Post Comment (January 7, 2008) — Dr. Meredith Cricco was a rarity among aspiring doctors.
While other medical students were picking "glamorous" fields like cardiology or surgery, she chose a specialty that never inspired hit TV hospital dramas, comes with one of the lowest average doctor salaries and has such tremendous shortages that experts say the open spots might never be filled.
Cricco is becoming a geriatrician, taking on the diseases, the debilities and all the other primary-care needs of the oldest patients.
"The most complicated procedure I do is flushing someone's earwax out," said Cricco, who graduated from the University of Iceland's medical school in 2001 and did her residency at Strong Memorial Hospital. "You don't get paid a lot of money for that. But if you can flush earwax out and people can hear again, the difference in their daily life is huge."
Senior health has never been a sexy topic, but Cricco, a New Hampshire native, found her passion during summer jobs with nursing homes and visiting nurses associations in Iceland. Now the 36-year-old and a shrinking group of others like her stand to inherit the medical care of tens of millions of aging baby boomers.
Last year, just 91 of the nation's more than 16,000 medical school graduates entered geriatric fellowship programs, which are required for board certification in senior health. Cricco is one of four fellows at the University of Rochester, which runs the only program in the area.
The results are obvious: As of April 2007 there were 7,128 certified geriatricians in the country, down nearly 24 percent since 1996. In Rochester-area hospitals, there are fewer than 50 doctors in geriatric medicine.
Economic disincentives
Even as medical school enrollments reach record highs, the American Geriatrics Society projects that fewer and fewer doctors will specialize in senior health care and that by 2030 only one geriatrician will be available for every 4,254 Americans older than 75. "We're dropping like flies," said Dr. Steven Rich, chief of the geriatric division at Rochester General Hospital. "If we now look at what we have promised to the baby boomer generation as they get older, it is an absolute impossibility. The numbers are so bad; there's never going to be enough geriatricians."
To Rich, the problem is economic. In 2005, the median salary for a geriatrician in private practice was $162,977, about $11,687 less than what a general internist would make in a year. For medical students eager to pay back hefty tuition loans, the dollars don't add up.
As a result, older people often turn to primary-care physicians, but those "geriatricians by default" are taught that young families with children are best for business, Rich said. Many turn away elderly patients who are more likely to have complex conditions and rely on Medicare or Medicaid, which don't reimburse as quickly or as fully as commercial insurance plans.
"The perception is, it's a lot of work and too much paperwork," said Dr. Paul R. Katz, chief of the division of geriatrics and aging at the University of Rochester. He believes the federal government should revamp Medicare reimbursement programs and offer loan forgiveness programs to encourage medical students to specialize in geriatrics.
Another part of the problem, though, is that geriatrics is still a widely undervalued field, he said. "I think most people on the street don't even know what a geriatrician is. Even in the medical field, most people don't realize what geriatrics does."
Confronting a mind-set
In 1988, geriatric medicine became a certified specialty under the American Board of Internal Medicine and American Board of Family Medicine, as aging issues generated public interest and advocates spoke out on the importance of expertise in senior health. The number of geriatricians climbed but then fell, with fewer and fewer medical students showing interest in all aspects of primary care.
Now, when UR fellow Cricco gives lectures to medical students and residents, "they'll roll their eyes," she said.
"People look down on geriatrics and think the excitement is elsewhere. Their basic feeling is that it's just too late to make any difference."
That mind-set is indicative of a larger issue, said geriatrician Dr. Michael Nazar, Unity Health System's vice president of primary care. As the senior population balloons, too few people understand the particularities of old age, which comes not only with multiple medical conditions and chronic diseases, but also with varied issues such as isolation and mobility, he said.
"I think the problem is more complex than just, 'Do we have enough geriatricians?' People need medical care providers who are sensitive to the needs of older people, and we need to make it more part of medical school training, residence training, physical therapist and pharmacist training. We have to change a lot of society."
Recognizing the mind-set and the practically unrecoverable geriatrician shortages, Rich operates a consulting service through ViaHealth to teach internists, family practitioners, gynecologists and other doctors how to treat older patients better. Until 2006, he ran the service through Lifetime Health Medical Group, but it was "not bringing in the revenue it needed to support itself," said Lifetime spokeswoman Cynthia Eberl.
Though the service still isn't lucrative, Rich believes it's a stopgap until major financial changes are made in Medicare and the geriatric field.
In the meantime, he tells aspiring doctors that working with older patients provides an opportunity to take on the challenges of multiple, complex conditions and see treatments that have an impact on quality of life.
And if nothing else works: "When people ask, 'Why go into geriatrics?' I often tell them, 'Well, it's to save the world.'"
