Physician Recruitment into Geriatrics—Further Insight into the Black Box

Charles Ketering is quoted as having said, "We should all be concerned about the future because we will have to live the rest of our lives there." As professionals and academic leaders in health, we know that, by 2030, the United States will consist of 70 million persons aged 65 and older. For the past 25 years, health professionals and academic leaders have been confronted with a singular problem: how to recruit superior trainees into the field of geriatrics and provide them with adequate training and career satisfaction that results in high-quality patient care at a sustainable cost. However, the problem appears intractable, with demand consistently exceeding supply. The paper by Weeks et al.,1 one of a series of contributions by the Dartmouth group in the past 10 years, contributes important new data that we hope policy-makers will not ignore. The most recent documentation of the state of the field by the Association of Directors of Geriatric Academic Programs (ADGAP) and its commitment to maintaining an ongoing data base is a major and important contribution to the field.2,3 The ADGAP report and its related publications document that, in the last decade, there has been a slow increase in the number of fellowship programs, with the addition of 27 new allopathic geriatric medicine programs, bringing the total to 119; in addition, seven new osteopathic programs have been initiated. The number of fellows entering programs has also increased slowly and in 2001–02, a total of 345 fellows were in the system for all years of training. Forty-six percent of programs offered only 1 year of training experience, and a survey of program directors reported that application rates for positions were stable. Further data from the American Medical Association/Association of American Medical Colleges National Graduate Medical Education census showed a fill rate for the first-year fellows of 69% (259/373);4 just over half of the programs had two or fewer first-year fellows, and 36% reported having no U.S. medical school graduates as first-year fellows. There were 61 post-first-year fellows in the 51 programs offering second-year training opportunities. Thus, the recruitment of high-quality U.S. medical school graduates into the field of geriatric medicine persists as a serious problem and continues to challenge the field of geriatrics. In addition, the number of fellows completing the first year seeking 1 to 3 or more years of training is disastrously low; it is from this pool that future faculty leadership will emerge. The natural history of recruitment into a new field within medicine has been one of a hesitant beginning usually followed by flourishing training programs over a 2-decade period. A number of factors enhancing or impeding this transition has been identified in the field of geriatrics, and a review of them and the subsequent outcomes seem appropriate. Although much progress has been made in the area of lack of professional recognition by many health professionals, perhaps related to ageism, it is our impression that the general public has outdistanced the medical profession in overcoming this problem. Stimulated by the support of the federal government and the private sector, particularly the Hartford and Reynolds foundations and the Alliance for Aging Research, substantial progress has been made in addressing the problem of inadequate exposure of students and house staff to the field during their educational and training experiences, including the relatively short supply of outstanding role models, the latter playing an important role in career choice.5 One might question the Association of American Medical Colleges' stance of recommending incorporation of aging content into established course offerings. When this strategy was examined by one of us earlier (JCB) by sitting in on course offerings, it appeared to be largely a "lip-service" effort. Progress has been made in addressing lack of visibility compared with other specialties of highly active research programs in basic, clinical, and health services research, a deterrent to career choice for those primarily interested in academic careers, largely due to the funding efforts of the federal government and the foundations. Much more remains to be done. A disproportionate amount of the most important research in the field is taking place outside of geriatric units and often reported in prestigious nongeriatric/nongerontological journals. We believe that lack of recognition of the field by prestigious individuals in the health sciences and the universities who play an important role in setting policy continues to be an important problem, perhaps related to the low visibility of geriatrics in many academic health centers and the university as a whole. Prestige is an important stimulus to career choice in the health sciences. The elevation of practice in the field to specialty status by the American Board of Internal Medicine and American Board of Family Practice in 1988, was an important step in the recognition of geriatrics. Anecdotal evidence suggests that it has made an important contribution to attracting some young people into the field. The absence of a reimbursement differential related to certification that exists in most specialties remains an important problem. Attractiveness of clinical and research training programs in the field. In the absence of any qualitative or quantitative data, one must rely on indirect evidence. This is clearly apparent in the ADGAP report in the data summarized earlier with low fill rates, few trainees per program, low numbers of U.S. medical graduates, and few second-, third-, and fourth-year fellows. The mean number of physician faculty in allopathic and osteopathic academic programs was 7.5 full-time equivalents (range 0–42) and in nonphysician research faculty was 2.5 (range 0–43). From a potential trainee's perspective, comparing this career choice with other specialty training programs would from our perspective be a deterrent to selecting geriatrics. Although the reduction in training time in allopathic medicine from 2 to 1 year as a prerequisite to certification seemed largely driven by difficulties in recruitment into geriatric medicine, there is little evidence that it has had a persistent salutary effect, although a small majority of program directors continue to consider it advantageous. It has also had a disastrous effect on funding of fellows beyond the first year. Rheumatology used this same strategy many years ago without a significant effect on recruitment into the field. This continues to differentiate other specialty areas within medicine from geriatrics and may serve as a long-term deterrent. Medicare reimbursement for services rendered by primary care physicians and geriatricians, together with failure to fashion reimbursement to certification in the field has undoubtedly contributed to the recruitment problem. There is evidence that the downstream financial benefits—professional and hospital—are such that it would be advantageous to the medical centers with affiliated geriatric care programs to contribute institutional support to the activities of these programs. The present fall-off in medical student applications to generalist medicine training and high U.S. medical student debt (average $100,000)6 augers poorly as we look to future recruitment. An unexpected discordance emerges when examining career satisfaction and the recruitment problem. More than a decade ago, the first study addressing physician satisfaction with career choices in geriatrics (geriatric medicine and geropsychiatry) was reported.7 In a national survey of previous fellows, the majority expressed satisfaction with their work. Greater satisfaction was seen in physicians who had large practices of patients aged 75 and older, accepted Medicare assignment, spent time as clinician researchers, and had a medical school appointment. A recent study examining career satisfaction across specialties supports these earlier observations, with geriatric internal medicine being significantly more attractive than many other procedural and nonprocedural specialties.8 Although self-selection might contribute to the findings in these two studies, it seems difficult to accept that this is the only important variable. Potential trainees at the undergraduate or graduate level do not generally know this career satisfaction message at a time when they are making their career choices. The findings reported in this issue of the Journal by Weeks et al.1 on the return on investment in geriatrics training presents new insights into what we have conceptually labeled as the "black-box" containing the many factors impeding recruitment into this increasingly important specialty. This study is the fifth one addressing the long-term financial implications of specialty training that this group has reported, and is has important policy implications. In the latest study, they examine financial return of additional training in geriatric medicine for general internists. Self-identified geriatricians in the American Medical Association data system had overall lower incomes and lower incomes per hour than general internists, with some diminution in the disparity recently. These disparities were in part attributable to the large proportion of revenues coming from Medicare. Returns on educational investment for geriatrics training was negative, although less so in recent years, with a suggestion that emerging Medicare policies might reverse this narrowing. This trend was more dramatic if fellowship training lasted 2 years. Thus, we conclude, on the basis of the evidence discussed previously, that genuine interest in the challenges of geriatric medicine and the problems that older persons experience, perhaps even idealism, motivate those who enter geriatrics, but clearly not financial return. Where then does the solution to the problem of recruitment in the field lie? We have previously repeatedly emphasized the geriatric imperatives—the growing number and proportions of older persons, the age-related disease burden, soaring healthcare costs, and ageism or prejudice towards age. But what can be done? Further and much more intensive development of private-public partnerships to develop academic centers devoted to geriatrics must occur. Whereas one of us (RNB) has emphasized the importance of departments or departmental equivalents for many years, the other (JCB) has, during the past 5 or more years of emeritus status, become convinced that departmental status is the most important action that needs to be taken. The contrast between institutions where geriatrics/gerontology is a department or some other department-like structure (e.g., a clearly identified center) and most of the nondepartmental units is telling. We are convinced that this is where the field must go if it is to survive as the multiple forces pressing on health professional education evolve over the next decade. The existing departments have large amounts of institutional resources committed to the development of the field, which has permitted them to attract increasingly large amounts of resources from the public and private sectors. This would facilitate the growth, visibility, size, and quality of educational, basic, clinical, and health services research programs. It would address many of the previously mentioned disincentives, for example, size and attractiveness of training opportunities, role-model development, and undergraduate and graduate training experience in geriatrics. These academic units should be supported generously by governmental and private funding. There should be a major reexamination of Medicare reimbursement for geriatric services. The present policy decisions, if left unchanged, will further impede the development of the field. For example, adding Medicare payments for geriatric assessment and care coordination, proven to improve care of the elderly, would be an important step in reform. It would also serve as an incentive for physicians to enter geriatrics. Other incentives would include loan forgiveness programs comparable with those recently initiated by the National Institute of Health and integrated 5-year research fellowship and junior faculty awards. As emphasized by Weeks et al.,1 it is imperative for policy-makers to ensure that remuneration is adequate to compensate geriatricians for the additional training required, and this must be considered an essential part of developing an appropriately sized and appropriately trained workforce. Marketing of the career satisfaction data for the field, which has persisted for more than a decade, to medical students and resident staff who one assumes would want to select a specialty for which a high percentage of incumbents are very satisfied would seem an important mission for the professional societies in the field to pursue. With respect to the future, and it being an integral part of our lives, the public, elected policy-makers, professional and academic leaders in health, and universities as a whole have the responsibility to act now—time is rapidly running out.