The Physician Role in the Care of the Frail Elderly
Observations on the size and readiness of the physician workforce in WNY and CNY and possible avenues for intervention or support.
Prepared by:
Edward J. Marine, M.D. with assistance from Angel “Lito” Gutierrez, M.D.
David Murray, M.D.
The Physician Role in the Care of the Frail Elderly
Part I
Readiness of the Physician Workforce to Address Geriatric Medicine in
WNY and CNY
Summary of Findings:
The physician workforce providing care for the frail elderly in WNY and CNY needs to be strengthened. Internists and Family Physicians, a small proportion with formal training in geriatrics, carry much of the workload. Most are less than fully prepared and find themselves inadequately supported for the essential, often subtle, transitions involved. In addition to mastery of the complex
interactions of the aging process with acute and chronic diseases, the standard of successful, high quality outcomes inevitably shifts from “curative” care to “palliative” and “comfort” care. Interdisciplinary teamwork, pain management, polypharmacy, caregiver support, and end-of-life care management are among the special challenges. Nor is there adequate access to educational programs for those motivated to take advantage of them. The pipeline supplying well-prepared physicians shows improvement but appears quite inadequate to the tidal wave of emerging need. That much can be said with certainty in both regions.
Beyond these general conclusions it is not possible to quantify shortages or further specify these needs with confidence at this time. There is a shortage of fully trained and certified physicians specializing in geriatrics. The dimensions of the shortage are arguable due to a lack of agreement on the proper physician role. The complexities involved in high quality health care for a frail elderly population cross all medical specialty lines. In addition, to meet a high standard, special competencies are required in a range of other health professionals in a far from ordinary team setting. Determining the number of physicians required
and standardizing the needed level of special expertise will depend on a yet to be defined “model of care” within a given community.
This report is biased towards a model in which fully trained and certified sub-specialists in Geriatric Medicine serve primarily as consultants and teachers to the full range of physicians and to other health professionals working in
interdisciplinary teams. Such a model is often cited positively, but is far from prevalent. The success of such a model requires a high level of awareness and sensitivity to the major issues across the spectrum of physician specialties and all the other health professions. In the absence of broad agreement on a vision of truly good care and outcomes for this unique population, and the ability to measure such quality, this may well be the more difficult task.
Some Perspective
The problems are national in scope. There is wide variation but only a few urban areas appear to have barely sufficient numbers of physicians with formal
qualifications in geriatrics. New York State has nearly twice the national average number per unit of population. The New York City area and Rochester have a large concentration of programs and many trained specialists with fewer geriatric trained physicians in the rest of the state. Thus, by any of the currently used standards of Geriatric physician workforce needs, the case can be made that WNY and CNY, with the exception of Rochester, are indeed in crisis.
This may also be said with reference to the prospects for improvement. The academic medical centers represent the principal, realistic line of supply. While the New York City area is, not surprisingly, a center for multiple excellent
Geriatric education programs, Syracuse and Buffalo are barely on the national radar screen. Rochester is, on the other hand, quite different and a very worthy regional benchmark.
The SUNY Schools of Medicine (Stonybrook, Brooklyn, Syracuse and Buffalo) share a huge disadvantage. All four of them are inadequately funded and thus
understaffed in the field of geriatrics and gerontology. Sharing a dependence on State funding, the pace of adoption of national trends in Geriatric medical
education by these schools follows the fiscal health of State government. Post 9/11, the SUNY schools of medicine have been told to “forget about” financial support for new programs. Considering the allocation of scarce resources in a State blessed with extensive private medical education, it is not difficult to understand.
Notwithstanding these realities, the academic leadership in WNY and CNY has pursued and discovered foundation support for advancing the cause of Geriatric education (see below). The Family Medicine Departments of both Schools have demonstrated good efforts to integrate the essential competencies. A number of quite worthy and substantial initiatives are underway in both University medical centers as a result. CHF needs to be aware of them and alert to opportunities to support advances towards, at a minimum, a level playing field for these academic “generators” of the physician manpower required to meet foundation objectives for the frail elderly. Any strategies of the foundation should coordinate with the university geriatric programs and their leaders.
As a result of several months of study, by a rather humble investigative team, the Foundation should have a useful educational “fact and opinion” database for evaluating potential investments in physician preparation and remedial and continuing education. The mission of this reporting team was restricted to the physician component, but the interdisciplinary nature of the problems and solutions towards excellence in the care of the frail elderly are excruciatingly clear and obvious.
Initial, remedial and continuing education of physicians in Geriatrics and Gerontology
Our focused concern in addressing this question is current and future impact on the health and healthcare of the frail elderly population in WNY and CNY. There are no simple boundaries for the underlying educational issues and potential
solutions. In identifying our target community sector, chronological age is not an adequate gauge and frailty has wide variation and, apart from dementia, may be limited or even reversed to some degree. Therefore, we require a higher altitude view of the larger stage before reporting and interpreting our more local findings of fact and opinion.
Health officials have been sounding the alarm that there are too few health providers knowledgeable about multiple aging issues. There are ongoing efforts to get Congress to address the areas of highest public impact as lawmakers consider and write far-reaching Medicare reform legislation. For an example from the national press: "The shortage of geriatric-trained health care
professionals is reaching crisis levels," said then Sen. John Breaux, D-La., chairman of the Senate's Special Committee on Aging. In focusing on the elderly, and a subset of the elderly, we at CHF must take into account the growing awareness that the underlying dynamics of the entire US system are untenable. Recognition that it is unaffordable may lead, at long last, to badly needed fundamental and heretofore unacceptable system-wide change.
With the preceding cautionary notes, conventional analysis of Physician
workforce requirements in Geriatric Medicine indicate a current need for 20,000 geriatric-trained physicians to adequately care for the 35 million older people in this country (according to the Alliance for Aging Research, an advocacy group1). A Physician Committee on the Future of Geriatrics states, however, that fewer than 9,000 of the nation's current 650,000 licensed physicians have met the qualifying criteria in geriatrics. Astonishing as it may seem, that number has been falling to an estimate of as few as 6,000 at present.
A somewhat confusing metric being widely used is the number of geriatric physicians per 10,000 people age 75 and above. There is a reported national decline from 5.5/10,000 in 2001 to 4.2/10,000 in 2003. For a better sense of scale, New York State has 9.5/10,000 but the number outside of NYC is much lower, estimated as below even the national average. Perhaps more ominous is
the lack of qualified faculty, academic physicians needed to train the next generation of physicians responsible for the medical care of this anticipated surge of elderly population.
Reasons given for the shortage of trained physicians are ranked differently and vary with the perspective and bias of the source. Inadequacy of the geriatric curriculum at medical schools is uniformly cited. However, topping everyone’s list is Medicare's relatively paltry payments for doctors who care for the elderly in a conventional fee-for-service (FFS) manner. In 2003, doctors treating Medicare patients learned there would be a 5.4% cut in their Medicare payments. A further reduction in 2004 was reversed to provide a 1.2% increase, too paltry to impress anyone. Experiments in payments for needed cognitive and team care services offer more hope.
If the figures and trends cited appear alarming, the future needs multiply
geometrically with a projected year 2030 need for 36,000 Geriatricians. This is based on the expected increase of the over 65 population (growing by a net of 1 million per year).
Drilling down produces more of the same with special problems in gero-psychiatry where current demand far exceeds supply and the pipeline is
inadequate. The American Psychological Association (APA) and the American Association for GeriatricPsychiatry (AAGP) pointed out in written statements to the Senate Special Committee on Aging that, since 1991, 2,508 psychiatrists have been certified ingeriatric psychiatry by the American Board of Psychiatry andNeurology. AAGP predicted that twice as many geriatric psychiatristswill be needed by 2010 to meet the projected demand for service. An additional 1,221 academic geriatric psychiatrists will beneeded by 2010 to train future residents in that specialty,added AAGP. While we need a grain of salt here and more clarity on the premises of the advocates, their argument shows a substantial
Models of Care
Current models of care for the elderly are being challenged everywhere. The field of geriatric medicine is in itself relatively new, still evolving and by nature interdisciplinary. Physicians providing high quality medical care to older adults must recognize and depend on the skills of many other disciplines to an
extraordinary degree. Those few physicians who specialize in geriatrics
recognize this dependency quite clearly. The great bulk of medical care for older adults has been and will continue to be delivered by physicians and other health care providers who are not specialized in geriatric medicine. Is that appropriate and what are the alternatives?
In pursuing the question of work force adequacy it is important to define a model. This is not clearly done in any of the estimations we have seen. Some argue that increasing complexity predicts a need for larger numbers of Geriatricians to fill a combined primary care, consultative specialist model. Others emphasize the obvious importance of better training in the care of the elderly for all physicians regardless of their specialty. Supply and demand modeling does not clarify the question of work force status, especially not in the current unstable health care economy.
At this time, wherever one sets the bar, we neither have in place nor in the pipeline nearly enough specialists and educators in geriatric medicine to meet current and future needs. Most physician care for truly frail elders is now provided by “self selected’2 nursing home coverage specialists and community primary care physicians. These physicians may or may not have had any specialized training or pursued certificates in the complexities of the health care needs of frail elders, and the special interactions of multiple conditions and medications. Multidisciplinary team care is essential, by any definition of quality, in producing successful health outcomes for the frail elderly.
With this in mind, the role of the physician is placed in better perspective. Specialists and sub-specialists must recognize that just as children are not
simply small adults, the frail elderly are often not simply adults with more than one diagnosis. Taken together, this presents us with a multidimensional
problem. Furthermore, the public appetite for health services of apparent (if not necessarily real) added value does seem insatiable. Could it be done, simply meeting the currently estimated need for geriatricians would not be sufficient, certainly not without new dimensions of awareness and capability for the whole range of medical specialties.
Dimensions of the Problem for WNY and CNY
Over a four-month period, many meetings, interviews and written exchanges were initiated with academic and practice leaders in care of the elderly in WNY and CNY. In addition almost all available databases have been examined for documentation of the fundamentals. As stated earlier, using national standards and estimates, the inadequacy of the physician workforce in New York appears less severe on a state-to-state comparison. For the most part, we can explain the discrepancies discovered when comparing WNY and CNY to New York State and the nation.
There are eleven (11) schools of Medicine in New York State. Four (4) are part of the SUNY system. Of the schools with any activity in geriatrics, the SUNY units generally have far fewer faculty, and far less funding for education and research in geriatrics3. The units in Syracuse and Buffalo are near the bottom by every measure. For a time, the problem and the need were being recognized and a Geriatric Education Center was funded based at SUNY Upstate. After 9/11/2001, citing budgetary exigencies, the program was defunded and had to be closed. Requests for additional support to advance the weak programs in Buffalo and Syracuse have been met with4: “don’t even think about it.”
There is some good news. Local bright spots include the Hartford-AAMC supported initiative in Syracuse5 and the very substantial Reynolds Foundation grant received in 2003 by the SUNYAB Geriatrics program. The University Of Rochester School Of Medicine is, on the other hand, quite strong and competitive
on a national scale. Recipients of an earlier Reynolds Foundation award, Rochester has a relatively long history of attention to geriatric education with results to show for it.
In the current practice arena, there are predictable consequences of these anemic generators of workforce. The problem is complicated by relatively unattractive settings for physician recruitment in general. This is attenuated in part by earlier success in Buffalo where a strong University Geriatrics training and Gerontology Research program was initiated at the Veterans Administration6 unit of SUNYAB. This produced a fair number of Fellowship trained Internists. Some are practicing as members of one of the two Geriatric groups in WNY. Both Family Medicine Departments showed recognition of the challenge and each has several faculty with a Certificate of Added Qualifications (CAQ) in Geriatrics.
Programs for Medical Students, Residents and Practitioners
The curriculum for medical students at SUNY Upstate (Syracuse) has been revised concurrently with the introduction of the LinkAges7 program over the last few years. The structural design certainly looks strong, but with a core of only two fully trained and qualified faculty there is a serious problem in modeling ideal practice approaches, delivering rich experiences, and inspiring future
geriatricians. There are insufficient funds to fully implement the new design. In any event, some real improvements have been implemented with a version of the EPEC8 (Education for Physicians on End-of-Life Care) as a required element in the third year.
The residency programs in Medicine and Family Practice both suffer from the lack of available Geriatric Faculty. In addition to the usual gero-friendly, out-of- hospital bias of family medicine, the program leaders seem more concerned about the deficiency. In some medical centers and many training programs the widespread problem in the past of “not knowing what you don’t know” (the extent to which gaps and deficiencies are fully recognized) continues. If faculty, across
the medical disciplines, fail to recognize and teach the qualitative differences in caring for the elderly, including the difficult cure/palliation crossroads, there is little gain from program design or increased curricular time.
At SUNYAB, with the Reynolds grant as a multiplier of resources, there is more reason to anticipate improvement. A core geriatrics curriculum is under
development9. There is required experience for all students in each of the first three years. Palliative care has some distinct time, having been bundled with geriatrics previously10. A very strong Palliative Care (EOL) elective is available in the fourth year, but only 10-20 students are reached.
The residency program in Medicine is also being addressed as part of the Reynolds grant initiative and, apparently, it starts with a pretty weak base. The Family Practice program is stronger with a Chairman who has earned a CAQ (Certificate of Additional Qualification) in Geriatrics. The model supported by the Department sees a strong geriatric physician role in consultative practice and, more importantly, in the education for practice of the residents in family medicine and other disciplines11. The surgical residency program has been receptive to such efforts offered now by the Division of Geriatrics.
There are Geriatric Fellowship positions in Syracuse and in Buffalo. When they are filled, it is predominantly with foreign graduates on limited visas. The
explanation for this is probably complex. All the residency programs share some of the difficulty in recruiting US graduates and especially those who might be likely to stay and serve these regions. Any deficiency in faculty or in the clinical experience, quantitative or qualitative, will magnify the recruiting problems. In geriatrics, the reward system for clinicians is a serious deterrent to entry in the field. With medical school and hospital budgets under great stress, faculty recruitment issues add to a vicious cycle. As daunting as these challenges appear, there is little doubt that undergraduate and graduate educational efforts will offer the best hope of a better-prepared physician workforce for the future.
The challenge of CME for practitioners is a more daunting one. The Physicians who “know what they don’t know” and have the desire to pursue the knowledge and skills of concern in our mission, have few local opportunities. Those that occur are generally supported by drug companies with the usual baggage of such sponsorship. (Rochester appears to offer much more in the range and availability of programs.) Those national and regional programs that are available tend to be expensive as well as time consuming; here too, there is no financial incentive to the busy practitioner to take time out. There are of course, for the highly motivated and computer literate, excellent distance learning programs with and without official CME credit. Awareness of this and its use is not clear from our exploration thus far.
Tentative Conclusions for CHF Purposes
The conclusions that follow apply to WNY and CNY and are based on less than complete data and information, often reflecting the opinions of reasonable
sources. A far better definition is needed for community and societal models and goals for elder health and health care. Nonetheless, our regions have shortages that are greater by an order of magnitude. The reader should also examine the Annotated Sources and Contacts which can be found in Section III of this report.
1) Most physician services in the care of frail elders are delivered by generalists and specialists who have had variable, but generally limited, specific training for the special challenges and needs associated with frail elders.
2) While NYS is exceeding national averages, there are too few physicians trained and qualified as geriatric specialists in WNY and CNY; the situation may be a good deal worse in CNY5.
3) There are few applicants for the geriatric training opportunities that exist and too few physicians in the pipeline to meet even the most conservative estimates of future need.
4) The number of fellowship trained and currently certified (CAQ) Geriatricians is in decline as those who have been trained and certified choose to limit their exposure due chiefly to financial and professional disincentives.
5) There are numerous relevant innovations in medical curriculum affecting many medical students and residents in both Schools. These efforts may be under- funded in Syracuse in particular, but a large Reynolds Foundation grant has helped a great deal at SUNYAB.
6) The undergraduate experience is stronger than graduate. The culture of Family Medicine at both schools is more “gero-friendly” than Internal Medicine. They are moving to strengthen the program at all levels at SUNYAB with the Reynolds grant
7) There is a problem with a limited availability of CME credit for training in issues relevant to this population. For physicians now serving the frail elderly there are issues of CME costs and available time as well.
8) There is a serious shortage of faculty at both “generator” stations in our regions.
9) The University of Rochester has programs and faculty far in excess of those available in our two SUNY units.
10) While there are problems and issues particular to our regions there are endemic and systemic problems at the State (SUNY) and the National level as well.
Final Comments
An analogy between geriatrics and pediatrics has been drawn to help explain the need for a real subspecialty of adult medicine. In particular, the frail elderly are not merely older adults. The physiology of aging alters the face and course of disease along with often dramatic changes in direct and side effects of
the standard methods and tools of evaluation and treatment must be adapted or even discarded.
Physicians, particularly in our society, are self selected and trained to see disease and death as the enemy and to believe in the limitless possibilities of science and its application. Small wonder then that a career in geriatrics is a hard sell to the young physician. When frailty and dementia supervene, it takes a rare blend of skills and personality to function at a consistently high level.
Whether gradually or suddenly, comfort and palliation emerge as the more important objectives and standards for measuring quality of care. It is often a challenge, yet seldom acknowledged, to have and to bring that understanding to bear at the right time in the individual case. A “good death”, with all the
variations implicit in any definition, must become more widely accepted as a valid quality of care measure. When there are sufficient numbers of physicians with mastery of this as part of the complex interface of health and disease in the aged, we will know that medical education has done all it can.
Separate sections of this report provide a preliminary list of programmatic ideas and concepts (Section II) and an Annotated List of Sources and Contacts (Section III).
1
Testimony before Senator Breaux and the Senate Special Committee on Aging.
2 Conversations with local physicians including Drs. Sharon Brangman, Bruce Naughton,
Judith Setla and James Collins.
3 See Section III-1 for information on the Association of Directors of Geriatric Academic
Programs (ADGAP) “Longitudinal Study of Training and Practice in Geriatric Medicine.”
4 Conversation with Dr. Sharon Brangman, SUNY Syracuse.
5 See Section III-5 for information on the Hartford-AAMC Geriatrics Curriculum Program
and Academic Medicine Volume 79, Supplement, July 2004.
6 Interviews at SUNYAB with Drs. Evan Calkins, James Nolan, and Kenneth Garbarino. 7 See Section III-5.
8 See Section III-2 for information on Education for Physicians on End-of-Life Care: The
EPEC Program.
9 Conversation with Dr. Bruce Naughton; See Section III-3 for information on Aging and
Quality of Life.
10 Conversation with Drs. Robert Milch and Jack Freer. 11
