Дефицит гериатров в США: нехватка специалистов и низкие зарплаты усугубляют кризис ухода за пожилыми

Dr. Amy Beauprez found her calling where many people would have seen no hope: a nursing home in the early days of COVID-19, when nothing could stop the virus and people nearing the end of their lives couldn’t be with family for fear of contagion. Beauprez, who is now a family medicine physician in Salida, was completing her residency in family medicine in Greeley at the time, and happened to be assigned to a nursing home rotation when the pandemic changed everything. “I would be the person holding somebody’s hand when they died and hearing their stories,” she said. “It felt like the most important place that I could be at that point.” Beauprez is part of a dwindling number of doctors looking to specialize in caring for older people. Colorado only has four slots for young physicians who want to complete fellowships in geriatric medicine, but even so, the state couldn’t fill them this year. One doctor matched in through the traditional process after finishing their residency, another joined at the last minute because their spouse got a job in Denver, and Beauprez took a leave of absence from her job for the training. Geriatric medicine fellowships in other states have also struggled to find doctors interested in the field, according to the data analytics company Trilliant Health. Nationwide, about three-fifths of fellowship slots sat empty, which was both a decrease from 2023 and the lowest fill rate of any specialty. Of the 33 states that had a geriatrics fellowship program, only seven managed to fill more than half of their slots via the matching process, though some, like Colorado, may have added nontraditional students. As of 2020, the country had about 6,500 geriatricians — roughly one for every 8,600 people over 65. In comparison, there is roughly one pediatrician for every 1,100 children nationally. At that time, the majority of Colorado counties didn’t have a geriatrician or nurse practitioner specializing in older adults, with access concentrated along the Front Range and in Mesa County. The geriatrician workforce is shrinking, which means fewer mentors who could help spark interest in the field, said Dr. Tyson Garfield, associate program director for the University of Colorado School of Medicine’s fellowship. A decade ago, all medical students had to complete a two-to-four-week rotation in geriatrics. Now, some only get a few lectures about caring for older people, and the field often isn’t top of mind for someone in their late 20s, he said. “Geriatrics is definitely not perceived as one of the fun specialties,” he said. And, of course, the fact that it isn’t a well-paid specialty turns new doctors off, Garfield said. On average, doctors in geriatrics earn about $292,000 per year, which is less than half of what a cardiologist could earn and at the lower end of medical specialties, according to Trilliant’s data. “An additional year (of training) for less pay is not that enticing for trainees who are hundreds of thousands of dollars in debt,” Garfield said. Geriatricians typically max out at about 12 patients per day, while someone with a mixed-age panel may see 18 to 24, Garfield said. On top of that, most patients will have Medicare, which generally pays less than job-based insurance. While general practitioners can care for patients of all ages, older people face challenges that aren’t common in younger groups, such as an increased risk of certain side effects from medications or delirium if they spend too long in an emergency room. Additionally, they have to consider whether tests such as cancer screenings still make sense, especially if their life expectancy is less than a decade. The existing geriatrician shortage will only grow if current trends continue, with rural areas hit hardest because their populations are aging faster and they have fewer providers, said Lori Parham, policy principle in government affairs at AARP. Older people with more severe needs struggle to find providers who understand how to treat someone who has dementia or communication challenges, or relies on a caregiver, she said. At the same time, doctors who aren’t trained on older people’s needs may dismiss treatable conditions as inevitable parts of aging. “If we don’t act, older Americans and their caregivers are the ones who are going to pay the price,” Parham said. Matching every older person with a geriatrician isn’t necessary, but all providers need to know the basics of age-friendly care, she said. AARP has pushed for all medical residents who will go on to treat patients covered by Medicare to demonstrate they can give appropriate care to older people. “We’re never going to close the geriatrician gap through subspecialists alone,” she said. With younger people, medicine can sometimes feel “algorithmic” and focused on getting someone’s cholesterol, blood sugar and other numbers down to levels that minimize long-term risk, Garfield said. While managing chronic conditions can still be important for older people, preserving someone’s daily functioning takes center stage, he said. “As we get older, those numbers may matter less,” he said. Treating patients who have complex conditions, which become more common with age, requires more work to prepare for appointments and to push insurers for prior authorization, Beauprez said. But it also brings the opportunity to really get to know the patients and what they value. She got to see how important those relationships were when the families of two patients who died in the last year, both of whom were in their 90s, opted to thank her in their obituaries. “I can’t fathom a higher honor,” she said. Sign up for our weekly newsletter to get health news sent straight to your inbox.