The commentary about Missouri’s “solution” to a shortage of primary care doctors in rural areas in the face of an aging population (“Not enough primary-care doctors? Try Missouri’s prescription,” Aug. 26) points out a serious problem and demonstrates a gross misunderstanding of the work of primary care specialists.

The columnist, a medical ethicist working in New York City, underestimates the complexity of caring for vulnerable older adults and of rural primary care. It is clear, as the demographics shift and we are caring for more older adults, that the health care system we have developed is not ready to meet the needs.

These needs generally will need to be met through primary care. There are currently only 7,000 geriatricians in the United States and their primary role will need to be consultative and supportive to their colleagues in primary care.

The American Geriatrics Society has an initiative on the management of multiple chronic illnesses. This reflects the fact that more than half of older adults covered by Medicare have three or more chronic conditions. Further research has demonstrated the frequency with which vulnerable elderly patients have seven to nine chronic conditions. These conditions not only increase the risk of mortality, but impair function leading to increased dependency.

There is very little scientific data about the management of multiple conditions. There may be guidelines for each individual condition, but older and more complex patients are left out of the studies from which the guidelines are developed. Sometimes these guidelines are seriously wrong about the best care for the older patient. Often the impact of the individual guidelines is in conflict with other disease-specific guidelines or in combination create problems that interfere with the individual’s health and function.

A primary care specialist seeing a vulnerable elder in the office may need to deal with an acute problem, preventive care needs, one or more chronic illnesses, specific geriatric syndromes such as memory loss or falls and significant social issues. This is not easy work and requires special skills, knowledge and aptitude.

This is why the decision in Missouri is such a risk. To practice primary care you must have a passion for it, you need training and you need an aptitude for dealing with multiple variables and uncertainty at the same time.

Maine is taking a different track. There is a recognition of the crucial role of team care in the care of vulnerable elderly patients. Under leadership from multiple people in multiple disciplines as well as state government, there is a concerted effort to address the shortage of primary care specialists, to introduce training that addresses the care needs of the vulnerable elderly to all potential members of the needed teams.

All nursing schools in Maine now incorporate a geriatric-specific educational curriculum. Other caregivers and medical assistants receive education regarding the care of the older adult and tools with which to provide optimal care. The University of New England has woven geriatric training into physician and physician assistant training. Nurse practitioners trained in Maine also are acquiring specific geriatrics training. All of this is crucial to providing the necessary background for team function in the care of the geriatric patient.

At the physician level, the Tuft’s/Maine Medical School collaboration places medical students for up to nine months in rural communities to learn rural medicine. There are four family practice residencies in the state, which tend to retain well-trained primary care specialists for Maine. Maine Medical Center is exploring placing family practice and internal medicine residents in small communities for a one-year rotation.

Here in central Maine we are fortunate to have the Family Medicine Institute training family practice residents whose training is integrated into the teaching of a geriatric fellowship. This produces a cadre of primary care specialists with a strong background in the care of the older adult.

The state’s Office of Aging and Disability Services has a grant to make Maine “dementia capable.” Part of this grant is to work with primary care offices to improve recognition, diagnosis and management of the older adult with memory-related problems.

The Affordable Care Act, through support to structural changes to our health care system, opens the door for innovative change in how care for older adults is provided.

This is a challenging and exciting time for medicine in Maine and the nation. We in Maine are on a much better track than Missouri to address the opportunities and challenges of an aging population. With an openness to innovation and hard work, we will get this right.

Dr. Roger Renfrew, of Skowhegan, a fellow of the American College of Physicians, is the clinical geriatrics facilitator for MaineGeneral Health. A member of MaineGeneral Medical Center’s active staff, he is certified by the American Board of Internal Medicine with added qualifications in geriatric medicine.