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Short of recruits, not patients: geriatric medicine strives for “critical mass”

As Canada deals with a sharp increase in the number of frail, elderly patients, the medical subspecialty that was created to care for these patients is proving a hard sell with new physicians.

“There are only 242 certified geriatricians in Canada,” says Dr. Frank Molnar, who represents the Canadian Geriatrics Society (CGS) on the CMA Specialist Forum. “No one knows what the ideal complement is, but the roughest estimate is that we need around 700 geriatricians, and we’re only bringing in 15 to 25 a year.”

So why is recruiting so difficult? Molnar says there are several reasons.

One is that geriatrics has had a hard time “branding” itself because it is a hybrid specialty that deals with complex comorbidities and brittle patients, and is closely linked to other specialties such as psychiatry, neurology and general internal medicine. The difference, says Molnar, is that geriatricians concentrate on patients with multiple conditions: “We’re the ones who provide the ultra-complex care,” he says.

Certification in the field involves three years of general internal medicine training and two years of fellowship training in areas such as neurology and psychiatry.

The CGS thinks medical schools are one of the reasons for its low profile. For instance, students typically receive 300 hours of exposure to pediatrics during their undergraduate years, compared with 80 hours for geriatrics. “This distribution is at odds with societal needs because of the growing proportion of seniors using the health care system,” says Molnar, “and it may help explain why we have 242 geriatricians and 2,500 pediatricians.”

Geriatric medicine also faces challenges during residency training. For example, although training programs in psychiatry include compulsory rotations in geriatric psychiatric, many internal medicine residency programs do not have compulsory rotations in geriatric medicine.

Molnar said the inadequate exposure to geriatrics at both the undergraduate and post-graduate levels contributes to geriatric medicine’s recruiting difficulties.

“There are other factors as well,” says Molnar. “Many of us were actively discouraged from pursuing this career because it has a low profile, is not procedurally based and used to be grossly underpaid.”

Geriatricians in Ontario now earn the same as general internists, but Molnar says geriatricians in many other provinces still earn “far less.”

The demand for geriatricians’ services has been growing rapidly as the number of seniors almost doubled, from 2.7 million to 4.8 million Canadians, between 1986 and 2010. It is now estimated that Canadians older than 65 will account for a quarter of Canada’s population within about 20 years.

The CGS has responded to its low profile and recruitment problems with a series of research publications and commentaries in the Canadian Geriatrics Journal (CGJ),and by raising its issues with bodies such as the CMA Specialist Forum, as Molnar did Feb. 7.

Molnar’s own journey into geriatric medicine began in medical school, which he entered with plans to pursue a career in surgery. “Once there I decided that I liked complex systems and complex cases best, and things seldom get more complex than in geriatric medicine,” he said.

He described the field as a “grinding specialty” that may see him diagnose 100 patients with dementia during a three-month rotation.

“It is a difficult specialty in which you are often dealing with dementia in patients who also have other illnesses,” he said. “But it’s also a very satisfied and satisfying specialty because the work is so important.

“I’m not a salesman for geriatric medicine — I leave that to my peers — but if I was delivering a message to new doctors, it would be this: we deliver the care that you would want for your parents.”

Geriatric medicine’s hopes of reaching critical mass will not happen overnight. One reason is that the specialty is too focused on academic centres — Molnar calls it “hyper-concentrated” — and has little presence outside teaching hospitals. “We definitely need a broader reach,” he said.

The CGS says it also needs the help and support of larger organizations, such as the CMA and Royal College.

“A call to arms has been sounded,” a CGJ commentary stated in December 2013.

“. . .Geriatricians can play leadership roles in providing expertise for system redesign and support strategic health care sectors such as primary care. Now is the time for all health care stakeholders to understand and affirm the importance and relevance of geriatric medicine.”

And medical students may also wish to consider another issue, given the employment problems facing some specialties. “All of our grads find work,” says Molnar. “In geriatrics, there are plenty of opportunities across the country.”

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