The forgotten population: A growing need for geriatricians
As fewer physicians choose to specialize in geriatric medicine, experts at VCU strive to meet the health needs of an increasing population of older adults.
Brittany Craven, M.D., program director of the geriatric medicine residency, is one of about 20 geriatricians at VCU. (Photo by Arda Athman)
A handcrafted wooden Superman shield, with the word “doctor” across the middle, sits on Brittany Craven, M.D.’s desk. It was a gift from a patient, whose recent diagnosis and treatment of normal pressure hydrocephalus improved his mobility so much that he can now make it down the basement stairs to his woodworking shop for the first time in months.
“He said I was the first doctor to listen to him,” Craven said of the man in his 70s who had had poor balance and trouble walking until she referred him to a VCU neurosurgeon. “I’ve always loved working with older patients, and they are truly the forgotten population.”
Craven, a VCU School of Medicine alum, is one of about 20 geriatricians — physicians who care for adults over the age of 65 — in the Division of Geriatric Medicine. VCU’s geriatrics service includes outpatient, inpatient, palliative, home-based and nursing facility care across three locations, plus a 12-month geriatric medicine fellowship program, which Craven leads.
With older adults making up nearly 17% of the U.S. population in 2020, the demand for geriatricians is growing. Studies show that patients under the care of geriatricians have better outcomes and shorter hospital stays than those under the care of general practitioners. But according to a report by the U.S. Department of Health and Human Services, the national shortage of geriatricians is projected to reach a deficit of nearly 27,000 by 2025.
“Everyone wants their loved ones to come see us, but there are very few of us,” Craven said of the specialty. “Outside of major city centers it can be really hard to find a geriatrician.”
Experts across disciplines at VCU have been preparing for this shortage through enhanced curriculum for M.D. students, a robust fellowship program and continuing education for other specialists to care for older adults within their practices.
'You can’t fix aging’
During the 2023 match cycle, 245 out of 419 geriatric medicine fellowship spots in the U.S. went unfilled, illustrating the challenge the field faces in the coming years.
Tracey Gendron, chair of the Department of Gerontology in the VCU College of Health Professions and director for the Virginia Center on Aging, said that ageism and the fear of getting older factor into the declining interest in geriatric medicine.
“We’ve pathologized aging,” she said. “Part of the issue is that ageism drives our understanding of aging as being focused on our bodies. We don’t talk as much about decline and growth, and the real opportunities as we age to have different milestones and different contributions.”
Sarah Hobgood, M.D., associate program director of VCU’s fellowship, agrees.
“A lot of people don’t want to take care of older adults because they think everyone is going to just get old and die,” Hobgood said. “You can’t fix aging, and it’s hard, because physicians want to fix people.”
Geriatric care often entails long-term maintenance of conditions, rather than curative treatments. This, she said, in addition to lower reimbursement rates from Medicaid and Medicare, can make geriatric medicine a less desirable specialty. For those who are drawn to geriatrics, however, Hobgood said the work is both challenging and rewarding.
Hobgood’s appreciation for older adults started in an intergenerational household. She was 10 when her grandmother moved in with her family, and she has fond memories of “babysitting” with her sister, Allie. The girls often helped their Gram — who had Alzheimer’s and affectionately called them both “Sally,” a combination of their two names — bathe, take her medications and get ready for bed.
This relationship set her on the path to geriatrics, a field in which she has found fulfilling patient relationships and intellectual stimulation. Function, cognition and comorbidities all factor into determining care, she said, requiring teamwork and complex problem-solving.
“It’s incredibly interesting and nuanced, because age is just a number,” Hobgood said. “It requires a lot of interprofessional work, not a singular physician offering a specific cure.”
'Every doctor learns geriatrics’
As a 2021 AAMC article lays out, the widening gap between the aging population and available geriatricians already has a long-term solution: “Every doctor learns geriatrics.” At the School of Medicine, that exposure starts early.
Since 2016, the M.D. program has included a longitudinal geriatrics course spanning all four years. The curriculum includes topics such as healthy aging, age bias and medication management, plus a home-based primary care visit.
The course’s senior mentor program matches each M1 with an adult who’s “aging in place independently,” and the pairs meet periodically throughout the year. Jesse Dahringer, an M3 and member of the geriatric medicine student interest group, loved connecting with her assigned partner, an 80-year-old woman who spends her free time belly-dancing and volunteering at the library.
“It was helpful to see that we shouldn’t take age as a constant presupposition of what someone might look like or be able to do,” Dahringer said. “It’s easy to assume things, especially when you’re seeing a lot of sick patients in the hospital.”
Hobgood, who directs the longitudinal course, hopes it will inspire more students to pursue geriatrics. It is also part of a broader effort to prepare the health care workforce to care for older adults. She encourages her non-geriatrician colleagues to look into the American Geriatrics Society’s educational offerings, like mid-career training modules, annual conferences and the Geriatrics for Specialists Initiative, which educates physicians in surgical and related specialty care fields on treating aging patients.
“And, you know, they can come back and get a fellowship any time,” Hobgood said with a laugh.
Patience, compassion and nuance
As a volunteer EMT during college, Dahringer found herself drawn to the older patients, and was thrilled when her first clinical rotation was on geriatric consults.
“I think it may not be an exciting field for a lot of people because it’s a slower pace,” she said. “But I've found that I really liked talking to the patients. They have so much wisdom and are often overlooked, and I think I’m just drawn to helping in that area.”
Her time as an EMT also provided a key lesson in geriatrics: Not every issue requires medical intervention. Some patients may need help with “very simple things” that Dahringer admits she never would have considered without seeing them for herself, like poor lighting or a misplaced rug at home that caused a fall.
"It was very eye-opening to see what patients struggle with,” she said. “Maybe they don’t need a drastic prescription change, but maybe they do need a pill box to help them remember to take their meds. Maybe it’s a simpler fix to help them than you might think.”
It is that unique approach, plus the relationships formed with patients, that experts want students to understand when considering a career in geriatrics. As Craven gears up for the next round of the fellowship match — applications open in July — she remains optimistic about her field. It requires a specific blend of patience, listening skills and empathy, and surveys have shown that geriatricians report higher career satisfaction than physicians in most specialties.
“I’ve never met an unhappy geriatrician, which says a lot for people who don’t get paid as much as other doctors,” Craven said. “Older people have so much life experience and can really change how you look at your own life. It is so fulfilling and so rewarding.”
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