The future of geriatrics: Questions to consider

LESLIE KERNISAN, MD, MPH | PHYSICIAN | SEPTEMBER 13, 2013

Recently, the New York Times featured a post about me and my practice. Titled “Walking Away from Medicare,” it describes my decision to opt-out of Medicare and create a different kind of geriatric practice.​

It has generated quite a lot of comments. Most of them judge me pretty harshly. It seems that many people feel that I’m doing this for the money. And that I don’t care about society or older people.

Of course, if you know me, then you’ll know that nothing could be further from the truth. My practice is fairly small, in part because my goal in having this practice was to have a way to keep working with patients and families, while having the flexibility to pursue my other professional interests. Since I started the practice, I’ve spent most of my time writing for this blog, learning about the worlds of digital health and healthcare innovation, and thinking about how we can teach geriatrics directly to caregivers.

Although I’ve phased out working with Caring.com, I’m thinking about how I can build on what I learned there, and keep connecting caregivers to resources that leverage geriatrics expertise.

I recently gave a talk to a group of family caregivers, at a retreat sponsored by Family Caregiver Alliance. We talked about what caregivers should know about the geriatric approach to care, and how they can learn more about medical care that is tailored to the needs of aging adults. We talked about delirium, and how caregivers can recognize it and get better help from clinicians.

We talked about participatory medicine — they were all savvy, experienced caregivers but none had heard of the e-patient movement — and the Beer’s criteria, and then we got into how tech tools might help caregiving feel more manageable.

I loved every minute of it, doing this session with family caregivers. I can’t wait to participate in more events with caregivers.

So why am I writing all this? Mainly because I hope to illustrate in a time of geriatrician shortage, there many ways we can be of service to society, even if we make the decision to leave Medicare, or otherwise aren’t as available to serve patients in a one-on-one fashion.

The future of geriatrics
Just for the record, I don’t think the future of geriatrics should be that geriatricians leave Medicare en masse and require that patients pay them an hourly rate, out-of-pocket, for services.

Instead, I hope my own story and struggles will foster more conversation on the following topics:
How should we — as a society — best deploy a very limited supply of geriatricians, given an aging population and inadequately prepared healthcare workforce? The projections are sobering.

• ​How many patients should expect to get primary care from a geriatrician, and how do we decide which those people are?
• Should geriatricians in the outpatient setting continue to mainly work as primary care doctors? Or should there be more opportunities for families to request a consultation?
• How can we best share our skills, in order to effectively provide teaching and support to as many healthcare providers — which includes family caregivers — as possible? (Muriel Gillick recently called for “massive online courses” for caregivers; a good idea given Pew’s recent findings on how avidly caregivers search for information online.)
• What can we learn from other developed countries?

​​How can we make practicing geriatrics attractive and sustainable for geriatricians? Most geriatricians I know love caring for older adults, but many complain of stress and burnout. (Some have emailed me this past year, having heard of my practice.)

• What changes to reimbursement or work structure would attract more clinicians to geriatrics?
• How can we make practicing geriatrics within Medicare feel more sustainable? (Answer: we may need to think beyond debt relief and 10% salary increases.)

​​How can we make geriatric care doable for all front-line clinicians? As people age, they benefit from a geriatric approach to their care. And for the foreseeable future, that approach will have to be delivered by non-geriatricians: the primary care clinicians who will hopefully have had some geriatric training, but didn’t do a fellowship.

• With front-line clinicians already suffering from high levels of burnout and dissatisfaction, how can we support them in effectively caring for a growing number of older patients?
• Earlier this year I proposed that the job of PCP for complex Medicare patients be doable within 35 hours, which could help retain all those empathetic clinicians with young children. Other ideas?

​​Food for thought and future conversations, I hope.
Leslie Kernisan is an internal medicine physician and geriatrician who blogs at GeriTech