As advanced practitioners become more prominent in the skilled nursing setting and elsewhere, geriatricians are on the decline, according to a new report from the University of California, San Francisco (UCSF).

But what that means for the geriatrician role isn’t immediately clear.

“Basically, there’s a growing shortage of geriatricians, and they’ve tried many things to try and increase the number of geriatricians, but ultimately the numbers show they’re not effective in doing so,” Aubri Kottek of UCSF told Skilled Nursing News. “If we can’t get more people into the field, what can we do with those of us are there?”

The researchers conducted a review of both peer-reviewed literature and other documents focusing on medical geriatricians. They found the supply of geriatricians has been declining over the past few decades due to several factors, including more stringent training and certification requirements and lower income compared with other specialists.

The next phase of the research will involve examining how different health care entities, ranging from SNFs to accountable care organizations (ACOs), use geriatricians, Kottek said.

Declining numbers

Though the number of geriatric fellowship programs and first-year fellowship positions have grown considerably, the programs are not operating at full capacity, according to the report. In 2017, 44.6% of geriatric fellowship positions were filled, compared with a high of 91.2% in 1998.

As of June 30 of this year, there were approximately 7,393 certified geriatricians in the U.S., according to the American Board of Medical Specialties. The current ratio of certified geriatricians to the patient population is 1:1,940, which is almost three times the optimal ratio, the report said.

Despite the declining numbers of geriatricians, the demand for care among the population they serve is high and growing higher. An increasing number of advanced practitioners and doctors are focusing on nursing home care, a study from the University of Pennsylvania found, which makes the decline in certified geriatricians stand out all the more.

“APRNs [advanced practice registered nurses] are really moving into that field and providing more of that primary care role in geriatrics,” Kottek said. “I think geriatrics themselves are moving up into a consultancy or leadership kind of role, and leaving the on-the-ground work to APRNs.”

Rise of the APRN

One study that analyzed 2012-2013 Medicare claims found most nursing home claims were billed by geriatricians, suggesting nursing home care is a key part of geriatrician practice. But those numbers may not tell the whole story, the UCSF report noted.

“Geriatricians are definitely part of these settings and moving more into this realm, but some of the other data suggests that also true for APRNs,” Kottek said. “So one question that we have moving forward… are geriatricians providing care mostly in these kinds of facilities, are they more in a consultant kind of scheme?”

The report noted that some publications have detailed projections about the geriatric field, with several experts arguing for focusing on teaching geriatric principles to all health professions rather than on growing the numbers of board-certified geriatricians.

Though the report itself constitutes an assessment, its findings give some food for thought for how long-term care (LTC) facilities use the people available to them.

“I think it’s because there are so few geriatricians in number it’s really all about…how to use this really specialized part of the workforce to leverage their skills in the best way possible,” Kottek said.

Written by Maggie Flynn