Every year, about 300 doctors begin their careers specializing in geriatrics in the United States. By every account, it's nowhere close to enough. By 2030, the American Geriatrics Society estimates the country will need 36,000 geriatricians to care for a country that has been growing steadily grayer. "We're way behind the eight ball here," said Dr. David B. Reuben, former president of the American Geriatrics Society and a prominent geriatrician who runs the UCLA Multicampus Program in Geriatric Medicine and Gerontology. "There's this huge mismatch, and every year it's getting larger." It's not difficult to figure out what's gone wrong, he added. Young doctors coming out of medical school aren't generally attracted to the idea of devoting their careers to elderly patients. Growing amounts of student debt also make it hard to choose a specialty that pays far less than others and is largely governed by Medicare's rules and regulations. "I think it's a major crisis that most people are totally unaware of," said Dr. Harrison Bloom, a practicing geriatrician and senior associate with the International Longevity Center. Also on the decline: the number of medical students choosing to go into primary care and family medicine, a group of doctors that provides a pool of future geriatricians. In practice, that's meant that more of the elderly are routinely being treated by primary care physicians. But that's far from ideal. "There's a list of what I call geriatric syndromes, things geriatricians see all the time," said Reuben. "And when you see the same conditions, you get really good at caring for them. Those are conditions like dementia, delirium, arthritis, functional impairment, falls. We just see this all the time; this is our bread and butter. Primary care doctors don't do a really good job at it." The whole approach to caring for older people also requires special expertise: goal setting, balancing burdens and considering the long-term benefits of therapy for patients who often don't have much longer to live no matter what a doctor does. Reuben recently had a 91-year-old patient with dementia who was on statins. In talking with the family, considering the time she had left to benefit from the therapy, they decided to stop the treatment. It's that kind of decision making — understanding what the future might bring and weighing options — that geriatricians can do best. "It gets more and more complex," he added. "With most younger people, you're dealing with one condition. With the elderly, there are almost always a host of competing morbidities. Older people have so much going on." When residents find themselves working with a 92-year-old with eight to nine conditions, "they just freeze. They don't know how to begin." Bloom said, "There are changes that occur with aging, to the body and to the mind, that clinicians need to pay attention to." Comorbidities require multiple medications, which raise the risk of dangerous drug interactions. And they need to be aware that symptoms are often presented in the elderly in a far different way than the young experience. The typical 50-year-old suffering a heart attack experiences crushing chest pain which radiates to the arm and neck and is accompanied by nausea and by shortness of breath and sweating. "That same exact problem in an 80-year-old may present the same way, but in a significant minority of cases, that same heart attack will present with no pain or little pain," he said. "If you're not aware, you're going to miss it, and that can be quite serious." Side effects and adverse reactions from a lineup of medications are also often demonstrated much differently in the elderly than the young or middle-aged. The big dissuader of would-be geriatricians remains the way that they're reimbursed for their work. "The payment system is just so broken," said Reuben. "Physicians earn money now based on productivity; the more patients they see, the more they earn. But that doesn't work in geriatrics, where a 95-year-old patient may simply need some counseling on staying home, getting help and so on. Forty years ago, it made sense to pay people for procedures, but now doctors are working on finding ways for elderly patients to stay home and remain in their communities. That's something the payment system doesn't even recognize." For example, said Reuben, "If I have a patient who needs somebody to come into the house and see them, get tied into community services at senior center, needs a list of care givers, and I spend two, three hours trying to make it work, I don't get anything for it. If I see the patient and take off a skin tumor, I can be paid very well for it." Bloom added, "When you deal with someone who has 70, 80, 90 years of history, you can't do that in five to 10 minutes. It takes time, and also one deals with families a lot. A lot of communication needs to take place. But in order to make a living, it's very difficult to take the time that's necessary." Pay-for-performance models could work to help improve the situation, Reuben said, but so far, little concrete improvements have been put into place. One practice model for working with the elderly seems to work, said Reuben. In the Kaiser Permanente system, which has its own network of physicians and hospitals, "they have a fixed set of money per patient and can allocate it the way they feel will benefit the patient." But geriatricians complain that instead of moving forward on geriatrics to reform the system, the federal government has been moving backward. Last year, Congress eliminated public support for clinician teachers of geriatrics. "It was a terrible step in the wrong direction," said Reuben. "I don't think the field has recovered from it yet." February 2007