The Senior Boom Is Coming: Are Primary Care Physicians Ready?

What will be the greatest challenge to U.S. health care in the 21st century? Our aging population, many experts say. As the Baby Boomer generation ages and the average lifespan increases, we face a crisis: we may not have adequate resources to treat elder Americans in the next century. In addition to lack of financial resources, we face a severe shortage of physicians trained to care for elderly patients. This shortage will only become more acute as the older segment of our population increases, and medical students continue to receive inadequate training in geriatric medicine. We must act now to address this critical issue in U.S. health care. This Project-in-a-Box will provide the tools necessary to take action: a description of the changing demographics in the U.S., an explanation of the impact of these demographics on health care, and a discussion of the changes we must make in medical education and health care to care for our aging population.

• What will be the impact of the senior boom on U.S. health care?
• Why do we have a shortage of geriatricians?
• What is the senior boom?
• What can we do to increase the number of physicians trained to care for older patients?

The Problem: A Health Care System That Cannot Respond to the Needs of a Growing Older Population

Part One: Increasing Size of the Elderly Population
The United States is experiencing a demographic revolution. The U.S. birthrate increased dramatically during the 1950s and 1960s , giving rise to the "Baby Boomer" generation. As this segment of the population ages, we will see a dramatic increase in the number of older Americans. Between 1980 and 2040, the population of Americans over 65 years old will increase 160 percent while the total population will only increase by only 41 percent.1

As a result of improved medical technology and preventive health measures, Americans live longer; and this trend will continue into the 21st century. In 1996, the average life expectancy at birth was 75 years. By the year 2020, the average life expectancy will be 82 years for women and 74.2 years for men. By 2040, the average life expectancy will rise to 83.1 years for women and 75 years for men.2 This increase leads to a dramatic rise in the oldest segment of our population; Americans 85 and older are the fastest growing segment of the U.S. population. In 1996, there were almost 4 million people in the U.S. over 85 years old. By the year 2000, the U.S. Census Bureau projects 6.7 million Americans over 85; by 2040, 13 million Americans will be older than 85.3

Part Two: Increasing Health Care Needs
Older patients will become a larger proportion of the patients we care for. For example, in 1980, 38 percent of hospital beds were occupied by patients over 65 years old; in 2000, this proportion will increase to 50 percent.5 Similarly, by the turn of the century, more than 50 percent of physicians' time will be spent with older patients.6

As our population grows older, we will have an increased demand for health care services, along with a dramatic rise in cost of providing this care. At present, people over the age of 65 make up 12 percent of the U.S. population and account for one third of U.S. health care expenditures. By the year 2030, costs of caring for elderly Americans will represent more than half of all health care dollars.7

Finally, and most significant, we may face a serious doctor shortage. Not enough physicians are prepared to care for elderly patients and few medical students are expressing interest in geriatrics as a career.

Part Three: Not Enough Doctors
After 20 years of concern from policy leaders, educators and physicians, geriatrics remains only a small part of American medicine. Although most physicians care for some older patients, few doctors have received formal training in the specific needs of this population. As a result, many older Americans receive inadequate care and others have difficulty finding any doctor who can care for them.

• To provide comprehensive care to the elderly, we must produce more than three times the number of clinicians with specialized geriatric training.8
• We have only 25 percent of the academic leaders necessary to provide students, residents and physicians with training in geriatrics.9

Although there has been an increase in the number of geriatricians in recent years, there is still a severe shortage, which will only become more dramatic as our population ages. According to an Institute of Medicine report, the number of geriatricians may actually fall by the end of the decade as many physicians with geriatrics training retire and few new physicians become geriatricians.

STUDENT ORGANIZERS GUIDE
Along with information on the impact of the aging of America on the practice of generalist medicine, this Project-in-a-Box provides suggestions for activities designed to teach medical students about how they can get more involved in caring for the elderly. It also gives tips on how to find speakers for your activities, key questions to ask them, and where to find more information on the topic. Use your own ideas and the suggestions below to create a fun and informative activity on primary care for the elderly.

Suggested Activities

• Organize a brown bag lunch or obtain sponsorship from an organization on campus (such as the local AMSA chapter or a Primary Care club) to offer free food for those attending the discussion.
• Invite a physician who is knowledgeable about primary care for the elderly to discuss his/her experiences with the elderly and describe a "typical" day caring for the elderly. In addition, invite someone interested in public policy related to the elderly who can further emphasize the need for physicians to care for this population.
• Try to arrange a "Shadow a Resident" program in which medical students are matched with residents for the day. The residents should be in primary care fields with high volumes of elderly patients. You can announce this program after another program in elderly health, when students will be both most interested in learning more and most willing to commit time to this important field. After the shadow day, have all participants gather and discuss their experiences.
• It is often best to hear problems from the people they affect. Visit a nursing or adult home and plan a few hours for the medical students to interact with the residents. Have the students ask the residents about their concerns and attitudes toward modern health care. Ask the residents their opinions on Medicare and how it might be improved. You could even arrange for the students to have lunch with the residents. Again, have a debriefing after the visit. Gather all the students together and discuss their conversations with older people and their reactions to the people themselves.
• Plan a panel discussion by inviting physicians, nurses, pharmacists, psychologists, social workers and other members of the geriatric health care team. Allow members of the panel to discuss their role in an interdisciplinary approach to caring for the elderly.

Where can you find speakers?

• Community-based clinics and nursing homes
• Schools of nursing, pharmacy, psychology, and social work
• Professors or other physicians
• Local community centers for the elderly
• The "Resources for Students" section at the end of this Project-in-a-Box, which lists groups that might be able to suggest local speakers

Key Questions to Ask Your Speakers

• What are the unique needs of elderly patients?
• How is health care for older patients different from care for a younger population?
• How will the increase in geriatric patients impact health care in the U.S.?
• Why have so few students entered fields that provide primary care for the elderly?
• How will the lack of geriatric faculty impact the training of primary care physicians?
• Should medical schools require students to take a course in geriatrics?

Definitions

Geriatrics: "The style of medical practice that addresses the complex needs of older patients and emphasizes maintaining functional independence even in the presence of chronic age-related diseases."4

Geriatricians: Primary care physicians who have completed a fellowship in geriatrics.

Primary Care Physicians: For this document, "primary care" will refer only to physicians with training in general internal medicine, family practice and obstetrics/gynecology. Pediatricians, who are usually considered primary care doctors, will be excluded because they do not treat older patients.

Can Medicare Survive Until the 21st Century?
Medicare is a federally-funded insurance program which covers a portion of health care costs for people over 65 years old. Many older Americans depend on Medicare, which pays for physician office visits and most hospitalizations. Without the program many older people would quickly exhaust their financial resources, and be unable to pay for additional health care.

Unfortunately, Medicare is facing a financial crisis. The program will be bankrupt sometime in the next decade without significant program reform. Why is Medicare in trouble? First, health care expenses in the U.S. continue to rise dramatically. Second, as the population ages, we have an increase in the number of retirees in the Medicare program and fewer workers contributing to the fund that pays for their health care. Finally, in the next 20 years, as more people become eligible for Medicare, the costs will balloon significantly. As a result of these changes, Medicare costs could easily double between 1987 and 2020 unless we overhaul this federal program and our approach to care for elderly patients.10

The U.S. Congress is engaged in an ongoing debate about the future of Medicare, Social Security and other programs that support our older population. As future physicians, we can contribute to this debate by learning about the proposals at hand and expressing our opinions to our legislators.

Why Do We Have a Shortage of Physicians for the Elderly?

Insufficient Training in Medical School
The Alliance for Aging Research attributes the shortage of primary care physicians with training in geriatrics to the limited training medical students receive in care of older patients. Physicians-in-training may care for older patients, but they rarely receive training in the specific needs of elderly patients. Less than 10 percent of U.S. medical schools require students to complete at least one course in geriatrics.11

False Ideology About Elderly Patients
Older patients require a different approach than many other patients, which runs contrary to much of the philosophy that permeates U.S. health care. As a result, many physicians-in-training feel uncomfortable caring for the elderly and avoid careers in geriatrics.

The "heroic model" of American medicine, in which greater technology is thought to indicate higher skill and even intelligence, has been the prevalent value system within academic health centers. This model stresses technologies over the personal care required by geriatric medicine.12 "The low-tech care of older people doesn't have the same magnetic aspect to it as high-tech medical specialties and cutting-edge research," asserts Robert Butler, former director of New York's Mount Sinai Medical Center department of geriatrics.

A corollary to the first issue is the "cure" orientation that permeates American medical training. Although with experience, most physicians unlearn the unrealistic expectation of cure in most cases, it still pervades the values of the academic health center. The geriatric patient often has a number of chronic illnesses requiring the attention of various health care workers, but neither the incremental successes of maintenance nor gradual improvement in functional status in such a patient have ever been viewed as the central intellectual (or even moral) challenge of medicine.

Finally, many physicians suffer from an "ageist" bias, as does the youth-oriented culture from which they come. The frail elderly in particular represent an image of the future that young people would prefer to forget. For physicians, this denial of human decline has been explained by assertions that they won't (or can't) acknowledge the limits of human existence, have trouble accepting the inevitability of death in many instances, and consequently see their inability to "save" these patients as professional failure.

Shortage of Geriatric Faculty
Lack of faculty role models in clinical geriatrics adds to the problem of training future physicians. There are only 500 physicians with sufficient credentials to teach geriatric medicine in U.S. allopathic and osteopathic medical schools.13 According to an Institute of Medicine's committee addressing academic geriatrics, "to establish high-quality geriatric training in all U.S. medical schools by the end of the century would require at least three to five geriatricians (including clinical practitioners and researchers) in each major teaching center for a conservative total of 2,100 faculty members nationwide."14

Is Special Training in Elder Health Important?
Physicians who are trained to care for older patients are able to recognize the special characteristics of older patients and to distinguish disease states from the normal physiological changes associated with aging. To treat older patients effectively, physicians must be knowledgeable about the physiological and psychological changes related to normal aging and the complex clinical and social aspects of caring for older patients.

After completing extensive training in health care for the elderly, physicians will:

• Gain special expertise in conditions of the elderly (such as incontinence, gait disorders, osteoporosis) that have often received little attention in medical journals and textbooks. In addition, these physicians have expertise in clinical pharmacology for the elderly, which differs significantly from other patient populations.
• Have a different attitude toward the care of the elderly. They will be committed to the care of the elderly and help provide interdisciplinary and coordinated care, drawing on different fields of medicine.
• Be informed about community resources that may improve the quality of life for elderly patients and prevent unnecessary nursing home placements. This is vital in containing costs for treatment of the elderly.
• Serve as advocates for the elderly, raising public awareness, lobbying on behalf of the elderly and educating patients, families, health professionals and the public.15

Other Important Changes in Medical Education
In order to increase the number of students choosing elder care as a career, we must change the culture of medical education. In addition to increasing student exposure to geriatrics and adding geriatric faculty, we must reform our curricula to train students in the settings and styles common to high-quality geriatrics.

Hospital or Clinic: Which Provides the Best Training?
Medical students are frequently trained in tertiary-care hospitals, where health care focuses on acute care for serious diseases. However, the majority of health care for the elderly takes place in other settings, such as long-term care facilities, physician offices and even patients' homes. Students must be trained in these locations in order to learn a realistic and appropriate approach to older patients.

Moving medical education from the hospital to the clinic, nursing home and community has enormous financial consequences. Currently, the federal government underwrites education of students and residents through additional payments in the Medicare program. How will we pay for education outside of hospitals? Who will be responsible for paying for this education? These issues are hot topics in the current debate about the future of our health care system.

Training in Health Care for the Elderly
Primary care physicians can gain expertise in elder health through journal articles, continuing medical education courses and self-assessment programs. These may cover topics unique to geriatrics or may introduce a geriatrics perspective to a common medical problem. Topics may include Assessing Functional Status in the Elderly, Management of Complex Medication Regimens, and Aging: What's Normal and What is Not?

For more extensive training, primary care physicians can enroll in a fellowship in geriatrics and become eligible for a Certificate of Added Qualifications (CAQ). This fellowship, which is completed after a residency in internal medicine or family practice, lasts between two and four years and incorporates research as well as clinical training. In addition to primary care physicians, psychiatrists can also receive a CAQ after completing a geriatrics fellowship.

Interdisciplinary Health Care
The complex needs of older patients often require a team of health care providers. For example, a physician may diagnose a particular disease and prescribe a drug to treat it. A nurse may educate the patient about the disease and the drug regimen. A pharmacist then checks for interactions between the new medication and the patient's other drugs. A social worker discusses the patient's home life and ensures that the patient will be able to get and take the medicine. Finally, a home care nurse visits the patient weekly to help with medication and other health issues.

Each member of this team is a vital part of the patient's health care. Unfortunately, medical students are rarely taught about interdisciplinary health care. We are trained in settings in which a hierarchical model predominates, rather than one of collaboration and cooperation. If we were trained to be effective members of a health care team, we could provide more comprehensive, responsible care to all our patients, especially to our older patients. For example, during the past decade, comprehensive geriatric assessment and interdisciplinary intervention have reduced the disability and institutionalization of older persons.21

What Can Students Do?
We must advocate for a geriatrics component of our clinical and pre-clinical curricula so that we will be able to meet the needs of the growing senior population. These reforms might include a required course in geriatric medicine and an incorporation of geriatrics perspectives into other courses. In addition to the medical aspects of elder health, schools must train students to be aware of community programs and resources available to elderly patients. In order to offer these courses, medical schools must increase the size of their geriatrics faculty place added emphasis on research in elder health.

In the meantime, we can educate our fellow students about the importance of geriatrics, and the unique characteristics of this field of medicine. See the Student Organizer's Guide for activities and programs addressing elder health.

Additional Resources

Alliance for Aging Research

2021 K Street, NW Suite 305, Washington, DC 20006

(202) 293-2856

 

American Academy of Anti-Aging Medicine

7034 W. North Avenue, Chicago, IL 60635

(312) 622-7401

 

American Aging Association

2129 Providence Avenue, Chester, PA 19001-5506

(610)874-7550

 

American Association of Retired Persons

601 E Street, NW, Washington, DC 20036

(202) 434-2277


American Geriatrics Society

770 Lexington Avenue, Suite 300, New York, NY 10021

(212) 308-1414

 

Center for the Study of Aging

706 Madison Avenue, Albany, NY 12208

(518) 465-6927

 

Federal Council on Aging

Room 4280 HHS-N

330 Independence Avenue, SW, Washington, DC 20201

 

National Center for Health Statistics

6525 Belcrest Road, Hyattsville, MD 20782

(301) 436-8500

References

1. Rice DP, Feldman, JJ: Living longer in the United States: demographic changes and health needs of the elderly. Milbank Mem. Fund Q 61(3): 362-396, 1983
2. Alliance for Aging Research. Will You Still Treat Me When I'm 65? Washington, DC., 1996
3. Alliance for Aging Research. op. cit.
4. Alliance for Aging Research. op. cit.
5. Davis, D. (1986): Aging and the health care system: economic and structural issues. Daedalus, 15(1):227-246
6. Alliance for Aging Research. op. cit.
7. Alliance for Aging Research. op. cit.
8. Alliance for Aging Research. op. cit.
9. Alliance for Aging Research. op. cit.
10. Schneider EL, Guralnik JM. The aging of America: impact on health care costs. JAMA 1990;263:2335-2340
11. Alliance for Aging Research. op. cit.
12. Burnham, JF: The"scientific" value of personal care. Ann Intern Med 91:643-644, 1979
13. Alliance for Aging Research. op. cit.
14. Alliance for Aging Research. op. cit.
15. Andreopoulos S, Hogness. Health Care for an Aging Society. New York, NY: Churchill Livingstone Inc.; 1989

Case Studies
Except where otherwise indicated, these cases are adapted from the Alliance for Aging Research publication "Will You Still Treat Me When I'm 65?" They are intended to provide opportunities for interdisciplinary groups of students to evaluate and discuss treatment options for geriatric care.

Case 1: Geriatricians' approach to incontinence
Mrs. S. is 70 years old. She and her husband volunteered in a soup kitchen until her life became disrupted by incontinence so frequent that she often had to stop along the road to find a lavatory. Her only doctor was a rheumatologist, to whom Mrs. S. mentioned her problem with leakage. He referred Mrs. S. to a gynecologist who recommended surgery. Discouraged and not wanting to undergo surgery, Mrs. S. left the gynecologist's office and sought a geriatrician.

Mrs. S.'s first visit to the geriatrics program involved the taking of her medical history and a physical examination. Her medical history included arthritis and hypertension and her only medications were for hypertension and hormone replacement. Besides incontinence, her urologic history was negative and she had undergone two normal, vaginal deliveries. The urinary incontinence pattern was one of stress and urge, with urge symptoms appearing to be most prominent. Tests were performed related to her urinary volume, retention, bladder and stress leakage and she was asked to keep a bladder record for two weeks. The record indicated that she had approximately six urinary accidents per week, each related to some sense of urgency. Her voiding times were approximately every two hours.

• How do you feel the rheumatologist initially handled Mrs. S.'s problem?
• How do you feel about the gynecologist's recommendation of surgery?
• How did the geriatrician's approach to caring for Mrs. S. differ from the other physicians'?
• Does a multidisciplinary approach seem appropriate for Mrs. S.'s problem? If yes, why? How should this approach be undertaken?
• What other physicians and health care workers may be consulted regarding Mrs. S.'s problem?

Mrs. S. was instructed to use biofeedback to perform pelvic exercises and had four sessions of training, each at approximately three-week intervals. Her urinary incontinence decreased and her voiding time increased. Mrs. S. can now see improvement in her pelvic muscle strength and endurance through biofeedback. In approximately two months, she resumed delivering food to soup kitchens and no longer needed to search for lavatories along the way. Two years after treatment, she is now dry and volunteering every day.

Case 2: Collaboration and a multidisciplinary approach
Mrs. W., an 89-year-old widow, lives alone. Mrs. W. identifies with people and attends her local senior club. She has a medical history that includes hypertension, mitral valve replacement, and swelling in her legs due to chronic venous disease. Her only medication is to prevent blood clotting. Mrs. W.'s only child lives across the country and has become concerned over her mother's memory loss. She receives frequent phone calls from her mother, who forgets their previous conversations; the problem has recently worsened. With difficulty, Mrs. W.'s daughter found a geriatrician near her mother's town. Mrs. W. was examined and found to be pleasant but with a mild degree of dementia. A CT scan did not indicate any changes or that her dementia was irreversible.

After consultation with the daughter, the geriatric team proposes that Mrs. W. receive care in the familiar surroundings of her home. A neighbor agrees to provide support and report any changes to Mrs. W.'s daughter and to the geriatrician. A home visit is made by the social worker and the geriatric nurse. Several concerns arise: steep stairs; safety, especially in relation to the stove; bathing; and security. These are corrected in consultation with the patient's daughter. Mrs. W. is able to follow her medication instructions when they are written down.

Over several months Mrs. W. experiences a slow but steady decline. She requires assistance with her personal care and has become incontinent. Friends stop taking her to the senior club because of this problem. The neighbor simply can no longer participate in Mrs. W.'s care. The social worker arranges in-home care during the day. Meals are packaged for her by friends and left for her to eat. Arrangements are made for visitors from her church. A summer college student working in the geriatric primary care office becomes involved with Mrs. W. as a friendly visitor. The student visits during the week and often calls her on the telephone. These visits decrease Mrs. W.'s anxiety and fear of isolation. Mrs. W. will not participate in day care and does not have the resources to pay for an assisted living arrangement.

Finally, arrangements are made for an in-home aide to assist four hours per day, seven days a week. Over time, Mrs. W. requires more supervision and, eventually, a 24-hour live-in aide is arranged. This turns out to be less expensive than a nursing home, as the live-in aide needs the room and board support. Mrs. W. is able to remain in her home through this coordinated effort.

• How might Mrs. W's care have been different if she was treated by only a physician, rather than a health care team?
• What are the specific roles of the different members of the health care team?