The Otolaryngologist and the Imminent Crisis in Geriatric Medicine

With the growth of the elderly population, one would hope for a similar expansion in the number of geriatricians, geriatric nurses, and others specially trained in caring for the older adult. However, the reverse has occurred. The absolute number of geriatricians has actually been decreasing. According to the IOM report, only half of board-certified geriatricians have sought recertification. By 2030, the IOM predicts a shortage of at least 28,000 geriatric-trained physicians. David Eibling, MD, in his 2008 address to the American Society of Geriatric Otolaryngology, put this in perspective. He pointed out that this shortage is four times the number of practicing otolaryngologists in the United States. Similar decreases in the geriatric workforce are seen in nursing, dentistry, pharmacy, and rehabilitation medicine.

Geriatric care also carries unique burdens to physicians. Older individuals utilize health care at a far higher and more complex level. Twenty-four percent of individuals over 65 have four chronic medical conditions. According to the IOM report, geriatric patients, on average, have 10 outpatient encounters per year, nearly one per month. Geriatric syndromes, such as falls and malnutrition, lead to more acute care episodes. Cognitive impairment reduces the ability of individuals not only to care for themselves, but also to communicate clearly and efficiently with the physician even when they may be physically able. Geriatric patients are more complex and require more time then their younger counterparts.

There should be increased reimbursement for physicians to offset the increased time and effort required to care for older patients. The reality is the opposite. Couple the increased time required per geriatric patient encounter with decreasing reimbursements from Medicare, and there is little financial incentive for physicians to focus on the geriatric patient. Furthermore, the fragmented pay schema of Medicare provides no reimbursement for team-based approaches, which have been demonstrated to improve the care of the older patient. Physician remuneration in geriatrics is a currently a paradox: more time and effort for less pay. The result is a growing number of physicians either limiting or eliminating Medicare (and hence geriatric) patients in their practice.

An additional factor contributing to the shortage of physicians and specialists is the distinct scope of knowledge that is required to care for the geriatric patient, similar to pediatrics. The field of geriatric medicine has developed out of this knowledge base. However, most specialties have little training in geriatrics, despite the fact that older patients may make up a large part of the patient base. The geriatric patient is commonplace in most otolaryngology practices, yet few residency programs in otolaryngology have training in geriatric principles. Furthermore, there are no specific criteria pertaining to geriatrics in the American Board of Otolaryngology certification process. Our field is similar to most specialty disciplines with respect to these factors. With a shortfall of geriatric primary care physicians, patients will be increasingly seeking direct care from specialists. Specialty disciplines certainly could be better prepared for this geriatric surge.