Annals of Long Term Care

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Dr. Nusbaum is Professor Emeritus, University of Illinois.

Discussion about geriatrician workforce issues, such as a recent symposium of the Association of Directors of Geriatric Academic Programs,1-5 routinely begins from the premise that the number of geriatricians is clearly inadequate to meet the needs of the expanding number of older Americans. A recent Institute of Medicine report notes that in 2007 there were 7128 doctors certified in geriatric medicine and 1596 certified in geriatric psychiatry. It cites projections that these numbers may increase less than 10% by the year 2030, and notes that these current low numbers in fact may even decrease.6 From a societal point of view, one might consider where these few thousand geriatricians nationally could have the highest impact on the care of the tens of millions of older Americans.

A substantial fraction of the available pool of geriatricians would be required just to have a minimal presence of a few geriatricians at each of the medical schools nationwide, to inform the geriatric component of both undergraduate and residency medical education. Efforts to increase the overall national supply of physicians by increasing medical school class size and/or opening new medical schools could create additional need for geriatrician faculty. Efforts to incorporate geriatric education into other disciplines such as surgery could involve additional geriatricians. Such an expanded geriatric role in each of 130 medical schools7 in the United States might collectively employ 1000 full-time equivalent employees (FTEEs) for teaching, or an average of about seven geriatricians per medical school.

Others could be involved in leadership roles in federal geriatric-focused programs ranging from Medicare to Social Security. In addition to the programs whose primary focus is geriatric, a broad range of other federal programs could also benefit from geriatric expertise in meeting the elements of their mission related to older Americans; examples would be workforce retirement concerns for the Department of Labor, or aging-in-place considerations for the Department of Housing and Urban Development.

Many similar needs for geriatric expertise would also exist in each of the 50 states. Although no individual state would have the same workforce needs as the federal government, collectively the need among the 50 states might substantially exceed the need at the federal level.

The needs described above might well consume much of the available supply of geriatricians. It would also help to define career pathways for geriatricians that might be clearer and more attractive than one dependent on the vagaries of unknown future reimbursement under programs such as Medicare.

One wonders if the acute hospital care institutional role for geriatricians may also expand as Medicare expands the range of medical events for which it does not provide reimbursement. Geriatricians might well be used as an institutional resource in the first instance to reduce the frequency of such events (such as encouraging early mobilization to reduce the incidence of decubiti), or in the second event to devise and implement programs to care for patients most effectively once such an event has occurred. Such roles could readily absorb nearly 2000 FTEEs nationally, just to provide a 0.4 FTEE presence nationwide at each of 4897 community hospitals.8

An additional way in which the country might choose to use geriatricians would be to define a clearer role for their involvement in the administration of nursing homes (NHs). One might require, for example, as a condition for receipt of Medicare or Medicaid funding for a resident that a typical 100-bed NH have a 0.25 FTEE geriatrician on staff to support the quality of care in the facility. Given that there are 1.6 million U.S.