Its leaders have been able to fill only one of the three fellowship slots for training new geriatricians, specialists who treat the ills of older patients.

ECU's troubles are part of a larger crisis in the quality of care available for a growing population of older people.

A new Institute of Medicine report concludes that the 78 million baby boomers who start turning 65 in less than three years will face "a health-care work force that is too small and woefully unprepared to meet their specific health needs."

North Carolina has about 175 geriatricians, ranking near the national average of about four doctors for every 10,000 people older than 75. By contrast, state figures list 1,484 pediatricians and 1,001 psychiatrists.

Experts say that an inadequate supply of geriatricians could result in poor care for the wave that will nearly double the number of North Carolinians over 65 by 2030.

"We are not making any money, and we can't recruit new faculty and fellows because of the shortage," said Dr. Irene Hamrick, an ECU associate professor and director of geriatric fellowship program. "It's a downward spiral."

Young doctors are often unwilling to spend one to three years in geriatrics fellowships, only to enter jobs that rely on low Medicare reimbursement and require unpredictable hours. Geriatricians can earn about $160,000 a year, but colleagues in specialties such as dermatology and radiology can make nearly twice that.

Dr. Colleen Christmas, a geriatrician and Johns Hopkins University professor, said having fewer geriatricians means poor care. Many patients have more than one disease and, without a geriatrician, may take prescription drugs with bad interactions specific to older people. Or they may avoid the doctor, because their concerns aren't met.

"I think that older patients suffer from too much care, too little care and the wrong care," Christmas said.

Common diseases often show up differently in older people, said Dr. Laura Hanson, a geriatrician and assistant professor at UNC-Chapel Hill. A heart attack might be painless, or an infection can take hold without the patient's temperature rising above 99 degrees.

"They tend to go to surgery later," with worse results, Hanson said during a break from rounds at the nonprofit Carol Woods Retirement Community, where she's part of a rotation of five geriatricians.

During a visit with Elinor Koechley, 89, Hanson knelt by the bed and looked her straight in the eye. "How are you feeling?" Hanson asked, following up on Koechley's recent pneumonia.

"Reasonably OK," Koechley said, softly but resolutely.

After the visit, Hanson said she makes a point of connecting with her patients instead of rushing through appointments.

Engaging the patients

"People are in a situation where they typically have lost control for a variety of reasons, including their illness," she said. "I try to go out of my way to communicate with the patient even if her memory is not 100 percent or her energy is not 100 percent. That allows her to be part of the picture."

The typically more complicated medical situation of an older patient can be a challenge. The Institute of Medicine, a Washington, D.C., research group that's part of the National Academy of Sciences, found that the average 75-year-old American has three chronic conditions, such as diabetes, hypertension, arthritis and dementia, and takes four or more prescription drugs.

Medicare, the federal health- insurance program for people over 65, actually hinders care through its policies, according to the report. It often focuses on short-term treatment instead of chronic-disease management.

That model is at odds with a geriatrician's approach.

"What we try to do in developing geriatric care is deal with all the needs of the patients," said Dr. Kenneth Schmader, chief of the division of geriatrics at Duke and director of the geriatric research center at the Durham VA Hospital.

Experts on aging, demography and geriatrics said the coming generation of baby boomers is already asking for more information and better communication. One solution may be to increase geriatrics instruction in the overall medical school curriculum.

"Rather than start a whole new practice ... we need an academic discipline," said Dr. Robert N. Butler of the International Longevity Center think tank in New York. "I don't think we need a geriatrician on every street corner. We need people who practice medicine to know how to look after older people."

Absent major changes in the U.S. health-care system, it's unlikely that geriatricians will enjoy a major boost in their ranks, given the reputation as a "high-touch, low-tech" specialty.

"The work is very challenging, and you have to enjoy being around frail older patients," Hanson said. "Not everybody's cut out for that. Sometimes it's just simpler to work with younger people."

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