Stephen C. Shannon, DO, MPH
Confronting the Challenge of a Graying America
Have you thought about how the patients that are seen by osteopathic medical students and residents will differ in the future from those being seen today? We know that there will be differences. The general population will be older, more diverse, and (unless current behavioral trends are altered) more widely experiencing a host of chronic diseases such as diabetes, hypertension and heart disease.
The baby boomer demographic bulge that has driven many aspects of our culture, politics and economy is set to dominate much of our health care system in the coming decades. The United States will experience significant growth in its older population over a short time. Consider these statistics (from U.S. Census, The Next Four Decades, The Older Population in the United States: 2010 to 2050, May 2010)
- By 2030, the number of U.S. citizens age 65 or older will more than double (with the addition of around 37 million seniors), while the number of individuals under 65 will grow by less than 10 percent. Nearly 20 percent of the U.S. population will be seniors (compared to 13 percent today).
- The population of those age 85 or older will rise by over 50 percent (to nearly 9 million seniors—2.3 percent of the population). By 2050, that cohort will reach 19 million (4.2 percent of the population), 1.1 million of whom will be age 100 or older.
- The ethnic diversity of the entire population also is projected to increase; sometime in the 2040s, the U.S. population will no longer be majority white. Amongst seniors, by 2050, the percent of non-white Americans age 65 or older will more than double, to 42 percent (from 20 percent today). Amongst those 85 or older, the percent of non-white seniors likewise will rise, to 33 percent (from 15 percent today).
- The fastest-growing ethnic senior population in coming decades will be Hispanic. The percent of Hispanic seniors age 65 or older (currently 7.1 percent), will nearly double by 2030 (to 12 percent) and nearly triple by 2050 (to 20 percent). Amongst those 85 or older, similar growth will be experienced (5.3 percent today, to 10 percent in 2040 and 15 percent in 2050).
Projections for 2010 through 2050 are from: Table 12. Projections of the Population by Age and Sex for the United States: 2010 to 2050 (NP2008-T12), Population Division, U.S. Census Bureau; Release Date: August 14, 2008
The source of the data for 1900 to 2000 is Table 5. Population by Age and Sex for the United States: 1900 to 2000, Part A. Number, Hobbs, Frank and Nicole Stoops, U.S. Census Bureau, Census 2000 Special Reports, Series CENSR-4, Demographic Trends in the 20th Century.
This table was compiled by the U.S. Administration on Aging using the Census data noted.
The mere fact of growth in our older population will mean that chronic disease will place a greater burden on our health care system. Currently, 80 percent of those ages 65-79 suffer from at least one chronic disease, and 45 percent suffer from three or more. The frequency of physician visits has risen, and rises with age; currently, those over age 74 visit a physician twice as often as those ages 45-64, with most visits being ambulatory visits to family physicians or general internists (about one-third to family physicians, one-third to general internists and the remainder to geriatric physicians, nurse practitioners, or physician assistants). In 2005, individuals over age 74 in the United States visited their physicians an average of eight times per year (up from five times per year in 1990).
With current trends and workforce patterns, we should expect to see this picture worsen. For one thing, the current chronic disease epidemic can be expected to further exacerbate the need for care. The obesity epidemic that is impacting the entire U.S. population will further complicate the health care of our aging population. At the same time, there are just 7,100 geriatricians currently in practice, and their numbers are declining. The number of U.S. medical students pursuing careers in geriatric medicine also is declining, and this trend is evident among both DOs and MDs.
Primary care physicians provide older Americans with most of their health care. A number of studies led the American Association of Retired Persons (AARP) to conclude that people over age 65 who receive medical care from a primary care physician are more likely to live longer and stay healthier than those who do not. But it is clear that there will be growing challenges to maintaining the current system for this population. Fewer physicians than needed are pursuing primary care training and with current trends, we expect to have a deficit of 30,000 to 45,000 primary care physicians by 2025. The Affordable Care Act’s 2014 expansion of health insurance to cover around 40 million currently uninsured Americans will further complicate this picture.
I draw several conclusions from these trends:
- Prevention of disease and the maintenance of optimum health must be a priority for physicians, the health care system and local, state and national policy makers.
- The diversity of the health care workforce must improve to better reflect the changing population, and the cultural competency of physicians and all health care workers should be a priority in training.
- Practice patterns will change, and it is time to proactively plan for those changes by recognizing the need to prepare physicians and other health care professionals with interprofessional education for team-based practice that can help meet the needs of our changing population.
- All physicians and other health care professionals need more extensive training and experience with the geriatric population and with active complex chronic disease management. Given current trends, training focused on the diseases associated with obesity (such as diabetes prevention and management) should be a priority.
- Unless we institute the health system and medical education changes needed to deal with a burgeoning older population, we will be unable to provide the care needed for the patients most in need of that care.
Osteopathic medicine has an important role to play in ensuring that our nation’s aging population receives the high-quality health care it needs, in spite of the alarming trends noted above. With our traditional training and practice focus on prevention and optimizing health in community-based primary care settings, we should be able not only to contribute to the solutions needed, but to provide leadership in that regard.
Colleges of osteopathic medicine are undertaking a number of curricular initiatives that will better provide their students with the attitudes and tools needed to care for older Americans. Several years ago, leading geriatricians at our schools published “Geriatrics Curricula for Undergraduate Medical Education in Osteopathic Medicine,” proposing minimum standards for geriatric curricula in osteopathic medical schools. These guidelines are widely used as a curriculum benchmark.
In addition, a number of osteopathic medical schools have undertaken significant efforts to integrate geriatrics throughout their curriculum. Note, for example, the programs at the following two schools (both recent recipients of the prestigious Donald W. Reynolds Foundation grants for Comprehensive Programs to Strengthen the Training in Geriatrics of Medical Students, Residents and/or Practicing PhysiciansFrom the President):
The University of North Texas Health Science Center/Texas College of Osteopathic Medicine UNTHSC/TCOM received a four-year grant totaling approximately $2 million to develop and implement an innovative and sustainable program to strengthen physicians’ training in geriatrics. With this funding, the school developed the UNTHSC Reynolds Geriatric Education and Training in Texas Program, with the objectives of integrating geriatrics training throughout all four years of the medical school curriculum and throughout osteopathic residency training; establishing a geriatrics faculty development program for osteopathic residency training; and developing geriatrics medical education programs for practicing physicians.
The University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine (UMDNJ-SOM) also received a similarly sized Reynolds grant for its project, Geriatric Infusion: Preparing Physicians of the 21st Century to Care for Our Elderly, and more recently received three Health Resources and Services Administration (HRSA) grants that will send nearly $6 million dollars to the school over the next five years to support training programs for health professionals who provide care for older Americans. The new funds will be used to develop two-year fellowship training programs to prepare physicians, dentists and psychiatrists to become academic and clinical faculty in geriatrics; a geriatrics education center that will provide specialized training programs in delirium and mental health issues involving the elderly at two acute care hospitals and at regional training sessions throughout the state; and the purchase of video-conferencing equipment to support distance learning opportunities for health care professionals in multiple disciplines.
And these are just a couple of examples of myriad geriatrics-related efforts at the nation’s colleges of osteopathic medicine.
But the fact is that a variety of factors conspire against beefing up the numbers of physicians being trained to care for older adults. For one, geriatric and primary care specialists earn less than most other specialists. As the cost of medical education rises and new physicians are confronted with higher debt burdens, the interest in lower-paying specialties is diminishing. We must find ways of correcting this.
Of course, the work to be done in this important area is not osteopathic medical education’s alone. A variety of national organizations are devoting efforts to meeting one of the greatest challenges U.S. medicine has ever confronted—to provide relevant, high-quality health care to a burgeoning elderly population. I hope you will join in these efforts, and below I list some of the resources available.
Retooling for an Aging America: Building the Health Care Workforce
National Institute on Aging
Commentary: Aging America: Meeting the Needs of Older Americans and the Crisis in Geriatrics
POGOe (Portal of Geriatric Online Education)
Centers for Medicare and Medicaid Services
American Geriatrics Society
 U.S. Obesity Trends
 Aging America: Meeting the Needs of Older Americans and the Crisis in Geriatrics. Academic Medicine. 2009; 84 (5):539-686.
 Starfield B., Shi L., Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Quarterly. 2005; 83(3):457-502.
 Colwill, JM, Cultice JM,and Kruse, RL. Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Population? Health Affairs. 2008; 27(3):232-241.
 I have provided consultation to this foundation regarding osteopathic medical education since 2008. For further information, click here