallways to examine her gait and balance.
“I love being a geriatrician. I love having the opportunity to interact with them,” said Ohuabunwa, who is board certified in internal medicine as well as geriatric medicine. “With older patients there’s so much more I’m concerned about.”
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