The Waning Interest in Geriatric Medicine Fellowships and Where to Go from Here
Author. Treven W. Cade
Over the last decade, the amount of active certified geriatricians has not kept pace with America's steadily growing elderly population. In 2017, it was reported that 50 million Americans were 65 years in age or older, which represents around 15% of our nation's total population. Under current conditions, this age group was projected to increase another 55% by 2030 (FQHC Staff and Petriceks). In line with the previous statistics, the total number of Medicare beneficiaries is expected to grow from 40 million to almost 80 million within that same period (Castellucci). These key growth trends should highlight the growing importance of uniquely trained clinicians best suited to care for the elderly population. Federal estimates report that 30% of adults who are 65 or older need a geriatrician ("Why America Faces a Geriatrician Shortage . . ."). Currently, there are around 7,500 physicians that specialize as a geriatrician. Still, to care for the increasing population, the American Geriatrics Society (AGS) predicts 17,000 will be needed to care for this growing demographic. That one geriatrician can care for as many as 700 patients (Olivero). Regarding the demand of geriatricians, they are "being sought out by patients' more and more as a choice,' particularly if [patients] struggle with complicated issues like memory loss or frequent falls that a primary care doctor isn't trained to address" (qtd. in Castellucci). It is also vital to increase the number of geriatricians, as required in a Family Medicine or Internal Medicine program, adding an extra incentive to those looking into the specialty.
Even with this high demand, manifesting a profession as a geriatric physician is not as desirable as other specialties for graduating medical students—even though geriatricians report a career satisfaction greater than other medical specialties ("Why America Faces a Geriatrician Shortage . . ."). To become a geriatrician, one must complete a Family or Internal Medicine Residency program and an additional year of fellowship training for the geriatric specialty. This specialization path is currently not desired by most medical school graduates due to the high cost of medical school and the additional year of training required. The lower salary expectation is commonly reported by practicing geriatricians compared to their lesser trained Internal or Family Medicine clinician counterparts. According to the MGMA, in 2018, a Geriatric physician had a median income of $196,650, while Internal and Family Medicine (without Obstetrics) physicians report a median income of $228,260 and $200,824, respectively). This lower salary is primarily caused by the percentage of the elderly population that utilize Medicare to pay for their health care services, of which "reimbursement is generally lower than for privately insured patients. Thus, geriatrics is the only specialty in which the doctor often doesn't get paid more for having completed a fellowship" (FQHC Staff).
Geriatrics fellowship programs have generally had a tough time attracting enough residents to fill their programs for various reasons. According to 2021 Match Data, seen in Table #1 below, of the country's 400 available Geriatric fellowship positions, only 208 were filled—leaving 192 positions unfilled. More so, out of 150 programs, 103 programs were left unfilled. Looking at the same data back to 2017, these numbers have remained more or less stagnant. Ultimately, the number of Geriatric programs has remained relatively the same, while the number of positions within these programs has declined since 2001 despite the rising elderly demographic (Petriceks).
To help address the waning pursuit of this specialty across the industry, unique initiatives are being looked at and implemented at federal, state, and even individual provider levels to help mitigate the lower reimbursement for geriatricians and increase the general interest of the specialty among developing physician learners. For one example, states with elderly communities of the greatest needs have created student debt relief programs for physicians who agree to treat this older demographic in their communities (Castellucci). Additionally, independent geriatricians have been known to pursue a concierge medicine model. Each patient from their panel pays a monthly, bi-annual, or annual fee to have priority access to their physician (Castaneda). The ability to be paid upfront for care can be beneficial to geriatricians concerned with a lower salary and the patients who might have the means to pay for such high-level access to care and regular consultation. Aside from the potential financial benefit, concierge physicians often can develop a smaller patient panel and form strong personal/professional relationships with their patients (which leads to a more hands-on, preventative care approach and translates to better health outcomes). Many patients who pursue concierge medicine face complex or chronic medical conditions that require regular maintenance and individualized care. Many opportunities have presented themselves to incentivize one to specialize in geriatrics; however, these incentives are not available to every geriatrician, or in regard to concierge medicine, maybe an undesirable form of practice.
Due to the low desirability of becoming a geriatrician, some have argued that geriatrics shouldn't be a specialty. For example, Monya De poses that "[t]he solution is to give every doctor who is not a pediatrician —urologists, primary care doctors, cardiologists—the needed training so they can care for older patients." Other sentiments, while not specifically advocating for the elimination of the specialty, speak of reform for the geriatric specialty:
"if supply has not risen to meet demand, Geriatricians may need to alter their approach to ensure high-quality care for the rising population of older adults. For example, one recent commentary suggested that 'the right metric for success [in Geriatrics] should not be the number of fellowship slots filled, but rather. . . the number of older adults that clinicians care for using geriatric principles'" (Petriceks).
Much of this training and principal education concerns representing elderly patients in medical training, as "doctors often know more about rare pediatric genetic diseases than they do about clearing an elderly female for surgery" (De). De concludes with the sentiment that "[r]heumatoid arthritis and myelofibrosis are conditions that require switching to a specialist. Being old should not be." However, becoming older is a factor of switching specialties, and De's previous sentiment echoes this: "[t]he solution is to give every doctor who is not a pediatrician . . ." Our current healthcare structure has specialties for the youth just as it does for the elderly; however, a manner of tradition is by no means justifiable in itself. While De is commentating on the lack of desirability for the specialty to argue for an increased emphasis on general geriatric education, what ought to be the instigation for a medical specialty—the value it brings to a patient or the value it brings to the physician? Indeed, if potential physicians do not see a benefit to themselves in a geriatric specialty, there will be fewer geriatricians. It is also true that geriatricians, or those who can treat the elderly, will be required to consult with a large portion of the population in the coming decades.
What is the appropriate balance to this question of a specialty bringing value to a patient and its physicians? To begin with, what value does a geriatrician bring to the patient? The Department of Veterans Affairs has reported that patients who receive care in a special geriatric unit with a certified geriatrician have better functionality when discharged. They are more likely to be discharged to their homes than patients who receive standard care. More so, interventions where a patient has direct contact with a geriatrician are more likely to succeed than those with other supporting clinicians (Department of Veterans Affairs). Lastly, geriatricians acting as primary care providers prove to be more effective in medication management, although patients in inpatient and outpatient settings with a geriatrician have been shown to have a mortality rate that is more or less the same as with standard care (Department of Veterans Affairs). Geriatricians produce their value not by treating each medical condition of their elderly patients, but by focusing on pertinent conditions that affect one's functionality, and "by following these principles, geriatricians can improve the quality of life of older patients even though [they] cannot cure many chronic diseases" (Bludau). This includes heightened attention to a patient's cognitive function and general abilities involved in one's daily life (Olivero). Also, geriatricians, unlike other specialties, encounter and manage patients with five to eight chronic conditions. They work with the patient based on their own goals and preferences to develop a feasible plan of action (Olivero). In other words, geriatricians typically view their patients holistically, and by typically working with interdisciplinary team members, geriatricians can guide the care of their patients through other specialties as well. Aptly put by a wife keeping up with her 83-year-old husband's care regarding geriatricians, "' [y]ou need a quarterback . . . someone who understands the whole process." (qtd. in Peterson).
Referring to those who argue against the specialty of geriatrics in favor of general education of the elderly within one's medical upbringing, geriatricians treat their patients in a fundamentally different way than other specialties: geriatricians focus on functionality rather than treatment. This is, of course, not to mention the value they provide from working with other doctors on behalf of the patient and managing multiple conditions. Still, the different mindset a geriatrician has to treatment is perhaps their most unique trait. Could this be taught to a general medical audience, or ought it be reserved for a specialty? It is difficult to say, but as the demand for geriatricians grows, their value to the medical field and elderly population will become a more significant point of discussion. This discussion must involve and balance continuing to produce the value provided to elderly patients and increase the value perceived by potential geriatric physicians. The demand of the growing elderly population may prove to be where this increased value comes from. More so, Family and Internal Medicine programs will continue to be established that will require a geriatrician, furthering their demand and value. While this discussion about value will be proven or not, with time, the future of the geriatric specialty will no doubt have to examine itself in light of the wave of elderly projected to come about in the coming decades.
Bludau, Juergen H. A. "Geriatric Medicine and Why We Need Geriatricians." The Elliot, Layout 1 (elliothospital.org).
Castaneda, Ruben. "What is Concierge Medicine." U.S. News: Health, November 16, 2020. What Is Concierge Medicine? | U.S. News (usnews.com).
Castellucci, Maria. "Geriatrics Still Failing to Attract New Doctors." Modern Healthcare, February 27, 2018. Geriatrics still failing to attract new doctors | Modern Healthcare.
De, Monya. "Here's Why Geriatrics Really Shouldn't be a Medical Specialty." Center for Health Journalism, June 6, 2017. Here's Why Geriatrics Shouldn't Be A Medical Specialty | Center for Health Journalism.
Department of Veterans Affairs, et al. "Evidence Brief: Effect of Geriatricians on Outcomes of Inpatient and Outpatient Care." Health Services Research and Development Service, June 2012. Evidence Brief: Effect of Geriatricians on Outcomes of Inpatient and Outpatient Care (va.gov).
FQHC Staff. "Baby Boomers All Grown Up – The Impact of the Aging Population on Healthcare." FQHC.org, August 30, 2017, Baby Boomers All Grown Up - The Impact of the Aging Population on Healthcare — FQHC.org.
Olivero, Magaly. "Doctor Shortage: Who Will Take Care of the Elderly." U.S. News: Health, April 21, 2015. Doctor Shortage: Who Will Take Care of the Elderly? | For Better | U.S. News.
Peterson, Jonathan. "Where are the Doctors You'll Need." AARP, April 2016. Geriatrician, Medicine for Aging and Elderly People (aarp.org).
Petriceks, Aldis H., John C. Olivas, and Sakti Srivastava. "Trends in Geriatrics Graduate Medical Education Programs and Positions, 2001 to 2018." PubMed Central, NCBI, December 2018, Trends in Geriatrics Graduate Medical Education Programs and Positions, 2001 to 2018 (nih.gov).
"Why America Faces a Geriatrician Shortage (and What to Do About It)." Advisory Board, January 21, 2020. Why America faces a geriatrician shortage (and what to do about it) (advisory.com).