There Are Too Few Geriatricians to Care for the Growing Number of Older Adults.

By Pam Kelley, The Charlotte Observer, N.C.

Jan. 28–When Gaston Family Medical Center opened last May to serve the elderly, patients gave it rave reviews for its uncommon brand of senior care — longer appointments, medication reviews and lots of listening.

But this kind of care remains a rarity, for one giant reason: In the United States, there’s little money to be made caring for old people.

Reimbursements from Medicare are low, and older patients often take more of a doctor’s time. They’re such a drain on profits, in fact, that some physicians limit patients on Medicare, the government’s health insurance for the elderly.

America now has fewer than 7,000 geriatricians — specialists who care for the elderly. That’s one for every 5,000 people 65 and older. It needs about 14,000, experts say. The shortage is only expected to worsen as 77 million aging baby boomers clamor for this kind of care in coming years.

Dr. Anthony Caprio, who specializes in geriatrics at UNC Chapel Hill’s School of Medicine, sees a coming crisis: "a lot of older adults with chronic conditions…and a health care situation not prepared for it."

Time to listen

Chronic conditions — diabetes, rheumatoid arthritis, neuropathy — are what brought 81-year-old Mabel Earnhardt to Gaston Family Medical Center last year.Earnhardt began seeing Dr. Van J. Stitt Jr. at the urging of her granddaughter Christi Jolley. Jolley had been impressed when Stitt diagnosed her other grandmother with a urinary tract infection. Other health professionals had missed the infection, which doesn’t cause the same symptoms in the elderly as it does in younger people.

On Earnhardt’s first visit, Stitt evaluated her medications — an important but time-consuming task. Often, senior citizens take prescriptions from several doctors, plus over-the-counter medicines and supplements. And often, interactions and side effects can cause symptoms such as confusion, hypertension and dizziness.

Stitt discontinued several of Earnhardt’s medications, including one that can cause dizziness in old people. "When she was 65 and they put her on it, it might have been fine, but not at 80," Jolley says.

On a recent visit, Earnhardt complained about sore knees and swollen legs.

Stitt advised her to walk more, explaining that the muscles above her knees would deteriorate if they aren’t used enough. "The more you walk," he told her, "the better you are. So I need you to be walking for me."

Jolley likes Stitt’s rapport with patients. Earnhardt’s previous doctor was competent, she says, but his hurried demeanor often caused her grandmother to forget her questions. Stitt "takes the time to listen and process what they’re saying."

Meeting seniors’ needs

But the doctor can take that time only because the practice is a nonprofit created with the help of a grant from Gaston Family Health Services. Stitt sees about 18 patients a day. Typically, primary care doctors see 30 to 35.

In Mecklenburg County, the Carolinas HealthCare System’s Senior Health Connection and Presbyterian Senior Healthcare also focus on the elderly. Neither are profitable, but the two hospital systems that own them consider them part of their community service missions.

All three practices offer services tailored to senior needs. Gaston Family Medical Center in Gastonia has a diabetes management program, nutrition counselor, clinical social worker and a consulting pharmacist. Exam rooms have comfortable chairs instead of flat tables. And the waiting room TV plays nature videos instead of nerve-jarring news updates.

In Charlotte, Senior Health Connection brings specialists to its office at the Arboretum so patients can see multiple doctors in one place. And at Presbyterian Senior Healthcare, physicians help families choose resources such as home care, assisted living facilities and Medicare prescription drug plans.

Stitt came to his job last spring after serving as Gaston Memorial’s vice president of medical affairs. A family practitioner with a geriatrics background, he wanted to return to work that made an immediate impact with patients. And at 61, he could empathize with many concerns about aging.

"Plus," he says, "I think old folks are plain old fascinating." Since the practice opened in May, he’s been the recipient of cornbread, tomatoes, a birthday cake and an afghan, all gifts from grateful patients. He says he has never felt more appreciated.

That’s typical. In surveys, geriatricians report the highest job satisfaction of any specialists.

Low respect, low pay

Still, senior care often doesn’t win respect in the medical profession. Many medical schools teach little about geriatrics, and doctors who spend an extra year to specialize in it earn less than those who don’t do the extra training. Annual salaries average about $150,000, while other specialists, such as radiologists or orthopedists, can make $400,000 or more.Not surprisingly, debt-ridden graduates aren’t flocking to geriatrics. The number of geriatricians has actually declined by about a quarter since 1998.

The problem stems partly from history, says Dr. Paul Eleazer, director of the University of South Carolina School of Medicine’s Division of Geriatrics. When medical school education developed at the start of the 20th century, the vast majority of people were under age 12.

Medical schools have often assumed that students learn enough about geriatrics by treating old patients on hospital rounds. As a result, some doctors don’t understand that old people have different needs than middle-aged patients.

But today, old people are becoming a larger part of nearly all practices. Even pediatricians need to know about geriatrics, Eleazer says. That way they can spot serious health problems, such as dementia, in grandparents raising their grandchildren.

USC spends more time on geriatrics than many medical schools, integrating it into all four years of the curriculum. Students also are paired with senior citizens from the community. By following these seniors over four years, students learn firsthand about treating the elderly.

Such training is essential to prepare doctors for aging baby boomers, experts say. With the geriatrician shortage predicted to worsen, the expertise of geriatricians will likely be reserved for seniors with the most complicated problems. So internists and family practice physicians will continue to serve most old people.

More exposure to geriatrics might entice more students to the field. Emily Chang, a fourth-year medical student at Chapel Hill, recently spent a month in a geriatrics rotation at Carolinas Medical Center and found she loved the work.

She thinks it should be required. "If they have the pediatrics requirement, why shouldn’t they have the geriatrics requirement?"

Many health professionals also complain that Medicare reimburses for tests and procedures, but makes it difficult for them to help patients prevent diseases and maintain health. "Physicians are rewarded for illness," Stitt says.

Seniors often don’t need high-tech procedures. Services they do need — a review of their medications, or a discussion about starting hospice care — require such extensive documentation for Medicare that doctors seldom attempt to bill for them.

"It’s a high-feel, high-talk specialty," USC’s Eleazer says. "When does Mom stop driving? That’s never a quick conversation. It takes quite a bit of time, but it’s incredibly important."

Such a conversation could take as much time as a colonoscopy, he says. Reimbursement for a colonoscopy is about $370.

But the discussion about driving? For that office visit, Eleazer says, it would be hard to get reimbursed at all.

Caring for an Elderly America

–By 2030, the U.S. population age 65 and up will exceed 70 million — about double the number in 2000.

–The number of geriatricians has decreased from 9,256 in 1998 to fewer than 7,000 today.

–Current estimated need is about 14,000 geriatricians. By 2030, an estimated 36,000 will be needed.

SOURCE: The American Geriatrics Society

Pam Kelley: 704-358-5271.

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Copyright (c) 2007, The Charlotte Observer, N.C.

Distributed by McClatchy-Tribune Business News.

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