Pat Early, 66, has lived with the autoimmune disease Sjogren’s syndrome since her 30s. She must rely on a stable of specialists — a rheumatologist, gastroenterologist, endocrinologist, ophthalmologist and the like — to manage the fatigue, muscle pain and other complications of the disease, all helmed by her longtime primary-care doctor.

When that doctor started cutting back his staff, she began searching for someone new and stumbled across a medical practice of geriatricians — doctors who specialize in patients over age 65. Early didn’t consider herself old, so “it never even crossed my mind that that’s something I should be looking at,” she said. But she’s grateful for the switch.

“They said, ‘We want to have a personal relationship with you, and we want to stay with you until you die,’” Early said. They seemed deeply understanding of aging to end-of-life issues that older people and their families confront. “I feel so lucky because I know other people my age don’t have that.”

People over 65 use more health care than other age groups and make up nearly half of hospital admissions. But there are just 7,300 board-certified geriatricians in the United States, which is fewer than 1 percent of all physicians, according to the American Geriatrics Society. By contrast, more than 60,000 pediatricians were practicing in 2021, according to the Association of American Medical Colleges (AAMC).

Yet research suggests that geriatricians more effectively and efficiently manage older patients than doctors without such training — leading to lower inpatient death rates, shorter hospital stays and reduced patient costs. Right now, the United States has roughly 1 geriatrician for every 10,000 older patients. Only 41.5 percent of geriatric medicine fellowship positions were filled in late 2023, down from 43 percent in 2022. Meanwhile, the number of people over 65 is expected to grow by nearly 40 percent within the decade.

“The vast majority of older people are getting care from people who have little to no training in the care of older adults,” said Louise Aronson, a professor of geriatric medicine at the University of California at San Francisco and the author of “Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.”

Mind, mobility, medications

This shortage stems from negative stereotypes about aging, lack of exposure to the field among doctors and lower pay than many other medical specialties, experts say, and can lead to doctors misdiagnosing symptoms or overprescribing drugs that can cause cognitive impairment or other issues in older patients. “It is dire,” Aronson said.

Changes in body composition as people age alter how drugs are metabolized, said Ryan Pate, a geriatric psychiatrist at Stanford University. Even at low doses, older adults may start to respond differently as they age to drugs they have taken their whole lives. Many doctors and patients don’t realize that some common medications can impair older adults’ executive functioning, attention, language and memory.

“The vast majority of older people are getting care from people who have little to no training in the care of older adults.”

— Louise Aronson, professor of geriatric medicine at the University of California at San Francisco

For instance, Digoxin — a prescription medicine used for abnormal heart rhythms — can cause appetite loss, while over-the-counter sleep aids like Benadryl and its generics can precipitate delirium and falls. Even the widely used anti-inflammatories Advil and Aleve can cause gastrointestinal bleeding, increase blood pressure, impair kidney function and raise the risk of heart failure in older patients, experts said.

Pate said he often sees patients experiencing confusion, hallucinations or sleep disruption caused by medications they have been given for other conditions. “Another important part of my job is sometimes as much de-prescribing or reducing medications as [it is] prescribing,” Pate said.

All physicians should have basic competence in the “Five M’s” — mind, mobility, medications, multi-complexity and understanding what matters most to patients, said Rosanne M. Leipzig, a professor and vice chair emerita in the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai in New York.

Some doctors “don’t understand that what they think is a new symptom or problem is actually an adverse effect of a drug, which in younger people wouldn’t cause that,” Leipzig said. “When [a patient] has got a lot of things going on, you need somebody to quarterback you.”

This was especially true for Early, who needed someone to connect the dots between various conditions. When covid-19 caused long-lasting swelling in Early’s legs that constrained her mobility, her new geriatric practice provider noticed that Early seemed depressed and asked her about it. Early couldn’t walk down her front steps, so she felt trapped inside the house, she responded. The doctor pushed her to get a ramp installed — and affectionately dubbed it “the ramp of freedom” — that Early said has transformed her day-to-day life.

Medicare’s part, student loan incentives

The supply/demand mismatch between geriatricians and those like Early who need them has been building for decades. Geriatrics only became a board-certified specialty in 1988, and accredited medical schools aren’t required to teach geriatrics — so many don’t. Pate wasn’t exposed to a specific geriatrics rotation until his third year of residency in psychiatry in 2020, though he felt drawn to it and later pursued a fellowship. The accreditation council only requires one month of geriatrics in a four-year general adult psychiatry residency program to graduate. “If we don’t have exposure to it or learn about it, then how do we know … it might be a path we want to pursue?” Pate said.

The shortfall is exacerbated by a dearth of primary care doctors — family medicine doctors and internists typically form the pipeline into geriatrics — and the lower salaries that geriatricians often make relative to peers.

Although fellowship-trained geriatricians have more training than general internists, their salaries tend to be about $20,000 less on average, according to a study in the journal Nature Aging. (The median starting salary for a geriatrician is around $186,000, according to the AAMC Faculty Salary Report from 2019-2020, compared with roughly $205,000 for general internal medicine and $216,000 for general family medicine.)

One reason for the lower salaries is that most geriatricians’ patients are on Medicare, the federal health insurance program for anyone 65 or older — whereas general internists see a greater share of patients with private insurance and some with Medicare. Private insurers pay nearly double Medicare rates, according to KFF. Health insurance tends to pay doctors for how many patients they treat, but geriatricians often don’t see as many as internists do, given that older patients can require more time and out-of-office management.

Experts highlight creative ways to boost financial incentives and exposure. Leipzig pointed out that since Medicare funds part of residencies and fellowships, regardless of the specialty, “why doesn’t Medicare require that these trainees demonstrate basic competency in the geriatric field?” Making program funding contingent on this would ensure some knowledge of geriatric issues for residents across specialties. Aronson suggested student loan forgiveness programs for doctors who specialize in geriatrics, similar to medical school loan forgiveness offered to doctors at qualifying nonprofit or government hospitals.

Leipzig pointed to a new pilot program in the works to encourage more geriatric expertise by creating a midcareer pathway for general internists, similar to executive MBA programs. Some experienced internists will be able to pursue intensive short-term geriatric training without sacrificing their salaries or established practices.

For the growing number of older people, this brings good news. “It’s easy to lose your confidence when your body stops working like it used to,” Early said. “You already feel overlooked as an older person.”

“If you don’t have a doctor that you feel is in your corner, or really sees you and cares about you … it’s possible to say, ‘Well, I guess I’m just not worth it.’”