The Otolaryngologist and the Imminent Crisis in Geriatric Medicine

Michael M. Johns III, MD, is Director of the Emory Voice Center and Assistant Professor of Otolaryngology at Emory University in Atlanta.

We are on the verge of a crisis in geriatric medicine. Over the past 100 years, the proportion of Americans over age 65 has been growing incrementally. However, in the next several years, the number of people over age 65 will soar exponentially, with especially large increases in the >80 age group. Although the elderly currently make up approximately 12% of the population, this number will double as early as 2030.

Despite knowledge of the impending increase of elderly patients, our health care system is not ready. To care for this burgeoning geriatric population, substantial changes will be required in the way we deliver health care. In the Institute of Medicine report titled Retooling for an Aging America: Building the Health Care Workforce, committee chair John W. Rowe, MD, calls on all health care providers to become aware of what is upon us in geriatrics and to make changes to help effectively care for the aging American population. Changes will be critical in all areas of medicine, including otolaryngology.

Scope of the Problem

Too many patients, not enough capacity-that is the problem in a nutshell. Two main factors are driving the growth in the geriatric population. The first is an increase in life expectancy. According to a report from the US Census Bureau, the number of centenarians nearly doubled, from about 37,000 to an estimated 70,000, during the 1990s. Analysts at the Census Bureau indicate that this per-decade doubling trend may continue. At this rate, the centenarian population could reach 834,000 or more by 2050. The second factor driving the growth in the geriatric population is the advancing age of the baby boom generation. Born in the two decades following World War II, the 78-million-person baby boom generation will reach retirement age beginning in 2011.

Coupled with the increase in the elderly population is a dramatic shortfall of both informal and formal geriatric caregivers. Informal caregivers, such as children of the elderly, play a critical role in the care of the older individual. Unfortunately, these are becoming scarce. Part of the reason is the decreasing number of births in Western society. Since 2003, no Western European country has been replacing its workforce as individuals retire. It is estimated that by 2030, there will be fewer individuals working than those who are retired. In addition, high divorce rates and an increasingly mobile society have resulted in a large increase in divided families. In modern America, children often live far from their parents. These factors leave fewer informal caregivers to help ease the burden of geriatric care.

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.

The perfect storm has arrived. There is a burgeoning geriatric population that is coupled with a scarce geriatric workforce, and no incentive to turn the tide.

Emerging Solutions

The Institute of Medicine has analyzed this problem in detail and has eloquently summarized their findings in its report (www.iom.edu/CMS/3809/40113/53452.aspx ). It has made specific recommendations on how to approach the situation going forward. First of all, the committee has requested that Congress require an annual report from the Bureau of Health Professions to monitor the progress made in addressing the crisis in supply of the health care workforce for older adults. Raising awareness in Congress of the workforce size problem would likely have secondary effects in other areas, such as remuneration for geriatric care.

The second group of recommendations is directed toward growth and retention of the geriatric health care workforce. The report states that public and private payers should provide financial incentives to increase the number of geriatric specialists in all health professions, and to include a specific enhancement of reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in geriatrics. Another incentive program suggested by the IOM is loan forgiveness, scholarships, and direct financial incentives for professionals who become geriatric specialists. Geriatric specialty care goes beyond primary care geriatrics, and new incentive models should include medical and surgical specialists caring for the geriatric patient.

A third set of recommendations is to improve geriatric competence. Enhancement of geriatric expertise in specialties starts at the residency level. The IOM states that hospitals should encourage the training of residents in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes. A related key recommendation relates to health care worker certification: All licensure, certification, and maintenance of certification for health care professionals should include demonstration of competence in the care of older adults as a criterion.

As stated earlier, the traditional physician-patient encounter model that Medicare supports leads to fragmented care with limited interdisciplinary approaches. The IOM encourages the development of new models of care that are more efficient and effective. Enhancing research in new models of care, particularly those that leverage technology and teamwork, will ease the burden of the swelling geriatric population on the health system.

Otolaryngology has recognized the need to address the changes that we are facing, and has been making accelerating strides for some time. Publications specifically focusing on clinical care of the geriatric otolaryngology patient have appeared in the literature since the 1950s. As early as 1989, leaders in otolaryngology have recognized the need to integrate geriatric medicine into residency training programs (Johns M et al, Otolaryngol Head Neck Surg 1989;100:262-5). This integration has been enhanced by grant support from the American Geriatrics Society and the John A. Hartford Foundation. Grants from the Geriatric Education for Specialty Residents program have been awarded to four residency programs to develop geriatric curricula. Much of the content of these curricula is available at the American Geriatrics Society Web site (www.americangeriatrics.org/specialists/otolaryngology.shtml ).

Additionally, educational resources in geriatric otolaryngology directed at the field as a whole are growing rapidly. The American Academy of Otolaryngology- Head and Neck Surgery, through the efforts of its geriatrics committee, has done great work in bringing specific geriatric topics and principles to our field. The committee has developed an online free text titled Geriatric Care Otolaryngology Online (www.entnet.org/EducationAndResearch/geriatricOtolaryngology.cfm ). The text covers geriatric topics across the field. The committee has also sponsored a number of geriatric-focused miniseminars, and members of the committee are increasing the number of instructional courses in geriatrics at the annual Academy meeting.

Furthermore, Calhoun and Eibling have published the first comprehensive textbook for the subspecialty: Geriatric Otolaryngology (Dekker, 2006). Our colleagues have done an excellent job creating resources for learning in geriatric otolaryngology topics. More work integrating basic geriatric care principles and working on ways to improve penetration of the fund of knowledge into the field as a whole are important next steps. Achieving this is one of the missions of both the Geriatric Otolaryngology Committee of the Academy, and of a new society, the American Society of Geriatric Otolaryngology. ASGO meets annually immediately prior to the Combined Otolaryngology Spring Meeting and offers a diverse program on geriatric otolaryngology topics. The ASGO Web site also offers access to a number of geriatric otolaryngology resources (www.geriatricotolaryngology.com ).

Most otolaryngologists have a substantial number of geriatric patients in their practice and thus are practicing geriatric otolaryngology. If we recognize this and also acknowledge that understanding of the basic principles of geriatrics will improve our care of older patients, then it makes sense that specific geriatric criteria be integrated in the certification and maintenance of certification process, as the IOM suggests. This straightforward change will help drive training programs to include learning experiences that will enhance the care of older patients.

Summary

We are on the crest of dramatic growth in our elderly population, and substantial changes will be required to provide health care for them in the way they deserve. Specialists will not be immune to the changes that will come, and we need to prepare. We need to lean on our leaders to work for increased payment for geriatric care. We also need to improve our knowledge and competence in geriatric care as a whole. Hopefully, we will all be able to individually reap the benefits of the changes to come in how we care for our aging society.

©2008 The Triological Society