Sunday Election Issues - 3 August 2008
The Importance of Simulated Aging

Medical Favoritism

category_bug_journal2.gif According to a recent story in the Baltimore Sun, there are about 7,000 practicing geriatricians in the U.S. According to the Census Bureau, there are about 38 million people 65 and older, meaning there are about 5,425 elder patients per geriatrician.

That's why most old people, like me, have an internist or family practitioner, who may or may not have any geriatric training, as our primary care physician. Some of the time it doesn't matter. But there are differences in treating elders that many non-geriatricians are not familiar with. This, from the Baltimore Sun story is an example:

"...geriatricians' specialized training is helpful to patients who might be prescribed several different remedies by several different specialists, [geriatrician Thomas] Finucane said.

"As an example, Finucane describes a patient who came to him with chest pains, heart disease, an irregular heartbeat and a spot on her lungs that looked like it could have been cancer. The patient, in her 90s, had been to see a thoracic surgeon, an oncologist, a radiation therapist, a cardiac surgeon and an electrophysiologist. Each recommended a different treatment. And each treatment would have been costly.

"'If you tried to fix everything that was wrong with her, she would be sick as heck, she'd be quite delirious, she'd suffer a good bit," Finucane said. "And in the aggregate, it probably would not increase her [life span]. In fact, it might decrease it.'"

Although a few medical schools have recently added geriatrics departments, it is hardly enough particularly with an elder population that will swell to more than 71 million by 2030.

All that is preliminary to telling you about a disturbing story recently published in The New York Times that concerns dermatologists and plastic surgeons who maintain differing systems of treatment depending on whether the patient's treatment is a medical need or just vanity.

"'Cosmetic patients have a much more private environment than general medical patients because they expect that,' said Dr. Richey, who estimated that he spent about 40 percent of his time treating cosmetic patients. 'We are a little bit more sensitive to their needs.'

"Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists' offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.

"In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients."

The Times also reports a 2007 study by The Journal of the American Academy of Dermatology, finding that in 11 cities, a person phoning a dermatologists' offices about Botox got an appointment faster than one calling about a suspicious mole. According to The Times, some young dermatologists are advised to give cosmetic patients appointments within seven days and then fill empty time with medical patients.

Some doctors maintain preferential policies for cosmetic patients, supplying separate reception areas, subdued lighting, a less clinical atmosphere and sheets to lie on instead of the usual paper cover on examining tables we are all accustomed to. At least one physician has two telephone numbers - one for medical patients that goes to voice mail and one for cosmetic patients that is answered by a person.

Not only is this a perverted idea of medicine, it could be deadly.

"Dianne Ryan, who works for an airline in Dallas, went to a dermatologist in her insurance network three years ago after her husband pointed out a mole growing on the side of her foot, she said. The doctor dismissed the mole as benign, she said, but recommended she buy his brand of bleaching cream for pigmentation on her face.

"A few months later, Ms. Ryan said, she sought a second opinion from another dermatologist, whose diagnosis was melanoma."

This story struck home for me, having had a patch of squamous cell cancer removed not long ago, the surgical wound repaired with a skin graft. I was diagnosed and treated in a timely manner, and I have no complaint, but what about next time.

Geriatricians are not like most other specialists who treat specific diseases or body parts. Instead, they are trained to treat the whole body and find connections among ailments, diseases and prescriptions that may be complex. But they are among the least compensated in medicine.

"'Geriatricians are making, on average, $12,000 less than other internal medicine doctors,' said Elizabeth Bragg of the Association of Directors of Geriatric Academic Programs. 'And they have to go through at the very least another year of training. It's like you're going to school for another year to make less money.'

"[Geriatrician Thomas] Finucane again offers a real patient as an example. If an older man fell at home and broke a wrist but couldn't explain why the fall happened, he would see two doctors afterward - someone to set the bones in his wrist and possibly a geriatrician, trained to understand falls among the elderly.

"'The 15 minutes to set the wrist would be far more richly compensated than the time it takes me to sit down and talk with that patient about what happened, why he fell, what is going on there,' Finucane said, 'by about 4 to 1.'"

Baltimore Sun, 13 July 2008

The system seems rigged, doesn't it. Geriatricians are paid less for a more complex practice than some other specialties. Their training costs more and there are more people who need (as opposed to want) their services than, for example, dermatologists and cosmetic surgeons. You can yell at me all you want in the comments, but I believe these two things:

  1. It is our "greed is good" culture that leads some doctors to give preferential treatment to non-medical patients (and I don't want one of them anywhere near me).
  2. It is our ageist, youth-centric culture that leads to millions of cosmetic procedures each year and creates an atmosphere that makes the treatment of an entire segment of the culture based on age alone, less attractive to young doctors.

AFTERTHOUGHT: What, if anything, should be done about physicians who favor and give preferential treatment to patients with no medical need?

[At The Elder Storytelling Place today, Sylvia Kirkwood reflects on growing old in Memory Flashes.]

Comments

Wouldn't giving preference to patients who have no bona fide medical need be a violation of the Hippocratic oath? If so, off with their heads to borrow a line from the Queen of Hearts!!!

My cute lil' dermatologist who looks about 16 treats me just fine!!!

One of the bigger problems for anyone who has any medical problem at any age is this specialization. It leads someone like me, who at one time had abdominal pain, going to different doctors, who don't talk to each other, trying to figure out what is going on instead of one good old general practitioner which used to be the norm and was great for many years. I realize sometimes you need specialists but when you have no idea what is wrong, they can take a long time to get anywhere and often lead to incorrect treatments that get you nowhere fast.

With a geriatrician, what age would one need one? One of my good friends has gotten her in-laws a good one but they are in their 80s. I know there is a time where meds are even different for the dosages but am less sure what age that starts happening. If there are a limited number of geriatricians, it seems we'd want them for those of us who need them most but not miss out on getting their benefit when we do need them ourselves.

It is indeed difficult to find a geriatrician. At 80 my mother was showing her first signs of Alzheimer's. I tried everything, called everybody I know. Nobody knew of a gerontologist or geriatrician. Finally, when I did find one, the nurse said, "Is your mother able to walk up stairs?" No, not at all, I said. This doctor's office - a geriatrician, mind you - was on the second floor of a building with no elevator. I was flabbergasted. We did find a good internist whose practice had a large percentage of elders but I will never get over the nightmare I had trying to get help & treatment for my mother, while she suffered from severe depression, along with a myriad of other chronic diseases. We knew she needed an overall evaluation, psychiatric and physical, but just could not find the person to do it. Frustrating doesn't begin to describe it.

This again points up one of the many ways in which our health care system is broken. I think this is what happens when you use a patch work quilt way of fixing problems. The end result is the nightmare system we now have.

If I could have my way our whole system would be scrapped and we would study the best of other countries universal health care plans,take the best ideas and start over. Of course that will never happen as long as the naysayers keep up with their mantra "Socailized Medicine." They conveniently forget that 'socialized medicine' by definition is what our President, Veep and legislators have. It's the best medical plan in the nation.

One of America's disadvantages in terms of setting social policy is our market-driven capitalist system. Corporate interests control the dialog and the media that report it. We incentivize our physicians to provide unneccessary services over necessary services, and then we include the cost of those services when considering the overall cost of health care to characterize universal health care as unaffordable. Catch 22.
So long as we Americans approach these issues as consumers we will treated as consumers and milked for everything that can be extracted from us.

My godson is still in residency as an emergency room doctor. I asked, and he told me he had not had one course specifically about geriatric matters in all of his medical training.

I also talked to him early on about studying geriatrics. He said that there are few medical schools offering geriatric training and still fewer hospitals offering geriatric residency. He chose emergency medicine, and while that is needed, I think that geriatricians are much more needed due to our aging population.

My town of 250,000 does not have a single geriatrician!

Our physician is a D.O., and we find her "whole person" training is very helpful with out maladies. We feel fortunate to have her in our corner.
While she is not per se a geriatrician, she is closer than our previous M.D.

Ah, next time I have precancerous spots removed, do I get my own waiting room? How ugly a thought.

Personally, I think a better question might be – how do we get the AMA (or whoever controls these things) to adjust/change their priorities in terms of which fields of medicine are ‘promoted’. Call me a pessimist, but I seriously doubt anything can be done to change the existing situation. But there COULD be more hope for the future if whoever is in charge got on-board.

Well, duh, I guess. A for-profit medical system is going to result in doctors working for profit. #@$D#@% medical care? Well, is that news? I can't even find a primary care doc in my area who will take new patients!

Thanks for this post. I'm in my early thirties and am fascinated with the process of aging.

This is a subject near and dear to my heart. As a disclaimer, I work for the largest group of geriactric docs in the US and we get very little respect because we eat and breath, literally, caring for the aging population. Our docs have a mission to provide respect, along with care. I am lucky to be paid for doing good in a company that respects age. I am 64 and one of many so called aging people who work here. Who knew?

Usually this group focuses on the 65 plus population. It is a matter of understanding that as we age, the body changes and we are subject to some chronic conditions (those conditions or diseases that become part of our lives like arthritis, diabetes and others). Our medical director believes that its about putting life into your years not years into your life. He says the body is amazing and very forgiving and you can change how you feel by changing how you live.

Our docs decrease the number of medicines instead of increasing them cause they understand the little nuances that occur as the mind and body ages. The main difference here is that these docs get it. They know you can't treat a symptom, you treat the whole person: mind, body and spirit.

We get very little respect from the media and politicos. We're not considered "sexy" or newsy. I am the eternal optimist and believe some day people will get it. But somehow we have to influence younger docs that this is the place to practice medicine, real medicine with people who appreciate the time and treatments they get. It is more than rewarding. Its just the right thing to do and our numbers are rising!

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