ONE THING that is lost in the health care debate is how to care for the elderly. It’s ironic that at a time when thousands of Americans are struggling to find appropriate care for their failing parents, the field of geriatric medicine appears to be vanishing.
For geriatricians, one distinguishing feature of the specialty - and one that most threatens its future - is the in-depth conversations about care between doctors, their older patients, and their families. Critical issues covered include treatment options, the efficacy of treatments, and the impact of these treatments on quality of life. It takes time to manage multiple interacting medical, social and psychological problems, weigh the risks and benefits of various interventions, and discuss goals of care with patients and their families.
The problem is that geriatricians are not adequately compensated for the time they take to address their patients’ complex medical, psychological, and social needs. Consequently, the specialty is not attracting enough physicians to care for our rapidly expanding elderly population. In 2008 there were 7,128 certified geriatricians in the United States. By 2030, we will need 36,000 geriatricians. But the number of graduating physicians seeking specialty training in geriatrics is going in the wrong direction, dropping from 167 in 2003 to 91 in 2007. Fewer doctors are specializing in geriatrics, in part because it does not provide sufficient income to pay off their loans or compensate them fairly for the labor-intensive work.
Geriatric medicine cuts across all diseases that contribute to the functional problems an older adult might have. An older patient typically goes from one specialist to another, with each doctor treating a single problem, but often not looking at the patient as a whole. The patient may receive treatment, but quality-of-life goals are rarely discussed.
In contrast, the geriatrician often sits with three (or more) individuals: the patient, the patient’s spouse, and an adult child. Together they present a medical history and, often, a list of medications prescribed by different doctors. Medicare pays the geriatrician a small fraction of the true cost spent with the patient, taking a history, examining the patient, ordering appropriate tests, making a diagnosis, and developing a treatment plan. Following the visit, the geriatrician reviews laboratory studies, talks to family members and other doctors, organizes rehabilitative and social services, completes applications for supportive housing, renews medications . . . and gets paid nothing for this work.
Ironically, geriatricians actually save health care dollars by planning ahead; avoiding unnecessary hospitalizations, tests, medications, and treatments; reducing hospitalization and surgical complications; shortening lengths of stay; and facilitating the safe transfer of patients to appropriate rehabilitation settings and care at home. President Obama’s health care bill would, at least, require Medicare to cover counseling sessions so that physicians can develop appropriate care plans with their elderly patients.
It is critical to the future health of Americans that the field of geriatric medicine not be allowed to die. A first step might be for Congress to tone down the partisan rhetoric and present a more thoughtful discussion about reforming care, not just payment for that care. A second step would be to train medical students so that every emerging doctor has basic knowledge of geriatrics - the way every medical doctor has a working knowledge of cardiology. A third would be to train the academic leaders to teach students about the special issues confronting older patients.
As America’s population ages, more people will need to seek the expertise of qualified geriatricians. The health care system must support appropriate, proactive, cost-effective geriatric care in all settings - and help guarantee a healthy future for us all.
Dr. Lewis A. Lipsitz is a professor of medicine at Harvard Medical School and codirector of the Institute for Aging Research at Hebrew SeniorLife. 
