Geriatric medicine is advancing, not declining: A proposal for new metrics to assess the health of the profession

Much has been written over the past 40 years about workforce challenges in aging-related disciplines. Geriatric medicine has more recently been at the forefront of the debate, and the field has been characterized as waning.1, 2 But is it? Such bleak perspectives regarding the geriatrics workforce typically cite the number of practicing geriatricians, which remains stubbornly around 7000 board-certified geriatricians, yielding roughly 0.96 geriatricians for every 10,000 older adults. Reasons commonly cited for the inadequate number of geriatricians include low prestige, low compensation compared with other specialties, and low match rates into geriatric medicine fellowship programs.1 Many argue that the number of geriatricians must increase to meet the projected need of 28,000 geriatricians by 2025.3 The fact that only three residency programs—family medicine, internal medicine, and medicine/pediatrics—require geriatrics-focused training may contribute to the inadequate supply of geriatricians.3 Geriatric medicine fellowship fill rates remain among the lowest of all medicine subspecialties, although the overall fill rate is higher than the 43% reported by Gurwitz, with a geriatric medicine fellowship fill rate of 70% for the 2022–23 match.4 A metric that incorporates attention to both those who are exiting geriatric medicine and those who are embarking on careers as geriatricians is the American Board of Medical Specialties (ABMS) tracking of active geriatric medicine certificates. See Figure 1 below, which was developed by the American Geriatrics Society (AGS) based on a review of the last 18 years of data from ABMS.5 This figure demonstrates that the number of board-certified geriatricians has remained stable at approximately 7000 each year. This number is probably a slight underestimate because ABMS does not include osteopathic physicians who receive geriatrics certification through the American Osteopathic Association. However, the ABMS does include osteopathic physicians who receive geriatrics board certification through the ABIM and ABFM. Source: American Board of Medical Specialties. What can be done to increase the supply of geriatricians? Simply placing health professions trainees where older adults are present and expecting them to develop adequate competency in geriatrics does not work.6 However, immersion when accompanied by structured geriatrics educational experiences improves competence in caring for older adults.7 Negative attitudes related to aging can be improved with various exposures to older adults.8 Geriatrics care is best delivered by interprofessional teams, but interprofessional team training presents logistical barriers and is infrequently provided by academic health centers.9 The Geriatrics Workforce Enhancement Program and the Geriatric Academic Career Award, both funded by the Health Services and Research Administration, are vital in developing this expertise in the primary care workforce. Flexibly implemented geriatric medicine fellowship training slots for mid-career internal medicine and family medicine physicians, the pilot of a Medicine-Geriatrics Integrated Residency and Fellowship Pathway (also known as the Med-Geri Pathway), and a combined Geriatrics & Palliative Medicine (Geri-Pal) Fellowship are additional innovative approaches to increase this workforce. Geriatrics workforce statistics such as the supply of geriatricians do not account for the robust geriatrics care models responsible for advances in the science and care of older adults.10 As such, we contend that an accurate assessment of the capacity and vitality of geriatric medicine requires more than simply counting the number of geriatricians. "Geriatrics workforce statistics such as the supply of geriatricians do not account for the robust geriatrics care models responsible for advances in the science and care of older adults. As such, we contend that an accurate assessment of the capacity and vitality of geriatric medicine requires more than simply counting the number of geriatricians." Geriatrics care models such as Acute Care for the Elderly units and Hospital at Home have been in development for decades, and these programs have done much to improve the care of older adults. By design, they are accessible to all clinicians, not just the geriatrics care workforce, and have a solid and essential impact when implemented reliably. Malone and colleagues summarized the evidence-based geriatric care models and verified their impact,11 and McNabney and colleagues identified the elements that were common in successful models of geriatrics care.12 The Institute for Healthcare Improvement (IHI) Age-Friendly Health Systems (AFHS) movement, funded by The John A. Hartford Foundation, is an example of intensive implementation efforts to embed successful geriatric models of care, thus leading to the "geriatricization" of health systems. The AFHS social movement began in 2016 and was launched in 2017. There are now over 4000 care locations with AFHS designation in over 14 countries, with 46 countries represented in IHI Open School enrollment. Demand exists for an approach that can guide all clinicians to improve care for older adults and does not rely solely on the scarce resource of geriatricians.13 This is precisely what the field of geriatric medicine is striving for. Geriatricians are well positioned to lead health systems' efforts to implement and sustain AFHS, and some have suggested that geriatrician leadership of AFHS should be required.14 Using evidence-based models created by geriatric scientists does much to advance care for—and ultimately the well-being of—older adults. The Beeson Emerging Leaders Career Development NIA K76 Program is designed to support promising early-career clinician-scientists.15 Gurwitz notes that only 2 out of 33 Beeson Award winners have been geriatricians over the last 3 years.1 However, the fact that 31 of the 33 recent Beeson Award winners were not geriatricians could also be interpreted as a strength of geriatrics, as this program attracts intense interest from other fields, thus forging interdisciplinary work in aging that distinguishes it from other disciplines and helps embed age-friendly principles more broadly than just within geriatrics. The disproportionate number of non-geriatrician Beeson Award winners also could reflect increasing demand for geriatricians' expertise to meet clinical, educational, and administrative needs rather than a decline in geriatric medicine as a profession. Geriatrician researchers are also well represented in other leadership development training such as the Tideswell Emerging Leaders in Aging program.16, 17 Decades of work by interprofessional geriatrics educators established geriatrics competencies for medical students and nine other health professions, as well as emergency medicine, family medicine, and internal medicine residents, and surgical specialists.18-23 Geriatrician clinician-educators also developed innovative residency and geriatric medicine fellowship programs. The Medicine-Geriatrics Integrated Residency and Fellowship ("Med-Geri Pathway") is an innovative Advancing Innovation in Residency Education (AIRE) pilot program launched in 2020 in which medical students matched into an internal medicine or family medicine residency program have the option of electing to pursue a geriatrics fellowship early in their residency.24 While it is too soon to tell whether the Med-Geri Pathway will increase the overall number of practicing geriatricians, we anticipate that it will generate a cadre of geriatricians that is deeply invested in the care of older adults by means of their early identification of geriatrics as their chosen specialty and will help sustain the considerable advances made in age-friendly care. The current pilot of a combined Geriatrics & Palliative Care fellowship pathway allows for fellows to complete the clinical training requirements for both fellowships in 18 months, which creates time in their training to pursue projects that will prepare them for academic careers in geriatrics and palliative care. GERIAtrics Fellows Learning Online and Together (GERI-A-FLOAT) is an innovative educational program developed by geriatrician fellowship directors during the COVID pandemic to meet a gap in in-person geriatrics didactic content for geriatric medicine fellows. GERI-A-FLOAT has been sustained as a virtual national curriculum.25 There are emerging data that geriatrician salaries are increasingly on par with other primary care disciplines.26, 27 Perhaps more importantly, the modern-day geriatrician has multiple options for where and how they want to practice, and these opportunities are only likely to increase in the next decade. Of particular importance for the future of payment for the work of geriatricians is the widespread recognition in Congress and across the federal government that payment for primary care must be enhanced if we are to reverse the overall decline in people choosing primary care as a career path. The additional year of fellowship training positions geriatricians to thrive in population-based/value-based payment systems, particularly those focused on implementing and spreading age-friendly healthcare.28 We pointed out the limitations of relying solely on the number of board-certified geriatricians to assess the profession's health. The question remains: What are the best metrics to report on the health of geriatric medicine? In Table 1 below, we propose metrics that should be considered for inclusion in future workforce reports to answer this question, organized by the domains of clinical care, workforce, education, and organized medicine. Number of AFHS Level 1 sites Number of AFHS Level 2 sites Number of geriatricians pursuing 2- or 3-year fellowships Number of geriatricians receiving career development awards (e.g., NIA, VA) Number of recipients of HRSA Geriatrics Academic Career Awards Number and reach of HRSA Geriatrics Workforce Enhancement Programs Number of geriatrics academic programs Number of geriatrics fellowship programs Number of geriatricians in health systems leadership roles Number of geriatricians in federal, state, local, or private sector leadership roles Evidence-based, safe, and reliable care of older adults is a minimum standard that we all need to incorporate into our practice. The workforce development of geriatrics care specialists and models of care that all clinicians can implement continue to be the partnership that will ensure this minimum standard for quality and safety now and in the future. Creative strategies that integrate best practices for older adults within every discipline and specialty will help ensure that the growing number of older adults in our country and worldwide receive the care they need and deserve. New metrics to assess the health of geriatric medicine over a 5-year period will permit a more nuanced and accurate assessment of progress in this regard. Concept and design: Timothy W. Farrell and Terry Fulmer. Preparation of manuscript: Timothy W. Farrell, Amalia Korniyenko, Grace Hu, Terry Fulmer. The authors wish to acknowledge Nancy Lundebjerg, MPA and Mark Supiano, MD, AGSF for their critical review of the manuscript. The authors also wish to acknowledge Alanna Goldstein, MPH and Anna Kim, LMSW for their assistance with the data presented in Figure 1. The authors declare no conflicts of interest. None.