A recent opinion published in the Journal of the American Medical Association titled “The Paradoxical Decline of Geriatric Medicine as a Profession” and written by Jerry H Gurwitz lamented the diminishing numbers of geriatricians in training despite the overt need for specialists in this field and overwhelming numbers of elderly frail patients. He cited the decreased research funding, lack of exposure of undergraduates to medical school geriatric education, lower pay for higher complexity compared to other fields, less prestige and fewer career and research opportunities.(1)
The older population of Africa and South Africa is increasing rapidly and brings the challenge of high burdens of both communicable and non-communicable diseases. The life expectancy of people living with HIV has improved to near-normal levels, and diseases of ageing are also prevalent in this population.(2) Health systems are fragmented and underfunded. Universal old-age pension and free healthcare access for older people is limited to a few countries, including South Africa. However, public facilities are overburdened, and there is a shortage of specialist care and a lack of access to such care. Private healthcare provides for those with health insurance and the means to afford it. Most older persons in South Africa rely on state-funded healthcare. South Africa is a progressive country with laws protecting older people's rights and a commitment to improving the lives of the vulnerable.(3) Some unique aspects of the older population in South Africa include multigenerational households and “skip generations” lost to HIV, meaning that older people care for grandchildren. There is evidence that old age pensions not only have gains for older people, including health and emotional benefits, but also uplift other household members and improve outcomes for children.(4)
In South Africa, geriatricians are specialist physicians who complete a further two years of subspecialist training. There are 18 geriatricians that are currently working in the state and private sectors and only one fellow training in geriatric medicine. An additional three have retired. The majority of geriatricians were trained at the University of the Witwatersrand in Johannesburg and University of Cape Town (UCT), some are grandfathered, and one trained overseas. A geriatrician trained at UCT has returned to his native country Uganda to work there. An international benchmark recommends 1.25 geriatricians per 10,000 persons who are aged over 65 years.(5) Based on mid-year 2022 population estimates, South Africa should have 375 geriatricians. Currently there are no geriatricians working in the Eastern Cape, North West, Northern Cape, Mpumalanga, Free State and Limpopo provinces of South Africa.
Choosing to specialise in geriatric medicine can be a rewarding career path. Geriatricians surveyed find working with older people fulfilling. Many who chose the speciality cite a positive personal encounter with an older person as influencing their decision. Working in a team and tackling complex problems with a holistic and longitudinal view are attractive elements.(6) A Comprehensive Geriatric Assessment (CGA) is an individualised intervention central to caring for complex and frail older persons. CGA comprises multiple components, including medical history and physical examination, functional and cognitive testing, and medication review. In addition, the living environment and psychosocial factors are considered to develop a personalised holistic care plan that addresses the older individual's specific needs, wants and challenges. This approach allows healthcare professionals to develop interventions and recommendations to improve the overall quality of life, functional status, and health outcomes for older adults. It is instrumental in managing the complex health issues often faced by older people, promoting independence, and preventing or delaying further decline. It is a proven, cost-effective strategy in a variety of settings.(7) Despite the benefits of CGA, in South Africa, CGA is not recognised nor renumerated distinctly as more time-consuming and complex than a standard unidimensional medical consultation.
The South African Geriatrics Society (SAGS) comprises a national collective of geriatricians. It is active in training and updating a variety of health care workers, including general and specialist medical practitioners. Unfortunately, a popular Diploma in Geriatrics aimed at upskilling general practitioners has been suspended due to Health Professions Council of South Africa and Colleges of Medicine of South Africa red tape delays in accreditation. SAGS has an active mandate to foster teaching in the speciality and also to include sub-Saharan countries and allied professionals via an annual congress, which has been on an online platform for the past 3 years, attracting between 800 and 1250 attendees. Medical registrars have the opportunity to rotate through geriatric units if they are training in the centres which have such units. An online annual masterclass for medical registrars invited all universities including those without geriatricians. Additionally, SAGS hosts a monthly national online journal club and many of its members have been involved with radio, television and lay press interviews.
Some locally authored guidelines have recognised the niche care needs of older people and have included either geriatricians as authors or include specific sections on older patients. This includes the hip fracture recommendation,(8) the National Osteoporosis Foundation of South Africa guideline,(9) the pneumococcal vaccine guidelines,(10) the dyslipidaemia guideline (11) and the diabetic guidelines.(12)
We recognise that there are unlikely to be enough geriatric medicine specialists to meet the needs of our older population. It is, however, imperative for South Africa to maintain expertise in geriatric medicine, recognising the frailty and multi-morbidities inherent in the clinical complexity of caring for an ageing population. There are several proposals to improve the health care of older adults in South Africa and medical practitioners’ knowledge of geriatric medicine. Firstly, more universities should establish Geriatric training units in South Africa, thereby increasing undergraduate exposure to Geriatric Medicine more widely. In addition, the Geriatric Diploma should be reinstated and there should be a continuation of workshops, conferences, and seminars both online and in-person to improve networking and collaboration. Local guidelines and protocols should include sections on older patients if relevant. Improved renumeration of the CGA and funding for local research that is relevant to our communities may attract trainees and scientists.
Finally we echo the view of Jerry Gurwitz who recently opined “Geriatricians will never stop advocating for better care of our aging population and the need for physicians with expertise in geriatric medicine. The decline of the profession of geriatric medicine matters, and all too soon we will all realize why.”(1)