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Academic physician executive William Wertheim discusses his article, “America, our health care workforce training isn’t evolving alongside our needs.” He argues that the U.S. medical system is training professionals who will not meet the needs of the country’s rapidly aging population. With the number of Americans over 65 expected to reach 82 million by 2050, specialties like geriatrics are in decline, with only 42 percent of fellowship positions filled in 2023. William explains that this problem extends to projected shortages in primary care, oncology, and other specialties, which is especially acute in rural areas where “distance decay” limits access to care. He identifies a critical bottleneck in the training pipeline: while medical school enrollment is high, a lack of corresponding residency positions prevents qualified doctors from entering the workforce. While tools like AI and telehealth can help, they cannot replace the need for a comprehensive strategy to expand training capacity and align medical education with the demographic realities of today and tomorrow.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome William Wertheim. He is the executive vice president at Stony Brook Medicine. Today’s KevinMD article is “America, our health care workforce training isn’t evolving alongside our needs.” William, welcome to the show.

William Wertheim: Thank you for having me.

Kevin Pho: All right, so just briefly share your story and tell us about the KevinMD article.

William Wertheim: Sure. Well, I am a general internal medicine physician. I have been practicing at Stony Brook since 1996. I finished my training about two years before that, and I spent a lot of time as an educator for internal medicine residents and then all of graduate medical education. Then I had the good fortune to be able to be in charge of our health system, so here I am. The article really comes from both looking at what our needs are as a health system as well as looking at my own practice over the last 30 years.

When I started out doing primary care internal medicine, most of my patients were a variety of early- to middle-aged and middle-aged to older patients, and now it’s almost exclusively elderly patients, including people in their nineties and hundreds. It’s reflective, I think, of where the population is going. In our county, Suffolk County, New York, which has 1.5 million people in it, it’s estimated that by 2035, about a quarter of that population will be over the age of 65. Those are people who have a lot more and different health care needs that we don’t necessarily accommodate as well as we should in our health system.

Kevin Pho: All right. And what are some of the core reasons why that’s happening?

William Wertheim: Sure. Well, for one thing, there are fewer people who are interested in geriatric-focused specialties. Geriatric medicine itself is very undersubscribed. Many programs, I think the majority of programs, go unfilled in the match each year, even though they’re very robust and they’re very widespread.

In addition, many of the fields that also are required to take care of older patients, for example, nephrology, again, these are fields that don’t get as much interest from students or residents as other fields, which perhaps are viewed as being more exciting. Yet at the same time, these are very complex patients who require a lot of different kinds of care and a lot of different kinds of physicians and also require more in the way of coordination because they do have more medical problems.

Kevin Pho: For those who aren’t familiar with the path of being a geriatrician, just outline how many years it takes and what are some typical pathways one takes to become a geriatrician.

William Wertheim: Sure, the most common way is to do an internal medicine or a family medicine residency, which is three years, and then a one-year geriatric fellowship. A number of programs have extended the geriatric fellowship to two years and combine it with something like they spend half their time being a hospitalist so they can really earn more money than one might as a fellow, but it’s not a very lengthy training, especially when you compare it to things like neurosurgery or interventional cardiology, that kind of thing. So it’s certainly a shorter pathway. I think there are other things that make it less appealing to most graduating medical students.

Kevin Pho: And when you say in recent years these geriatric fellowships are going unfilled, can you estimate what percentage are being filled?

William Wertheim: Less than 50 percent.

Kevin Pho: And from your perspective as a medical educator, what are some of the core reasons why you feel that a lot of these students aren’t pursuing fellowships in geriatrics?

William Wertheim: Well, one factor is the appeal of technology is often found in a lot of surgical or interventional fields, and I get it. It’s very exciting to be able to use a cool new tool to do surgery or something like that. There really isn’t a lot of that in geriatrics. There’s new information, but we don’t have a lot of tools that are fun and fancy and require specialized training in the use of that tool, so that’s one thing.

Another thing is that it is easier to think about focusing on something very narrow than focusing on the widest array of things when one thinks about the enormity of what one has to do as a physician. There’s a lot of that in geriatrics. It’s a lot of talking to family members, counseling people, and having very difficult conversations. You have to tell people, “Maybe it’s time to not drive a car anymore. Maybe it’s time to not live independently anymore.” While those are necessary conversations, they’re not always the most appealing or most comfortable things for clinicians.

Even with training, it may be more satisfying, or people might think it’s more satisfying, to simply do a procedure, walk in, walk out, and not worry about the rest.

Kevin Pho: Sometimes when we talk about these issues like primary care shortages and geriatrician shortages, I find it’s often because a lot of medical students don’t have great role models in these fields. Then, sometimes when they rotate through, they just see the enormous amounts of bureaucracy and obstacles, so it’s not always the best foot forward. At a place like Stony Brook Medicine or other medical schools, what are some typical exposures that students get to geriatrics?

William Wertheim: Yes, I think you’re absolutely right, and I know you address this in a recent podcast. Our medical students all do a primary care rotation where they are getting an ambulatory experience with primary care doctors in their offices. Some of them are family medicine, some of them are internal medicine, some of them are geriatric-focused, and especially for the internal medicine doctors, those patients tend to skew older. So that’s one way they get some other training in geriatrics as well.

This is through both clinical experience and in their medicine and contemporary society course, which is more of a discussion format to deal with some ethical issues that people are likely to face or understanding cultural issues, et cetera. They do talk about things that are relevant to older patients as well. But you’re right, there aren’t a lot of role models. There are some; we have a primary care training program in internal medicine, we have a family medicine program, and we have a geriatrics fellowship. But that said, it’s not the preponderance of the experience.

Kevin Pho: So what are some paths forward? From your perspective as a medical educator, what can medical schools and residencies do? Then, broadening the scope, what are some policy options that we can consider to tackle this issue?

William Wertheim: Well, I think making sure that when students get experience and exposure to geriatrics, it is a robust experience and that the experience focuses on some of the particular rewards of taking care of older patients. A second thing is making sure that people training in specialties which relate to older patients more frequently also get more training in geriatrics. For example, a lot of orthopedic surgeons deal with older patients. Those are likely to be the ones who need joint replacements or have hip fractures when they fall. It would be helpful and provide a better experience if specialties like that, or cardiology or nephrology, could have more appreciation and understanding of some of these issues.

A lot of it relates to the care plan: what are patients really interested in from their lives? It’s one thing to say, “Well, you have heart failure,” but it’s another thing to know that they want to be able to walk three blocks to their grandchildren’s house. If you can get them to understand that, then I think it changes the dynamic. I think that would also provide a better experience.

In terms of policy, I think that it would be great if the fields of primary care and geriatrics were more highly valued. A lot of that relates to how we reimburse our clinicians and people who provide other kinds of care for those populations. I’m not saying it should be at the expense of something else, but I think we could do a lot of good and probably overall bring health care costs down if we could make clear that we’re valuing and promoting more primary care, preventive care, and the kind of care for older patients that make small changes that have large effects over time.

Kevin Pho: When you talk about a robust geriatrics experience for the students, tell us more about what exactly that entails, some of the rewards that the field of geriatrics provides, and perhaps a type of student that experience may appeal to.

William Wertheim: Well, I think even though we’ve made a lot of strides in changing the experience of medical students—we, for example, like many schools, have this primary care experience, which is ambulatory—a lot of the learning, particularly in an internal medicine clerkship, still occurs in an inpatient setting, and that’s about the worst place for an older patient, as you know. I think more of the experience in learning about the value and the enjoyment of geriatrics could be done in an outpatient setting.

I also think although skilled nursing facilities play a very important role, that’s also probably the wrong place to be because more of those patients have cognitive dysfunction. You’re dealing with people who may be bedbound, and in some cases, there aren’t other family members around. I think as much as we can get the experience of students in an environment where people are in their homes or in an outpatient setting where they are able to go back and forth, those are really beneficial.

Another thing that I would say is, as much as I love some of the technology which has allowed us to expand our reach, really in many cases driven by COVID, such as telehealth, we need to recognize where that fails, particularly for older people who may have trouble using technology which to the rest of us is simple. I remember talking about using Uber with somebody who is in their mid-nineties, and it probably took this fellow about half an hour to figure out how to call an Uber. To us, that would be two or three seconds. It’s very difficult, I think, and we have to recognize that we cannot necessarily replace some of the care that we might for a younger patient with technology. You have to be careful.

Kevin Pho: And just to your last point, especially during the pandemic with these virtual visits, assuming that all our patients have access to the internet and can navigate what we think is simple technology like a Zoom call or a virtual visit can be very challenging for the older population.

William Wertheim: Absolutely.

Kevin Pho: You mentioned geriatrics needing to be more valued. From your perspective, for students who are choosing fields, how much does that reimbursement factor play into their decisions? Knowing that a lot of these students have medical loans to pay off, is it something that is an explicit choice, is it something that they talk about, or how much do you feel that those financial pressures that students already have factor into the eventual career decision that they choose to make?

William Wertheim: I think it is definitely a factor. It’s not the only factor, and I would never say that it is, but I think that it is often unspoken. I actually remember there was a classmate of mine in medical school who sat down in a lecture hall one day and said, ‘I really would love to be a pediatrician, but I’ve got to make more money than that.’ So he went into GI, and I’m sure that—I hope that he is—I know that he’s still in GI, so he must be enjoying himself, and it’s a great field. But I always think of it from this perspective: every field that we have available to us in medicine does good for people. So if you have the choice of being of value and doing good things for people, helping them, and curing them, and in one field you can make five times as much as another field and you’re on the fence about which to do, it’s hard not to choose the field where you would be making a lot more money.

On top of that, life has gotten a lot more expensive. I think people in their twenties and thirties have a lot of difficulty thinking about buying a house or starting a family because those things are much more expensive than they were when I was in my twenties and thirties. So I understand it. I’m not being critical at all. Again, it’s not the only thing that plays into it. I think the appeal of some of the amazing technology that we have available to us, the sense that you have a discreet task that you can take care of, know that you’re done, and move on to the next thing, is also very appealing to a lot of people.

Geriatrics and primary care can be a little messy because you keep having these relationships with people and they keep coming back. I think it’s wonderful. I’ve enjoyed it tremendously in my career, but some people don’t necessarily enjoy that as much, and it’s not as supported. When I say valued, it’s not simply a matter of money. But you mentioned this: the burden of paperwork and bureaucracy, the number of times you have to contact insurance companies to get things authorized, or balancing the information that you’re getting from multiple different sources—these are all pretty challenging.

Kevin Pho: In your article, you also talk about the need in rural areas for physicians and primary care physicians, and sometimes our training programs aren’t really addressing that need.

William Wertheim: Yes, absolutely. I think it’s understandable why physicians would want to avoid rural areas if they want to have families. Although the cost of living may be less, it may be harder to find schools of the quality that they had growing up for their own children. They may be far from family, et cetera. But there are people there that need care, and although I’m not an expert in rural health, certainly there are challenges that people in rural areas face in terms of access: having to be able to get transportation, to get medications, or to get appointments. I think those are all real problems, and it’s hard to just sweep that under the rug.

We are not considered a rural area by the federal government, but we have some pretty rural and remote areas in Suffolk County, particularly in the North and South Fork at the very east end of Suffolk County. The community on the east end of the South Fork was desperate for years for access to emergency care. In the summertime, particularly when there’s more summer traffic, it could take two to three hours to get to the nearest emergency room. So we opened up a new, freestanding emergency department on the eastern part of the South Fork, and that’s been a very great advance for them. But it takes a lot of effort, time, and money, and many rural areas can’t afford that kind of investment.

So I think we have to be creative. Certainly, technology can help, such as telehealth, but I think we have to think about what other models might there be. I don’t have the answers, but I think it’s a very important problem.

Kevin Pho: So you have a unique perspective being on the executive staff of a major academic medical center. How difficult is it for academic medical centers, which, of course, provide the majority of residency positions in our country, to make the necessary changes that we’re talking about?

William Wertheim: Well, it is difficult because we can’t do it in isolation. There’s a degree to which we can change our curriculum, but if I expanded our geriatrics fellowship or our primary care training programs 200 percent, that doesn’t mean I would get any more applicants to our program. There’s just a limited pool of people who are applying. So it cannot simply be one system that is trying to change it, and certainly not change it to mimic what we’ve done so far. I think that’s probably not a successful strategy.

I think this is the kind of thing where we have to pilot a couple of different ideas, and some of it may be having advanced practice providers provide more care or be coordinated with physicians. Some of it may be using telehealth technology. Some of it may be using drones to deliver medications, that kind of thing. Some of it may be changing the curriculum so that more people can provide that kind of care even within their specialty. I don’t know that there’s one easy answer. I think we have to treat this like a performance improvement project.

Kevin Pho: We’re talking to William Wertheim. He is the executive vice president at Stony Brook Medicine. Today’s KevinMD article is “America, our health care workforce training isn’t evolving alongside our needs.” William, let’s end with some take-home messages you want to leave with the KevinMD audience.

William Wertheim: Sure, my pleasure. I think that we really have to think broadly and not simply assume that what worked for us 20 or 30 years ago is going to continue to work. I think we also need to remember that at the heart of what we do, there is a person, a human being who is looking for advice and looking for care. I do think that sometimes gets lost, especially now when there’s a lot more distrust of the medical system.

Having that kind of long-term relationship, I think, is the best counter to that kind of mistrust. I find when I’m talking to my patients that I’ve been caring for for 25 or 30 years, I can have the conversations about what they’re really afraid of, what they like or don’t like, or what they might accept or not accept. Other people can’t really have that conversation, so I encourage people to remember that. Despite the fact that we may need to make some changes, the core of that doctor-patient relationship continues to be the essence of what we do.

Kevin Pho: William, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

William Wertheim: Thanks for having me, and I hope you have a great day.