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:
- 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).
- 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.]