Making a Good Life in Retirement
INTERESTING STUFF – 6 May 2017

How Elders and Their Physicians Might Collaborate

patient-doctors-office

The U.S. geriatrician population has been hovering around 7,000 for several years without much change. At the same time, the elder population grows by about 10,000 a day. You see the problem.

One reason is that geriatrics is at the bottom of the pay scale for doctors and one reason for that is the time-consuming nature of the field wherein patients' needs are more complex than younger adults. As U.S. News reported in 2015:

”Unlike other physicians who might specialize in one organ system or disease, geriatricians must be adept at treating patients who sometimes are managing five to eight chronic conditions...

“Geriatricians also 'pay special attention' to a person’s cognitive and functional abilities, including walking, eating, dressing and other activities of daily living, McCormick says. 'Geriatricians take a holistic approach. We look at how we can help patients to be as functional as possible and exist in the community in the best way possible,' he says.

“For example, older adults may have a hearing or visual deficit that impacts their physical health and quality of life. Something as simple as eye glasses or hearing aids can make a world of difference.

“'We look for little things that can improve quality of life and surprisingly enough you can often make things quite a bit better,' McCormick says.”

Because there are far too few geriatricians to go around, most elders, like me, wind up with a family physician or internist for their primary care. These men and women do their best to help but they are hindered by time constraints and by the less than adequate education they receive in medical school about old people's health issues:

”Despite the diverse range of knowledge and skills required to appropriately care for older adults, the median time devoted to geriatric education in medicine in 2005 was still only 9.5 hours,” according to a 2012 report published in The Gerontologist.

“A survey of medical schools in the United States revealed that less than half (41%) of responding schools have a structured geriatrics curriculum and less than a quarter (23%) require a geriatric clerkship.”

(As you can see in the quotation, these statistics are dated which is due, according to the report, to “an absence of more contemporary information” - common in healthcare related to elders – we are too often not included in studies or, as in this case, the studies are not conducted frequently enough.)

Eighteen years ago, Dr. Edward Ratner, a geriatrician and associate professor in the University of Minnesota’s Department of Medicine in Minneapolis started a senior mentoring program that had medical students spend a series of afternoons with older people as their mentors.

That worked well enough but students were reporting a lot of loneliness and isolation among the elders. So, according to an article at Next Avenue, he changed the program:

”Students moved into the Augustana Apartments in downtown Minneapolis, where their mentors lived — some of them very independently, some with a few support services. Augustana residents got new neighbors and companionship.

“The building, run by the senior housing and services nonprofit Augustana Care, filled several apartments that were standing empty. Augustana’s social services director got volunteer help from students with recreational activities and other needs that residents had.

“And the students gained more learning time with elders, a place to live near the university and a discount on rent in exchange for their volunteer work.”

Dr. Ratner goes on to explain the problem with the limited amount of geriatric study in medical schools – which is so bleeding obvious once someone says it:

”The trouble with traditional medical education isn’t just that it gives students only episodic glimpses of older adults or that it leaves out all the context of seeing them in their homes and communities. It’s also that every older adult the students see is sick, Ratner says.

“'That’s a terribly negative stereotype because most elderly aren’t sick most of the time,' he explains. 'If students think that elderly are always sick and disheveled and confused — because that’s how they look when they see them — they won’t appreciate that [older adults] can be a lot better after treatment and they’ll discount the value of even trying.'”

I've been thinking about elder medical care all week as an appointment with my primary care physician, not a geriatrician, was scheduled for this morning.

We are to check up on the “mystery malady” that is still with me, though less so than a few months ago, and I want to discuss with him why I am not taking his recommendation for a certain, well-known drug to treat osteoporosis or, in my case, osteopenia.

My physician is young – there are reasons this is good. But he also has little experience with the medical issues of old people yet so since I first met him late last year, I have made myself a mentor to him.

I haven't told him this and I probably won't. But I speak with him differently than physicians I had when I was younger and in the past decade of my elderhood because I believe we share responsibility for my wellbeing.

I know a lot more about my body than all the tests he schedules can reveal and because of what I do (this blog), I read a great deal more about the health and medical needs of old people than he has time for.

So gently, carefully and as it pertains to what is on our schedule on any given visit or phone call, I share my knowledge, my life experience as an old person and sometimes what I have learned from you, TGB readers, over the years.

It's not a lecture or a lesson; I make sure it is a conversation – short, to the point and not to get in the way of the expertise he has that I need to know.

This doctor is a good guy, I like him. But given the medical school deficiencies in geriatrics and, as we have discussed here many times over many years, no one really knows what it's like to be old until they get here.

So maybe my little project will help my physician not just with me but with future elder patients.

Stethoscope

Comments

This is a timely post for me. My doctor is in his early 70's and still practicing but not as much as when he was younger. He has a lot of experience working with elderly patients and takes time to explain things to me about my health needs. I never feel rushed.
So right now at 62 years old, I am satisfied with my doctor but know there will be a day when I receive notice that he is retiring from practicing. By the way, his wife who is also in her early 70's, still teaches at a high school.

I like what you said about mentoring the younger doctor that is taking care of your health needs. Being proactive with our health needs by researching and bringing the information to them will become the norm as this generation grows older and the doctors are younger.

I too have osteopenia in my left hip and have no intention of taking a drug that doctors recommend. My research as well as listening to those who have taken it with lots of side effects, helped me make my decision to not proceed with the recommendation.

My husband and I have been with our doctor, who is an internist, for 14 years. We weren't elders at the beginning, but we are now. I don't mind that he's not specifically trained to treat elders because he knows us and how our bodies have changed in 14 years. He's younger than us, but not YOUNG. We're hoping he'll last us out.

We have a wonderful internist in Berkeley, CA, who's been our family doctor for 18 years. The only problem is we have relocated to another part of the state, an 8 hour drive away. Since he is practically a member of our family, and we dearly love him, we do see him for annual physicals and he is available for email and phone consults. Still, we need to find a primary care doctor in our neighborhood.

When we found this doctor, we were in our early 50's and had corporate health insurance. Now we are 70 and have Medicare. Such a difference! Finding a primary care doctor is a full-time project and so far not a fun one.

I like your idea of mentoring a new doctor. We are both pretty healthy, and you are right, don't see doctors unless something's wrong. I hadn't thought about it that way! Thanks, will try to do a better job with the "new doctor" project.

Mentoring you physician—what a great idea! All progress starts with a small step. Maybe what this doctor learns will carry on to educate others. Worth a try!

Ooops! Mentoring your physician, I meant!

My medical needs are scattered amongst several doctors and I feel only pieces of me are dealt with at a time. My primary care MD has ignored serious symptoms subsequently diagnosed by his locum so my faith in his abilities is compromised.

I'm glad I'm moving from this rural area soon so I can have a better choice of doctors.

Thanks for this timely post.

XO
WWW

My clinic has 2 geriatricians for a kazillion patients so they do not serve as primary care docs but instead operate as consultants. Most elder patients don't know they exist but any can request a geriatric consult referral from their doc.

They get an hour with a geriatrician who provides a wealth of diagnostic info and recs that both helps the patient and arms him/her with info to carry back to their regular doc. If needed the geriatrician will suggest a follow geriatric appt.

Not ideal -- and hard on the geriatric docs -- but better than no contact. I live in an affluent community so don't know how widespread this is.

I love your idea about mentoring your doctor. Like you, I have a young doctor whom whom I have grown to like. She is an excellent communicator, and she has respected my wishes about certain things.

After your visit, I hope you share a little more about how you go about mentoring your young doctor.

I also want to mention that we are allowed one free checkup on Medicare per year. Those checkups are mostly useless, but doing one might give us a chance to present our healthy selves to our doc. I ask for a regular physical once a year, and don't we have to do this for prescription renewal? It seems to me that going in for a checkup, taking along a list of concerns, might allow the doc to see us as smart and proactive.

When I wanted to change my primary doc a few years back, because of distance, I looked up geriatricians in the area. Lucky for me, the only one does serve as a primary care doc and is a dear. He listens, remembers me as a person and asks about my music and photography. He knows the value of a gentle reassuring touch on the arm, with a "You're going to be okay." He serves as a traffic cop--sending me hither and yon to specialists, but not one of them can diagnose. I find I have to do my own most of the time--thank goodness for Google.
With 6-7 active chronic illnesses, I just wish that they would all get together around a table and put it all together, rather than this fragmented medical care we have now. Won't happen in my medical care system, sadly.

Hi Ronni...very interesting blog (and timely). I am 72 years old, just moved to a new small community and have had a couple of traumatic Dr. issues since arriving here. I should mention that I rarely go to a doctor so am not endlessly whining about my health (even though I'd like to if anyone would care to listen ha ha). The two physicians I've had a short relationship with here were so curt and uncaring when talking to me that I honestly thought I'd never go to one again until one had to pronounce me "deceased". However, I have fortunately just found a lovely female doctor who is 40'ish and agreed to have me as her patient after a "meet and greet". At that first meeting I told her I have emphysema, arthritis and am old, but what I was totally looking for in my physician was KINDNESS to deal with this old age thing. She immediately said "that shouldn't be too difficult". She also said 72 is not old - 89 is starting g to get old! So I am thrilled to have such a wonderful advocate and just hope she doesn't move away in my lifetime.

I feel very fortunate to have two doctors who treat me almost like a fellow professional and certainly as a collaborator. They know I come from a medical family, worked in medical publishing, and have time to read up on anything that concerns me. I have questions written out before I visit them, so as not to waste their time or forget anything. My family practice doctor is perhaps 40ish and the last two times I've seen her, she's spent about 45 minutes with me. My oncologist is a bit more pressed for time, but treats me like an equal and gives me all the time I need. I consider myself extremely lucky to have these doctors and hope neither I nor they ever move away. They are young enough, I think, to see me through to the end (I'm 74), and I find that very reassuring.

Hi Ronni

I agree 100% with Carol Talbot's comment about what her doctor said, " 72 is not old - 89 is starting to get old." I like her doctor very much - When I was 72 life was a breeze - 80 - the wind starts getting weaker and then when I approached 89 - it really calmed down.

Now almost 92 - it's a very calm breeze but it keeps me going!

Great idea. Mine passes me off, and I am glad in the end. One ugly spot she blew off is scheduled now for a biopsy.

Mentoring, yes, that's it, isn't it? We, the elderly are such a mystery to everyone else. Twice lately, when struck with an illness, I found I couldn't get an appointment with my own doc, who was booked for several weeks in advance, and was seen by the alternate doc, who couldn't have been more dismissive or disinterested. At the end of the next appointment with "my" doc I found a way to nicely, quietly, firmly bring up this problem. He may have solved it or not, time will tell. But we definitely need to speak up for ourselves in many ways.

Our long time HMO got bought out by a larger HMO so everything is in a state of flux. I lost my doctor of 15 years last year. I don't think he was thrilled about the takeover. The doc I was assigned to is in her mid-40s (??), from Africa and seems to be very competent. When I think of the barriers and challenges she had to overcome (female, Black, immigrant) to get to where she is in this country, I have a great deal of respect for her based on that alone. There's sometimes a bit of a language barrier, but so far it hasn't been insurmountable. Y-a-a-y for email.

What I REALLY worry about is losing our outstanding retiree healthcare plan under the new HMO. We're so fortunate to have it! We'd still have Medicare, of course, but the retiree plan covers copays, deductibles and Rx drugs. My husband was promised "lifetime care" for himself and spouse as part of a buyout program for full time staff in the mid '90s (he was 66 at the time and worked 20-30 hrs/wk for another 10 years). However, plan literature has that super-scary clause they all have: "We reserve the right to cancel or modify this Plan at any time". What happens to us--two people in our 80s--if the plan gets canceled?!

Paying more out-of-pocket for healthcare would definitely have an adverse impact on our finances. I feel for the people who will be denied affordable coverage under the GOP's mean-spirited, exclusionary, me-first "replacement" for the ACA. Apparently, in Repug-world anyone who can't afford health insurance isn't entitled to live--unless they haven't been born yet. Repugs will go to the wall (unintended reference) to defend the unborn no matter what, but once they're born, they're on their own!

My own experience, being my late Mother's medical advocate gave me insight into the "white coat" treatment of elders. During an appointment with a new young primary, he stood over her yelling, "Helen, do you want someone pounding on your chest to save your life?" My Mother said "why are you yelling, I can hear you". He assumed she was hard of hearing. Right then I saw his lack of compassion and I told him off; how disrespectful and dismissive he was and to consider my Mother an ex-patient. I also reported him. That experience just ratcheted up my being very proactive for myself and I am.

There are plenty of people like myself who have done very well on the drugs recommended for osteopenia. I have experienced no side effects and do not take the drug if I am having extensive dental work done.

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