As part of its theory of change, the Foundation has made big bets on the specialty of geriatric medicine. (Click here for a nice summary of what geriatricians do.) Unfortunately, we are losing the numbers game. Geriatric medicine is the only specialty in which a physician takes a pay cut in return for additional advanced training. Why? Because almost all older adults are covered by Medicare, and Medicare pays relatively poorly for the core services of geriatric medicine: office-based evaluation and management services (diagnosing, adjusting medicines, referring to specialties, coordinating care, educating patients and family members). Therefore, geriatricians make about 10 percent less than generalists who treat older adults, but not exclusively older adults, and of course much, much less than specialists in the procedural areas such as dermatology, radiology, or gastroenterology.

It gets worse. To provide real geriatric care, the physician needs to work with a team of professionals: social workers, nurses, physical and occupational therapists, nutritionists, and others. Many of these services cannot be billed directly to Medicare and need to be covered out of (already meager) practice revenues. Finally, to add insult to injury,

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while expert geriatricians can provide good care to complex and slow-moving older people faster than one mightthink, they have a very hard time doing it in the unfortunate standard 11-minute primary care visit. So geriatricians have a hard time making up their revenue disadvantages by increasing volume of visits.

This puts geriatrics at a very serious crossroads. While the field can hold out as an academic specialty, it can't compete as a clinical specialty. At a time when physician trainees are graduating from medical school with very large debt burden (not outrageous compared to earning potential, but still daunting at $100,000 to $150,000), very few residents graduating from internal or family medicine programs are choosing geriatrics.

So the dilemma is becoming clearer. At the American Geriatrics Society meeting in April 2009, there was a great deal of discussion about the future direction of geriatrics and even some panic. On the one hand, some speakers argued that geriatrics should be primarily an academic specialty, teaching generalists to provide higher quality care and designing and directing clinical care systems. Other speakers suggested that the direct primary care role was very important to most geriatricians and vital to the field. Lastly, a kind of compromise position is that geriatricians do have a clinical care role, but only as consultant experts for a minority of very frail and ill patients.

Contributing to the crisis is the fact that the field itself-and certainly nobody outside it-doesn't seem to know what it is about. What does its brand mean? If you call for a geriatrician, who are you going to get? A teacher? A system leader? A consultant? Having some experience trying to support interested and smart people take on these challenges, I can say that none of them are easy. Geriatrics needs to get its act together and decide what it wants to be when it grows up.