Our health care system faces a disturbing paradox. While seniors represent the fastest growing age group in Canada, the country faces a growing deficiency of specialist physicians with expertise in caring for the elderly. But with seniors accounting for nearly half of all the country’s hospitalizations and visiting their family physician twice as often as younger patients, almost all health care professionals will require competency in care of the older adult.
This two part series will explore Canada’s shortage of health care professionals with specialization and competency in caring for Canada’s seniors. Part 1 will focus on physicians, while Part 2, published September 5 focuses on the other health care professionals, read Caring for Canada’s seniors will take our entire health care workforce here.
Canada is rapidly graying
The 2011 census reported that almost 15% of Canadians were 65 years or older, and this population is expected to double by 2036, while the number of those over 80 is expected to quadruple by 2051. With the first of the baby boomers turning 65 in 2011, for the first time in Canadian history the number of seniors will surpass the number of children by 2021. But perhaps the most compelling evidence that Canada is graying is that after the baby boomers, centenarians (those 100 years or older) are the fastest growing age group in Canada.
Despite representing only 15% of the Canadian population, seniors are disproportionately high consumers of the health care system. Seniors account for 40% of acute hospital stays, and visit their family physician twice as often as non-senior adults. Although population aging has only contributed to approximately 1% of the increases in health spending per year, seniors are still responsible for 50% of provincial and territorial health care spending.
In reality, the majority of seniors age successfully with the help of their families, social networks, and primary care providers. However, a number are especially frail and suffer from complex medical and psychosocial problems rendering them one of the most vulnerable patient populations in society. These individuals frequently require specialized physician services to help them maintain independence in the community and avoid adverse health trajectories including long-term care placement.
A major shortage of specialist providers
In Canada, specialized physician care for older adults is provided by geriatricians (internists with subspecialty training in caring for the elderly) and by family physicians with specialist certification in Care of the Elderly. In 2012, there were 242 geriatricians, 128 family physicians with Care of the Elderly certification and 34 additional physicians with other training practicing consultative geriatric medicine. All in all, there are approximately 325 full-time equivalent physicians working in the field of geriatric medicine in Canada.
Currently there are 129 active Ontario physicians holding subspecialty training in geriatric medicine serving a population of 2.0 million seniors. This yields a ratio of 0.65 geriatricians per 10,000 older Ontarians. By contrast there are 1641 pediatricians serving a population of 2.2 million children, yielding a ratio of 7.5 pediatricians per 10,000 Ontario children. This discrepancy is more alarming considering that by 2016 Ontario seniors will outnumber Ontario children.
Dr. Roger Wong, Clinical Professor in the Division of Geriatric Medicine at the University of British Columbia and past president of the Canadian Geriatrics Society says these physician shortages have “wide implications.” He is also the Associate Dean of Postgraduate Medical Education at the University of British Columbia.
“Our population in Canada is aging and when you look at the number of seniors in the country who will require specialty services, services that are provided by those in geriatric medicine, family medicine care of the elderly and geriatric psychiatry, these numbers are increasing.”
Wong also notes that Canada’s shortage of geriatricians risks putting seniors at risk of functional decline. “We are not just talking about looking after those seniors who are frail, but also those active seniors, who want to stay active.”
An unpopular career choice
The rapidly aging population and massive shortage of physicians with expertise in caring for older adults would make geriatric medicine an obvious career choice for junior trainees looking for jobs. After all, a 2012 national resident survey revealed that 1 in 5 residents were still looking to secure employment after residency training, and 1 in 4 were not confident about their job prospects. Furthermore, in the two largest surveys on physician career satisfaction, geriatric medicine ranked first and second in satisfaction amongst all medical specialties and subspecialties.
But, Roger Wong notes that the “net result has not come up the way that we hypothesized it would.”
In Canada, internal medicine residents in their third and final year of training are required to apply to the Canadian Resident Matching Services (CaRMS) Medicine Subspecialty Match. Residents can choose from 15 potential subspecialties ranging from cardiology to medical oncology to geriatric medicine.
During the last four annual Medicine Subspecialty Matches 1533 residents have successfully matched to Canadian fellowship programs, with only 58 (3.8%) residents selecting geriatric medicine. For years, some geriatric medicine fellowship positions have gone unmatched across the country, with no resident entering a fellowship program in Alberta from 2010 to 2012.
There is hope, however, that the tide may be turning. In the 2013 Medicine Subspecialty Match, the quota for geriatric medicine was nearly filled with 26 residents matching to geriatric medicine training programs.
But Roger Wong still questions whether “this a blip or a new trend.” He adds, “I would hope that this is a new trend.”
Teaching everyone to care for older adults
Even with marked increases in recruitment into the field, geriatric medicine is unlikely to ever reach a critical mass capable of providing the bulk of clinical care for Canada’s seniors.
“We’ll never have enough geriatricians to provide clinical care to every senior,” concedes Dr. Jayna Holroyd-Leduc a geriatrician and Associate Professor of Medicine and Community Health Sciences at the University of Calgary. Holroyd-Leduc is also the Scientific Director of the Seniors’ Health Strategic Clinical Network for Alberta Health Services.
“Part of our role is to provide clinical services for the frail elderly,” she notes. “We also have a role in educating other physicians about aging and care of the elderly.”
Holroy-Leduc emphasizes that all physicians need to have competency in caring for the older adult. “Every physician except for paediatricians looks after people over 65. We need to ensure that these physicians are equipped to provide appropriate care for these patients.”
And this process will need to start in our medical schools.
“Every medical school should have geriatrics in the curriculum,” says Holroyd-Leduc. “All medical schools have mandatory paediatric rotations; well more physicians are going to be taking care of older adults then children.”
But despite this sentiment, the most recent published data on the geriatrics content of Canadian medical training reported that only 7 of 16 Canadian medical schools had a mandatory clinical rotation in geriatric medicine.
There are signs, however, that things are moving in the right direction. The Health Canada-funded Future of Medical Education in Canada Postgraduate (FMEC PG) project was released in March 2012 and produced 10 recommendations to prepare the Canadian postgraduate medical education system for the century ahead. The first recommendation was to “Ensure the Right Mix, Distribution, and Number of Physicians to Meet Societal Needs.”
“I think geriatrics is well positioned,” says Dr. Roger Wong about the FMEC PG project. “It is our social responsibility and accountability for postgraduate medical education in Canada to respond to the aging imperative.”
Emerging models of care
In addition to serving as educators for other physicians, Dr. Jayna Holroyd-Leduc advocates that geriatricians will also need to play an expanded role in the health care system.
“We also have a role in aging research, informing policy and in making the system more elder friendly, “ she notes.
In particular, Holroyd-Leduc argues that geriatricians must help develop and lead innovative models of care that maximize the utility of Canada’s small number of specialist physicians with expertise in caring for the elderly.
This sentiment has not been lost on provincial policy makers grappling with the demographic imperatives imposed by an aging population.
The Ontario Ministry of Health and Long-Term Care’s 2011 report entitled Caring for Our Aging Population and Addressing Alternate Level of Care (ALC) stressed the need for primary care reform to make care for the elderly a priority.
In particular, the report called for the development of a Geriatric Assessment Clinic model that works with and supports family physicians, while taking into consideration existing primary care models.
This model of care is operating in the Champlain and North East Local Health Integration Networks, where nurses or other health care professionals are trained to perform comprehensive assessments on patients prior to being seen by a geriatrician. This process allows the assessor and the geriatrician to review many more patients in one session.
A similarly successful model is the Primary Care Memory Clinics that emerged out of the Waterloo Wellington Local Health Integration Network. These clinics are led by family physicians who have undergone an accredited standardized training program developed in collaboration with the Ontario College of Family Physicians allowing them to develop greater skills and confidence in managing routine cases of dementia and mild cognitive impairment. These clinics have maximized the efficiency of the limited available geriatricians, by involving them earlier with the more challenging cases. There are presently 31 such Primary Care Memory Clinics servicing approximately 450 primary care practices across 6 Local Health Integration Networks.
Earlier this year the Ontario Ministry of Health and Long-Term Care released a report entitled Living Longer, Living Well: Recommendations to Inform a Seniors Strategy for Ontario. The comprehensive report features 166 recommendations focused on improving care for older Ontarians ranging from strengthening primary care to improving acute care for elders.
The Seniors Strategy was led by Dr. Samir Sinha, the Director of Geriatrics at Mount Sinai and the University Health Network Hospitals in Toronto, Ontario.
“The Ontario Seniors Strategy represents the first comprehensive provincial approach in Canada to developing a framework and plan for meeting the needs of an aging population which is set to double in size over the next 20 years,” says Sinha.
And Ontario’s deficiency of specialist physicians with expertise in caring for the elderly was not lost on Sinha.
“It’s a vastly important aspect when we think about the future health and social care needs of an aging population,” he remarks.
The report explicitly acknowledges that a necessary enabler to supporting Ontario’s Seniors Strategy is the strengthening of human health resources that can specifically meet the needs of an aging province. Accordingly, the report includes several recommendations related to bolstering the geriatric content in medical school curricula, and supporting innovative models of care that maximize the efficiency of limited available geriatrician resources.
These recommendations include the establishment of an educational accreditation standard for training in geriatrics for all Ontario medical schools, and the development of a list of core competencies in the care of older adults for all Ontario postgraduate training programs.
Additionally, the report calls for the establishment of a provincial working group of specialist physicians and health care professionals with expertise in caring for the elderly to help develop a common provincial vision for the delivery of geriatric services. This working group could help develop a province-wide network of Geriatric Assessment Clinics to build on the successful models of care operating in the Champlain/North East and Wellington Waterloo Local Health Integration Networks.
“These are just two examples of innovative ways we can leverage the expertise of geriatricians for the patients with the most complex health issues, while at the same time building capacity amongst a range of health care providers to help deliver more proactive and responsive approaches to care,” says Sinha. “More should be done to foster innovative models that build capacity like these ones do.”
Reassuringly, Sinha is hopeful that the government will act on his strategy, particularly when it comes to his recommendations related to health human resources.
“The real key policy the government is currently looking to move forward with is how do we ensure all health and social care professional schools have access to good quality training in the care of the older adult,” says Sinha.
While there is no guarantee this will happen, addressing Ontario and Canada’s shortage of specialist physicians with expertise in caring for the elderly must be a priority.
Otherwise we may all be left wondering who will care for mom and dad.