Preparing for the Needs of Our Aging Population
Laura Weiss Roberts
Abstract
More people throughout the world are living into older age. Life expectancy globally has more than doubled since 1900, from less than 33 years then to more than 71 years in 2020.1 Older people also constitute an increasing proportion of the world’s population. In 1980, of the world’s 4.4 billion people, fewer than 6% were 65 years of age and older.2 In 2020, out of 7.8 billion people, the number of individuals 65 years and older increased to over 9%.2 By 2100, it is estimated that nearly one quarter (2.49 billion) of the world’s projected 10.35 billion people will be 65 years and older.2 Narrowing the lens to smaller geographies reveals that most, although not all, regions are experiencing an increase in median age.3 Births and birth rates have become considerably lower in Europe, North America, and South America,4 effectively raising the median age in these locations to be higher than in other areas in the rest of the world. Regions adversely affected by natural disasters, climate change, economic forces, or violence may experience changes in the proportion of individuals 15–64 years of age, with varying effects on median age.5,6 Communities with greater immigration may trend toward lower median ages as population numbers and rates of growth accelerate.7,8 Many rural areas globally, on the other hand, have more children and elders than working age adults.9 In the United States, this pattern results in a higher median age for rural residents than urban residents (43 years versus 36 years).10 In medicine overall, too, we have an aging and older physician workforce. According to recent data,11 for instance, nearly half of all active physicians in the United States in 2021 are over the age of 55. Medical specialties with the oldest average age workforces include pulmonary medicine, pathology, and preventive medicine, with 92%, 71%, and 68% over age 55, respectively.11 With particular relevance for academic medicine, the population of physician-scientists in the United States also faces an aging-related shortage.12 Between 2002 and 2013, the proportion of the physician-scientists in the workforce aged 61 years or older rose while the total number of physician-scientists in the workforce declined.12 Living into old age should be understood as a remarkable and positive development for humanity. The aging of the world’s population reflects both the great success of efforts to address poverty and also specific public health initiatives, such as the prevention of deaths in infancy and early childhood. The increase in life expectancy also demonstrates the effectiveness of treatments for health conditions that cause premature mortality across the life spectrum. Improvements in life expectancy, moreover, have been attained throughout the world, with the greatest gains in countries that historically have been most affected by resource limitations and health disparities.1 Other causes for celebration are the findings of studies of elders that demonstrate that aging, for most people, is accompanied by greater capacity for joy, emotional regulation, perspective, spirituality, empathy, and compassion.13,14 Elders also play important roles in society as teachers, mentors, respected community members, and bearers of wisdom, as has been explored across many cultures.15–17 Despite these positives, the aging of the general population and of the health professions workforce brings critical challenges for the field of academic medicine. One such challenge is a lack of attention to the topic of geriatric medicine in the undergraduate curriculum in most medical schools in the United States. A recent systematic review of the websites of 191 MD-granting and DO-granting schools in the United States18 found that only 45% of these schools included clinical activities related to geriatric medicine as part of their required curricula. The amount of attention in graduate medical education given to the care of older individuals depends certainly on the particular medical specialty, but the topic has been identified as a gap for resident and fellow training.19,20 And, interestingly, in an older study21 focusing on graduate medical education, only two-thirds of residents from diverse fields of medicine felt that the elderly would constitute a significant proportion of their patients. In this issue of Academic Medicine, Yogaparan et al22 advocate for greater attention in the undergraduate medical curriculum to the topic of health care for older adults. The authors report on their modified Delphi study to derive revised medical student competencies. The resulting 33 competencies are grouped into 7 categories: Aging; Caring for Older Adults; Mind; Mobility and Functions; Medications; Multicomplexity; and the psychosocial domain Matters the Most. Individual competencies within these categories were wide-ranging, including, for example, understanding the impact of social determinants of health on aging, the role of social isolation and loneliness in elder health, principles of prescribing to reduce risk of polypharmacy, and efforts to lessen hazards for elders in health care settings. In their proposal, the authors task medical students with becoming champions and activists in the care of older individuals. A second key challenge relates to the increasing unmet demand for physician services, with much of this need being driven by an aging patient population. In the United States specifically, by 2034, the expected physician shortage ranges between 37,800 and 124,000, with 42% of the projected demand relating to care of patients aged 65 years and older.23 The anticipated need for specialist expertise is underscored by the decline in geriatric medicine physicians from 10,270 in 2000 to 7,413 in 2022.24 These projections likely underestimate true needs, as many health professionals, including physicians, have retired early or otherwise left clinical work due to concerns regarding well-being, burnout, and the ongoing consequences of the COVID-19 pandemic.23,25 These departures contribute to current and anticipated gaps in the workforce. Ageism is a further challenge facing academic medicine and society at large, and has relevance both for older patients and for older physicians and other health care professionals.26,27 Ageism includes negative self-perceptions among older people about their age and abilities, discriminatory institutional policies and practices that affect older people, and individual biases against older people.28 Importantly, ageism has been found to be linked with worse health outcomes.28 Scholars have commented that “ageism is prejudice against our own future selves,”29 and that new and unexpected issues are arising. For instance, as medical technologies continue to develop, researchers warn health care professionals about potential ageism biases inherent in artificial intelligence and machine learning.30,31 More encouraging are the findings that efforts to address bias directly and to support the autonomy, strengths, and abilities of elders lead to elders’ improved quality of life and well-being.29 Medical schools and academic health systems, moreover, may implement policies and approaches that support highly capable later-career faculty members’ ability to continue to work,32 for example, by ensuring appropriate accommodations for individuals who may have mobility challenges or other disabilities.33,34 A letter to the editor by Wallace,35 also appearing in this issue, confirms the importance of equity and the imperative to recognize the overlapping biases of ageism and racism. This point was also made by Yogaparan et al.22 Wallace encourages attention to “racially diverse seniors and families in models, lectures, and case studies” when teaching. Similarly, the American Geriatrics Society has called for more research on “structural and system-level determinants that examines the intersection of race and age,”36 and the importance of inclusion in research on aging was also recently affirmed in the United States by the National Institute on Aging.37 As we look to the future, it is vital that the field of academic medicine gives greater focus to the health needs of those in our aging society.38 Increased attention to curriculum development, expanded training opportunities and workforce growth, and efforts to address attitudinal concerns related to aging are necessary. Such attention should complement innovation in clinical care services, partnership with communities and governmental agencies, and strengthened policy development. In taking on these challenges as opportunities, we should begin by engaging with elders. By listening to our elders, so to speak, we will benefit from the wisdom, compassion, and perspectives they offer. I expect that we will learn a great deal, and as members of the academic medicine community, we will be able to build more attuned and respectful approaches in our roles as teachers, clinicians, researchers, and leaders. We will also, Dear Reader, have the chance to embrace our future selves. Laura Weiss Roberts, MD, MAEditor-in-chief, Academic Medicine