Wednesday, April 25, 2018

As Tampa Bay population ages, few doctors want to specialize in geriatrics

TAMPA — Dr. Inna Sheyner cupped her hand to speak into the ear of her 91-year-old patient, pledging loudly to answer all his questions about his constellation of problems, from heart failure to constipation, requiring a dozen medications.

"The problem is, you're not taking half of that list," she gently scolded Everett Haehnel. "You know that, and I know that."

He promised to do better. Sheyner offered to have a pharmacist help him, and put in orders for a physical therapy session at his Sun City Center home and a consult for dementia.

Two University of South Florida medical students scribbled notes vigorously. But neither wants to follow Sheyner into a specialty that cares for the oldest, most complicated patients.

Anyway, they can't locally.

Geriatricians are in alarmingly short supply, yet USF closed its geriatrics fellowship last year due to lack of interest. While other Florida schools are hanging on, they aren't training anywhere near as many geriatricians as are needed.

Yet experts think more geriatricians like Sheyner could be the key to fixing a health care system that spends too much on too many doctors, drugs and surgeries for frail seniors who don't benefit and may even be harmed by excessive care.

"We are entering into a new era of medicine where the role of a geriatrician could be very important to a health care system," said Dr. Ken Brummel-Smith, chairman of the geriatrics department at the Florida State University medical school. "You will have doctors who need to be expert in increasing quality while decreasing cost — that's where geriatricians shine."

Medicare, the government health care program for older Americans and the disabled, sees about 80 percent of its spending generated by patients with four or more chronic conditions. Frail seniors tend to see so many health professionals, they fall prey to harmful coverage lapses and medication mix-ups.

Geriatricians — primary care doctors with an additional year of training specific to elder health — can often produce better results. They bring expertise in dangerous drug interactions. They know how caretaker issues and home environment can affect health.

"The usual care model that works for the rest of the population works to ill-serve this patient, because it becomes much more likely that the treatment of one of their conditions causes problems in some other part of their life," said Dr. James Pacala, president of the American Geriatrics Society.

With its large retiree population, Florida has an especially compelling need for geriatrics care. Florida has 424 board-certified geriatricians, serving a population of 3.3 million seniors, according to the society. That's 10 fewer than in 2010.

State leaders even mandated a focus on geriatrics when authorizing FSU's medical school. Yet in a decade, FSU has produced just one geriatrician.

"That's actually higher than the national average," Brummel-Smith said, noting the small size of FSU's first classes.

Most seniors are relatively healthy and can be cared for by internists and family doctors. Geriatricians believe that about one-third of those older than 65 would benefit from their specialized skill set.

Based on that projection, the society estimates that Florida needs an additional 973 geriatricians. Nationally, their calculations translate to a shortage of 10,315 geriatricians.

Medical schools and students don't appear capable of filling the gap. Many more young doctors would rather go into better paying specialties, especially considering the massive student debt they incur.

"It's a hard sell," acknowledged Pacala, the society's president. "Hopefully, there are still an awful lot of medical students and residents out there who really do have an altruistic interest in specialties like geriatrics, which are more about caring than curing."

USF, however, isn't seeing them. "When nobody applies, it tells you something," said Dr. Allan Goldman, chairman of internal medicine, which oversaw the geriatrics program before its closure last fall. "Everything is supply and demand. If nobody wants to go into it, you can't have much of a program."

Geriatrics is the only medical speciality in which an additional year of training results in lower incomes, according to a 2010 report in the highly regarded journal Health Affairs. Geriatricians' median income was $179,150, the report noted. That's about $12,000 less than general internists who go straight into private practices in primary care, another field struggling to recruit young doctors who could earn many times more in lucrative specialities like dermatology or neurosurgery.

Still, pediatrics, another lower-paying specialty, isn't facing alarming shortages. It appears that healing children is more appealing than helping seriously ill elders who may never be entirely well again.

"These are really complicated patients. That could deter some people. It's hard to really manage things and keep them under control," said Colin Sullivan, a third-year medical student at USF. "You have to be okay with a certain level of them not being okay."

During a recent rotation through the geriatrics clinic at the James A. Haley VA Medical Center, Sullivan marveled that he had the chance to examine a patient who had nearly two dozen medical problems, with a list of medications that was three pages long.

But it wasn't enough to change his mind about a career in emergency medicine — a faster-paced, higher-paying specialty.

Letitia Stein can be reached at [email protected] or (727) 893-8330.

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