A perfect storm is brewing in the United States and threatening to exacerbate an already overtaxed health care system. The biggest—or at least most visible—factor is the “elder boom” that logically follows from the baby boom that began in the 1940s. Thanks to advances in medicine and technology, more people are living longer. But as the number of older Americans increases, experts say, the workforce to care for them will experience insufficient growth.
Consider this: In 2005, older adults represented 12% of the US population. By 2030, they could account for nearly 20%. Meanwhile, the number of geriatricians (ie, physicians certified in geriatric medicine) is expected to increase by less than 10%. The already vast disparities in the patient/provider ratio—in 2007, there was one geriatrician for every 2,456 older Americans; by 2030, there will be one for every 4,254—are only going to worsen.
Perhaps Kathy Kemle, PA-C, President of the Georgia Geriatrics Society and Cofounder of the Society of PAs Caring for the Elderly, is not entirely joking when she says one of the advantages of choosing a career in geriatrics is “You’re always going to have a job.” Kemle has reasons beyond job security for loving what she does (see “The Joys of Elder Care”), although it’s hard to argue that opportunities abound in geriatrics.
But are NPs and PAs taking full advantage of them?
Insufficient Training
Clinician Reviews Editorial Board Member Freddi I. Segal-Gidan, PA, PhD, describes geriatrics as “high-touch, low-tech,” and every clinician knows what that means in terms of reimbursement. As in all areas of primary care, the R-word is a major issue in the recruitment and retention of clinicians in geriatrics.
In addition, misperceptions frequently discourage clinicians from pursuing geriatrics. Debra Bakerjian, PhD, MSN, FNP, President of the Gerontological Advanced Practice Nurses Association (formerly the National Conference of Gerontological NPs) observes that nurses often avoid nursing homes, thinking they are settings for unskilled workers who couldn’t cut it in hospitals. “In fact, what we need are the most skilled people in nursing homes, because we don’t have the technology in nursing homes that they have in the hospital,” says Bakerjian, who is also an Assistant Adjunct Professor of Social and Behavioral Science at the University of California–San Francisco School of Nursing. “Your clinical skills have to be much better than they would be in a hospital.”
But do most clinicians have the right skills to care for older adults in any setting? The Institute of Medicine (IOM) says they do not. In a report released earlier this year, an IOM committee concluded that “in the education and training of the health care workforce, geriatric principles are still too often insufficiently represented in the curricula, and clinical experiences are not robust.”
It is an assessment with which Segal-Gidan, an Assistant Clinical Professor in the Departments of Neurology and Family Medicine at the University of Southern California’s Keck School of Medicine, does not disagree. “Geriatrics is not a required part of training for many health care providers,” she observes. “PA curricula do require some geriatrics, but it’s very vague how much. So you can graduate PA school having had a couple of lectures and seen a few older people, while other people have had required rotations.”
NP training can be just as variable; while the American Association of Colleges of Nursing has a set of competencies for older adult care, there are no specific geriatric requirements for advanced practice nursing education. “Just like anything else, there’s good geriatric education,” says Barbara Resnick, PhD, CRNP, FAAN, FAANP, a Professor at the University of Maryland School of Nursing and Secretary of the Board of Directors of the American Geriatrics Society (AGS), “and then there’s geriatric education in name only, if you know what I mean.”
As older adults become a larger proportion of the US population, and as they seek care for multiple conditions in various settings, it will be essential for all clinicians to know how to provide care to them. “Unless they’re doing pediatrics, everybody does geriatrics,” Kemle points out. “They just don’t know it.”
Need to Know
What they also might not know is that from a clinical perspective, older adults are not simply adults who are older. Every day, Resnick says, she encounters colleagues who don’t recognize the distinctions. “They’ll try to blow off a temperature of 99.5°, and I think, ‘You know, this person is this-and-this years of age and his baseline temp is normally 99.0°.’” Her response is to bring the evidence. “I’ll send or quote a reference that says, ‘In older adults, a rise of 1° above their baseline is consistent with a fever.’”