In 1988, I became one of the first U.S. physicians certified in the new specialty of geriatric medicine, which focuses on the health care of older adults. As an idealistic and optimistic 32-year-old geriatrician, I believed that this branch of medicine would undoubtedly emerge as a vibrant field of medicine, benefiting patients and society. I was also confident that when I reached older adulthood, the health care system would be ready to care for me.
I had been drawn to geriatrics for several reasons. I enjoyed caring for my older patients and I valued their appreciation for the care I provided. I also realized that there were 76 million baby boomers out there. The U.S. was on the cusp of a dramatic demographic shift that would have profound implications for its health care system. It was obvious that many health care professionals with specialized expertise in caring for older adults would be needed, and I was excited to be among the first.
The expected demographic changes were right on target: Over the past 20 years, the number of Americans 65 years of age and older has increased from 35 million to 58 million; by 2040 that number will swell to 78 million. But the U.S. health care system and its workforce haven’t kept pace, and my optimism that the system would be ready to care for me has faded.
Aging is associated with numerous health risks, including multiple chronic illnesses, overmedication, fall-related injuries, cognitive decline, and more. Geriatricians can help manage, delay, and even prevent many of these age-related health issues. Caring for older people with complex chronic conditions, prescribing medications that are safe and effective for them, and addressing functional and cognitive decline are essential skills for geriatricians. We also prioritize aligning our patients’ preferences and values with their goals of care, and work hard to integrate the vital roles served by family caregivers.
Yet despite a clear demographic imperative, the number of health care professionals with special training, experience, and expertise in the care of older adults is declining. Fewer and fewer medical students and residents are choosing to become geriatricians. In 2023, only 174 of 419 geriatrics fellowship training positions were filled through the national fellowship specialty match, the lowest percentage of all medical specialties. Reduced interest in geriatrics is also seen in other health professions, including among nurse practitioners. There are nearly 400,000 licensed nurse practitioners in the U.S., who play increasingly important roles in every health care setting. Yet the opportunity to become a geriatric nurse practitioner ended about 10 years ago, as very few pursued this specialized career path.
Financial compensation, prestige, and respect are key factors that greatly influence the attractiveness of a specialty to medical students, residents, and nurse practitioners. Specialties like cardiology, oncology, and dermatology are substantially more lucrative than geriatrics, and those training programs have no trouble filling their slots.
But the situation geriatric medicine faces cannot be attributed to just lower compensation and less prestige. Medical career decisions are also shaped by societal attitudes about aging. One study of medical students and residents training at two urban teaching hospitals in northern California profiled the trainees’ negative perceptions about older adults, including that they were inherently “end of life,” that they were cognitively impaired, that their medical problems were complex and unlikely to be resolved, and that they were socially “needy” and “slow” to interact with.
Some argue that all health care professionals should receive training in the care of older adults. I agree. Such training could reinforce the principles of geriatric care and temper the effects of societal ageism. Unfortunately, U.S. medical schools, residency training programs, and schools of nursing are falling far short of achieving this goal. It’s not enough to assume that medical students, residents, and nurse practitioners will learn enough about caring for older patients simply because many of the patients they see in the hospital or in clinic are old.
Rosanne Leipzig, a geriatrician at the Icahn School of Medicine at Mount Sinai, has commented that “all medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby.” Yet with the changing demographic landscape, older adults will account for an increasing proportion of most health care providers’ workloads over the coming years. Ironically, as reported at the 2024 annual meeting of the American Geriatrics Society, only one in 10 U.S. allopathic and osteopathic medical schools has a required clinical experience in geriatrics, a decline from one in four in 2010.
Some ongoing national efforts aim to promote the principles of geriatric care, supported by organizations like the American Geriatrics Society and the John A. Hartford Foundation. The Hartford Foundation’s “Age-Friendly Health Systems Initiative,” for example, is a movement to improve the care of older adults that has spread to 3,000 health care sites across the U.S.
Despite these efforts, the U.S. lacks a well-trained cadre of health care professionals with special expertise in geriatrics to lead the development of new programs of care for older adults, to train the next generation of health care professionals, and to assure high quality care for the growing numbers of older Americans.
The U.S. is just beginning to experience the full impact of its aging population. Regrettably, its health care system and workforce are inadequately prepared to handle the oncoming surge in multimorbidity, dementia, functional impairment, and frailty. The leaders of health care organizations and medical schools have either failed to recognize this or, worse, have opted to overlook it.
I will never stop advocating for a health care system and a professional workforce fully prepared to care for our aging population. Unfortunately, it may already be too late. I am extremely worried about who will be there to care for me. And if I am worried, you should be too.
Jerry H. Gurwitz, M.D. is the Dr. John Meyers Professor of Primary Care Medicine at UMass Chan Medical School in Worcester, Mass., where he served as chief of the Division Geriatric Medicine for more than 20 years.