May 21, 2017

Despite Growing Numbers of Seniors, Geriatricians Remain a Rarity

Reporting Texas

Dr. Liam Fry is division chief of geriatrics for Dell Medical School at the University of Texas at Austin. David Lopez/Reporting Texas

Geriatric medicine remains an unpopular and underpaid specialty, even as 74.9 million baby boomers move into the age bracket where, experience shows, medicine focusing on elderly people improves health and reduces health care costs.

In 2016, there were about 7,200 board-certified geriatricians in the country, according to the American Geriatrics Society. The number is not expected to grow any time soon; the society predicts there will be only one geriatrician for every 4,000 seniors in the next 15 years.

Texas is home to the third-largest elder population in the United States, and it’s growing faster than in any other state, according to the Texas Demographic Center. Only six geriatric fellowship programs are located in the state, said Dr. Liam Fry, an Austin-based geriatrician and division chief of geriatrics for Dell Medical School at the University of Texas at Austin.

Growing up, Fry was close to her grandparents and often talked to her elderly neighbors. That emotional bond, coupled with an interest in the medical complexity of geriatric health, turned her childhood passion into a career.

Fry is part of a small community of geriatricians in Central Texas — “only a handful in Austin,” she said.

Geriatricians specialize in creating a better-quality life for their frail patients. As people age, they often deal with multiple health issues that together produce complex side effects and a poor quality of life. The combination of multiple diseases and many medications creates a complexity that typically does not exist in younger patients. Geriatricians manage all aspects of their patients’ health to create a unique care plan that suits specific needs.

Geriatricians must know when to prescribe medications and, more critically, know when the interactions of different medications and ailments pose a danger to patients. “Geriatrics is all about being very practical; it’s common sense,” Fry said.

The benefits of expert geriatric care are considerable. “People with geriatricians are healthier,” Dr. Neela Patel, a director of the American Geriatrics Society, wrote in an email. “Comprehensive geriatric assessment shows significant benefits both in terms of increased independence and a reduction in mortality.”

People 80 and older have the greatest need for geriatricians, who carry on the tradition of house calls and visiting patients in nursing homes and in assisted living centers. Geriatricians generally work with a team of other health care providers.

“Geriatricians help the quality of care and shorten the length of hospital stays for their patients,” Fry said. For example, one of the most common problems for hospitalized patients is dehydration, she said. The problem seems simple enough to fix, but many patients lose the ability to recognize they are thirsty and cannot communicate what they need. Geriatricians make sure that such common ailments are addressed properly; otherwise, they could extend a patient’s stay.

In senior facilities, geriatricians oversee teams of physicians, specialists and nurses to provide coordinated holistic primary care that helps control Medicare spending. HMO systems such as Kaiser Permanente, the largest managed care organization in the United States, have geriatricians on staff because it saves them money.

Two big obstacles stand in the way of an increased supply of geriatricians: training and pay.

Dr. Fry explains the types of walkers she has her patients use to ensure their mobility is not hindered. David Lopez Reporting Texas.

A physician who wants to become a geriatrician must complete a geriatrics fellowship, meaning another year of training and the costs associated with that year.

Once in practice, a geriatrician can expect to make less money than a family physician does. Despite the increase in the geriatric population, geriatrician pay has stagnated because most of their pay is funded by Medicare, the federal health insurance program for people age 65 or older. Medicare controls its costs by imposing strict limits on reimbursements to physicians.

“A doctor’s yearly pay is determined by the number of services they provide and the prices of the services they provide,” said Cristina Boccuti, a Medicare expert at the Kaiser Family Foundation. “Medicare determines what a doctor can charge for their services.”

Boccuti said family physicians, a closely related specialty, make more money because they have a wider range of insurers that often pay more generously than Medicare.

Dell Medical School is trying to promote improved geriatric care despite the unpopularity of the specialty. “I don’t think we are ever going to have enough geriatricians, but if we use them to teach more medical students, that is probably a more realistic goal,” Fry said.

The school is requiring a two-week geriatrics or palliative care rotation for all students, a rarity among medical schools. Fry supervises all geriatrics teaching for medical students.

Geriatricians like Fry are changing the way medical students are being trained to meet the needs of the growing elderly population. Unlike specialties such as oncology that have advocacy groups that attract attention from the public, geriatrics is not in the public eye.

“People aren’t advocating for older adults, and they aren’t likely to advocate for themselves,” Fry said. “I am cautiously optimistic that things will change.”