The Otolaryngologist and the Imminent Crisis in Geriatric Medicine

The perfect storm has arrived. There is a burgeoning geriatric population that is coupled with a scarce geriatric workforce, and no incentive to turn the tide.

Emerging Solutions

The Institute of Medicine has analyzed this problem in detail and has eloquently summarized their findings in its report (www.iom.edu/CMS/3809/40113/53452.aspx ). It has made specific recommendations on how to approach the situation going forward. First of all, the committee has requested that Congress require an annual report from the Bureau of Health Professions to monitor the progress made in addressing the crisis in supply of the health care workforce for older adults. Raising awareness in Congress of the workforce size problem would likely have secondary effects in other areas, such as remuneration for geriatric care.

The second group of recommendations is directed toward growth and retention of the geriatric health care workforce. The report states that public and private payers should provide financial incentives to increase the number of geriatric specialists in all health professions, and to include a specific enhancement of reimbursement for clinical services delivered to older adults by practitioners with a certification of special expertise in geriatrics. Another incentive program suggested by the IOM is loan forgiveness, scholarships, and direct financial incentives for professionals who become geriatric specialists. Geriatric specialty care goes beyond primary care geriatrics, and new incentive models should include medical and surgical specialists caring for the geriatric patient.

A third set of recommendations is to improve geriatric competence. Enhancement of geriatric expertise in specialties starts at the residency level. The IOM states that hospitals should encourage the training of residents in all settings where older adults receive care, including nursing homes, assisted-living facilities, and patients’ homes. A related key recommendation relates to health care worker certification: All licensure, certification, and maintenance of certification for health care professionals should include demonstration of competence in the care of older adults as a criterion.

As stated earlier, the traditional physician-patient encounter model that Medicare supports leads to fragmented care with limited interdisciplinary approaches. The IOM encourages the development of new models of care that are more efficient and effective. Enhancing research in new models of care, particularly those that leverage technology and teamwork, will ease the burden of the swelling geriatric population on the health system.

Otolaryngology has recognized the need to address the changes that we are facing, and has been making accelerating strides for some time. Publications specifically focusing on clinical care of the geriatric otolaryngology patient have appeared in the literature since the 1950s. As early as 1989, leaders in otolaryngology have recognized the need to integrate geriatric medicine into residency training programs (Johns M et al, Otolaryngol Head Neck Surg 1989;100:262-5). This integration has been enhanced by grant support from the American Geriatrics Society and the John A. Hartford Foundation. Grants from the Geriatric Education for Specialty Residents program have been awarded to four residency programs to develop geriatric curricula. Much of the content of these curricula is available at the American Geriatrics Society Web site (www.americangeriatrics.org/specialists/otolaryngology.shtml ).