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Where Are the Clinical Geriatricians of the Future?

158. It’s just a number, much like any other three-digit number. But it’s one that’s going to make a huge difference over the next few decades. It’s the number of medical residents that opted for advanced training in geriatrics this next year. It’s far lower than the nearly 250 from last year (fewer than a hundred of whom were graduates of US medical schools). It’s lower than it’s been for some years leaving the vast majority of training positions (something over 400 nationwide) unfilled.

More than half of the training programs across the country have no fellows coming in 2023. This lack of trainees means less hands to do the work. Less people coming up the ranks to provide the specialized clinical care that complicated older people need. And less visibility of the specialty in the health care system making it even harder to attract young physicians our direction.

2023 will see roughly 3.4 million US residents pass from age 64 to 65 and enter their “senior” years. (There were about 4.25 million babies born in 1958 and roughly 80 percent of them remain alive.) At current trends, half of those (1.7 million) will be alive in 2043 at the age of 85. And these figures remain roughly the same for all cohorts five years either way. So, we’re producing roughly one geriatrician for every 10,000 new senior citizens. Even the best and most efficient physicians have difficulty caring for panels of patients much over 2,500 and that’s for a young and healthy population. If numbers like this continue, specialized senior care in this country will collapse. It’s inevitable.

I’ve been fighting the good fight and telling anyone who will listen (and it hasn’t been many) for years about what demographics is going to do to the health system and what sort of things need to happen to make geriatrics a more attractive career choice to young physicians. Very little of that work has been done. It doesn’t generate revenue or headlines. And here we are—a rapidly aging population of Baby Boomers, a significant population of Silent Generation in their 80s and 90s still in good health but in need of assistance to maintain that, and a health system reeling from the strains of the pandemic that’s unable to change its entrenched models with any kind of alacrity. A healthcare workforce so burnt out by the last few years that more and more are pursuing early retirement.

I’ve devoted more than 30 years of my life to the pursuit of excellence in clinical geriatrics. I’ve taken care of thousands of patients, trained hundreds of residents and dozens of fellows, lectured to crowds of five and 500, and tried to follow the dictum of “you save the world one patient at a time.”

I knew it was an underserved specialty which ranked very low in the hierarchy of medicine when I entered it. In my early years of high energy, I naively thought that I and my generation would change all of that somehow. We didn’t any more than the generation before me or the generation after me has been able to. Usually, when confronted with concrete evidence of how little difference we’ve made like the 158 this year, I shrug it off and move on to the next problem to be solved.

This year, however, feels different. Maybe it’s my rapidly rushing towards my senior years myself. I keep getting patients with major issues who are younger than I am, which is enough to make me feel old and to remind me that we are promised nothing. Maybe it’s the departure of colleagues which has accelerated in the post pandemic era (we had 18 geriatrics faculty a decade ago—we’re down to eight now). Maybe it’s my continued perusals of demographic charts and constant adjusting to the rapid swings of Medicare policies as the Center for Medicare and Medicaid Services constantly adjusts to both clinical and financial realities. I’m feeling like my major life’s work hasn’t mattered. It’s mattered to individual patients and families, but not in the grand scheme of having made a difference to the world going forward.

But then maybe I’m just hangry because I skipped lunch. Perhaps some chicken masaman can restore my equanimity. At the very least, it might give me the energy to put Christmas decorations away. But then again, it might just put me into a post-prandial torpor, and I’ll lie on the bed watching Netflix and cuddling with the cats.

If you see my father, wish him a happy 90th. I think he’s a bit bemused by entering his tenth decade as I am from entering my seventh. He remains in good health and does the three things required to maintain it at his age—eat, sleep, and move. Mainly, he stays away from the one thing that must be avoided: visiting the floor. These days we should probably add handwashing and appropriate vaccinations to the list.

Contributor Andrew Duxbury, MD is a geriatrician who is passionate about helping the elderly live their best lives as they age. He specializes in falls prevention, mobility, Alzheimer’s and dementia care, and preventing overmedication in older people. Originally from Seattle, Dr. Duxbury practices medicine in Birmingham, Alabama. He is author of The Accidental Plague Diaries: A COVID-19 Pandemic Experience and The Accidental Plague Diaries, Volume II: COVID-19 Variants and Vaccinations.