(Viewpoint) Thirty-five years ago, geriatrics officially became a specialty of medicine. At that time, there were 76 million baby boomers who would begin turning 65 in 2011, a compelling demographic imperative for this new specialty that specifically focused on older adults.
Geriatrics is a field especially attractive to some physicians because of its differences from other specialties, including elements beyond single medical conditions such as multimorbidity, polypharmacy, function, and cognition. Geriatrics also places a special emphasis on interdisciplinary team care for complex older patients, and the needs of family caregivers.
However, accumulating evidence suggests that the profession of geriatric medicine has fallen into decline. The number of board-certified geriatricians in the US fell from 10 270 in 2000 to 7413 in 2022.1 This attrition relates to the retirement of many physicians who were among the first to be certified in geriatrics, as well as some choosing not to recertify as required every 10 years. This drop has been further exacerbated by a failing trainee pipeline. In the 2022 national geriatrics fellowship match, only 177 positions were filled of 411 positions offered (43%), the lowest percentage of all fellowships across 71 specialties of medicine.2
The irony is that despite substantial investments in geriatric research and education, the stars have never seemed to align for geriatricians. The National Institute on Aging (NIA), with an annual budget exceeding $4 billion (third largest across the National Institutes of Health), has funded applied geriatrics research and generous training awards for early-stage clinician-investigators who pursue research activities focused on improving the health of older Americans. However, of the small number of fellowship-trained geriatricians, very few pursue research careers. Over the past 3 years (2020, 2021, and 2022), of 33 Beeson scholars, the NIA’s most prestigious career development award program, just 2 have been geriatricians.
Beginning in 1988, to support efforts to increase the number of geriatrics-trained faculty and training initiatives in geriatrics focused on medical students and residents, the John A. Hartford Foundation and the Donald W. Reynolds Foundation combined to invest nearly $160 million.3 However, in 2011, the Hartford Foundation made a strategic decision to pivot away from supporting efforts to build academic capacity in geriatric medicine to fund more broadly focused health system initiatives. The other major funder of geriatric educational programs, the Reynolds Foundation, closed down permanently having spent down all of its assets.
Accrediting organizations like the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME) have overlooked the need to teach geriatric principles to medical students and residents, with no requirements of medical schools or residency programs to have geriatrics-specific, competency-based performance standards, or to have geriatricians involved in educational and training activities.
Even a favorable financial framework relating to the care of older adults under Medicare Advantage, with 31 million enrollees, has not been helpful to the profession of geriatric medicine. While insurers and health care delivery systems have invested heavily to “creatively capture” high-risk diagnosis codes, allowing for payment at higher rates, far less attention has been paid to implementing innovative programs developed by geriatricians to improve the care of older adults across all clinical settings,4,5 or to hire geriatricians to provide primary care to older patients with complex conditions. As a result, the profession of geriatric medicine has benefited little from this advantageous financial situation for insurers and health care delivery organizations.
Some attribute the challenges faced by the profession of geriatric medicine to lower compensation. That is because geriatric medicine is one of very few specialties for which fellowship training and board certification result in a lower salary than if neither had been pursued. According to the 2022 Association of American Medical Colleges (AAMC) faculty salary survey, the median salary of geriatricians was 9% lower than that of general internists and 14% lower than that of hospitalists. In addition, the attainment of board certification in geriatric medicine does not meaningfully influence job opportunities or practice activities.
However, the situation that has befallen geriatric medicine is more complicated than just lower compensation. Despite being a profession that also offers lower salaries, pediatrics remains an attractive career path for medical students. Attitudes of medical students and residents about aging and older adults strongly influence their career decision-making. In one study of medical students and residents training at 2 urban teaching hospitals in northern California, negative perceptions of older adults included that “they were inherently ‘end of life’ patients, that they were cognitively impaired, that their medical problems were complex and unlikely to be resolved, and that they were socially ‘needy’ and ‘slow’ to interact with.”6
In her 2019 book Elderhood,7 geriatrician Louise Aronson wrote, “When I tell someone what I do for a living, they usually have one of two reactions. Either their face contorts as if they’d just smelled something foul, or they offer compliments about my selfless dedication…These apparently opposite responses are actually the same. Both imply that what I’m doing is something no one in their right mind would ever do.”
While the importance of the profession of geriatric medicine and the need for geriatricians seem obvious, it should not surprise anyone that it is the career choice of ever-diminishing numbers of medical students and residents. The demographic trends in our population have not attracted them to the field; societal attitudes about aging have clearly compounded the negative effects of lower compensation and lack of prestige on their career decisions.
Our nation is beginning to experience the full impact of the aging of our population. Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia, and frailty. This is the reality that health care organizations and medical schools have not adequately appreciated, or have chosen to ignore.
It will be extraordinarily difficult to alter the trajectory of the specialty of geriatric medicine. Geriatricians will never stop advocating for better care of our aging population and the need for physicians with expertise in geriatric medicine. The decline of the profession of geriatric medicine matters, and all too soon we will all realize why.
Article Information
Corresponding Author: Jerry H. Gurwitz, MD, Division of Geriatric Medicine, UMass Chan Medical School, 365 Plantation St, Worcester, MA 01605 (jerry.gurwitz@umassmed.edu).
Published Online: August 4, 2023. doi:10.1001/jama.2023.11110
Conflict of Interest Disclosures: Dr Gurwitz reported serving as a consultant for United Health Care.
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