It should surprise almost nobody that seniors land in the hospital more frequently than younger people. Older adults tend to accumulate multiple chronic diseases over the years and are more prone to developing various physical and cognitive disabilities that often require regular monitoring. So a reasonable observer might assume that our healthcare system has cultivated a thriving crop of practitioners devoted specifically to helping elderly patients navigate their particular health challenges.
Reasonable observers would be wrong.
Despite a population of seniors that has grown to more than 57 million, the number of board-certified geriatricians in the United States has dwindled to fewer than 7,000. You can do the math, but any way you look at it, this gap between the demand for care and the supply of specialized caregivers does not favor older adults. Sure, a general practitioner can check their vitals, prescribe the appropriate meds, and send them off for more tests, but addressing the complex conditions these patients often present is probably not something they learned in med school.
Geriatricians are trained to go deeper with their patients: monitoring their medications, helping them manage multiple chronic diseases, and even providing end-of-life care. “It may take 15 minutes to just go through the medication list with a patient,” Timothy Farrell, MD, a geriatrician at the University of Utah medical school, tells The New York Times. “To me, geriatrics is very intellectually fulfilling, but for some people, it can be overwhelming.”
Aspiring physicians shy away from the specialty for numerous reasons: Elderly patients don’t always understand or follow a doctor’s recommendations, they require more of a practitioner’s valuable time, and treatment protocols often fail to produce much success.
Plus, the pay isn’t commensurate with the clinical challenges. Despite requiring an extra academic year of training, geriatricians typically earn nearly $100,000 less per year than the average physician. That’s because most of their patients are covered by Medicare, which reimburses providers at a much lower rate than does private insurance.
For all these reasons, the ranks of geriatricians are likely to continue dwindling for the foreseeable future. As Pamela Paul reports in The Times, there were 411 geriatric fellowships offered in 2022 and only 177 applications. None of the other 70 medical specialties offering fellowships that year reported such a low interest. The lack of enthusiasm has convinced some healthcare experts that geriatric principles will gradually morph from a clinical tool to a research and advisory role in the years to come.
Don’t tell that to Stephanie Johnson, NP. A Seattle-based nurse practitioner, Johnson is part of a fast-growing army of nurses specializing in geriatrics that has helped to offset the decline of geriatricians in recent years. Between 2010 and 2020, the number of these practitioners increased by 125 percent. A 2024 survey found that about 15 percent of the 431,000 registered nurse practitioners in the United States, or almost 65,000, are serving seniors.
“There are so many housebound older adults, and we’re barely reaching them,” Johnson tells KFF Health News. “For those still in their private homes, there’s such a huge need.”
Johnson and her husband run a private practice in Washington, one of the 27 states that allows nurses to operate independently from doctors. The six nurse practitioners at Pathway Geriatrics each visit about 10 patients a day, spending up to an hour with each. They’ll typically check in with each of them every five to six weeks.
These nurses aren’t usurping the role of doctors, notes University of California, San Francisco, nursing professor Laura Wagner, PhD, RN. They’re simply responding to the glaring absence of geriatricians. “One of the things I’m most proud of is the role of nurse practitioners,” she says. “We step into places where other providers may not, and geriatrics is a prime example of that.”
They do so, however, against the wishes of the American Medical Association (AMA). The influential physician-led organization lobbied fiercely last year against proposed legislation in dozens of states that would allow nurse practitioners and other providers to expand their roles independent of physician supervision. “It effectively — as we view it — removes physicians from the care team,” argues AMA attorney Kimberly Horvath.
And yet there’s some evidence suggesting that may not be much of a problem. Various studies over the years have shown that a physician-free healthcare approach can often lead to better patient outcomes, and this is especially true for patients coping with multiple chronic conditions (MCC), according to a 2023 analysis of 15 studies published in the journal Medical Care Research and Review.
“Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement,” the authors concluded. “No studies found them associated with worse outcomes.”
That may be due to the particular qualities nurses bring to the healthcare process, explains Elizabeth White, PhD, an assistant professor of health services policy and practice at Brown University. Simply put, they look at the big picture. “We tend to be a little stronger in care coordination, family and patient education, and integrating care and social and medical needs,” she says. “That’s very much in the nursing domain.”
And, despite the pressing need for more geriatric-care options, it’s a domain that too many doctors would like to see shrink rather than expand.
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