As I had done when I moved to Portland, Maine in 2006, I looked for a geriatrician when, four years later, I moved to Oregon. With each inquiry in both states, I was told that the doctor's practice was full.
That put me off for awhile. I am lucky to be healthy and over a lifetime have spent little time with physicians. But the need for a physical before cataract surgery sent me on the hunt again.
The primary care physician I found is nice enough and apparently competent. As the clinic's staff certainly is. But I'm the one who leads the discussion of my exams, he spends most of our truncated hour together tapping at his laptop keyboard and I find myself wondering if he's paying attention at all.
If you have heart trouble, you need a cardiologist. Pregnant? An obstetrician. Parkinson's? Probably a neurologist. And so on. For old age, that would be a geriatrician but you're unlikely to find one in the U.S.
I have written about the diminishing number of geriatricians in the past and it came to my attention again earlier this week when The New York Times published some well done reporting on the situation. The basics:
”There are about 7,000 geriatricians in practice today in the United States,” writes Katie Hafner. “The American Geriatrics Society estimates that to meet the demand, medical schools would have to train at least 6,250 additional geriatricians between now and 2030, or about 450 more a year than the current rate.”
But the fact is, as Hafner reports, openings in medical schools for the specialty go empty. Further:
”People avoid the field for understandable reasons. Geriatrics is among the lowest-paying specialties in medicine. According to the Medical Group Management Association, in 2014, the median yearly salary of a geriatrician in private practice was $220,000, less than half a cardiologist’s income...
“Since the health care of older patients is covered mostly by Medicare, the federal insurance program’s low reimbursement rates make sustaining a geriatric practice difficult, many in the field say.
“'Medicare disadvantages geriatricians at every turn, paying whatever is asked for medications and procedures, but a pittance for tough care-planning,' said Dr. Joanne Lynn, a geriatrician and the director of the Center for Elder Care and Advanced Illness at Altarum Institute, a nonprofit health systems research organization based in Ann Arbor, Mich.”
Certification in geriatrics requires one or two more years of training beyond completing study for family or internal medicine. In addition to clinical care, geriatricians are
”...skilled in navigating the labyrinth of psychological and social problems that often arise in the aging population.”
According to The Times and I've heard it before, some primary care physicians do not believe geriatrics, even as a specialty, is necessary, that their training is sufficient.
“'This is simply untrue,' Dr. [Elizabeth] Eckstrom, [a geriatrician] said. 'Just think about dementia, or delirium caused by a medication. Those are just two conditions you seldom see in middle-aged adults.'”
Exactly. While other kinds of physicians are accustomed to treating and curing individual medical problems one at a time in younger adults, elders often have multiple diseases, issues and conditions that make treatment more complex as they often can not be cured but can be managed. However, reports Hafner,
”Young physicians in training find it difficult to muster interest in the slow grind of caring for older patients, and days filled with discussions about medication management, insomnia, memory loss and Meals on Wheels deliveries.”
Even though there are not enough of them, some young medical students see it differently (and thank god for them):
”An old family member is often the inspiration for medical students who choose geriatrics. 'My grandmother was one of my best friends when I was growing up,' said Dr. Emily Morgan, 37, who recently joined Dr. Eckstrom in her practice.
“Dr. Morgan said that watching her grandmother’s decline after a car accident, followed by a terribly painful death, instilled in her a deep belief 'in the inherent dignity and worth of a life, especially towards the end.'”
One hopeful sign from The Times story is that some geriatricians think beliefs about their field are changing and that it
”...will soon receive the recognition it deserves. New payment models that hold doctors and health systems accountable for keeping people healthy are on the rise, and geriatricians foresee a day when they are better valued and compensated.”
Although there is nothing I can do personally to increase the number of geriatricians, I find myself feeling frustrated and resentful that at this time of life, even healthy as I am for the moment, I cannot have the kind of physician who could best keep me that way.
With the growing number of elders over the next 30 or 40 years, the shortage of geriatricians is a serious social problem. The Times story is a good explanation of where we stand on the issue as a country and you should give it a read.
With all that, the same newspaper just reviewed a new book, Remaking the American Patient, in which author Nancy Tomes, a professor of history at Stony Brook University, “outlines in a seamless and utterly fascinating narrative, [that] the good old days never really existed.”
Excerpts from the review:
”Do you feel dehumanized as a 21st-century patient because modern medical care is all about the technology? Sad to say, that process began long ago. It was back in the 1920s that doctors’ offices first loaded up with machinery in order to impress patients with 'new and improved' medical care.”
”Do you feel battered by the pharmaceutical marketplace, full of noisy ads masquerading as information? Ms. Tomes points out that it was always thus: Drugs have been enthusiastically hawked from the dawn of advertising.”
”Are you perplexed by our regulatory chaos, with layer upon layer of well-meaning but persistently ineffective efforts to guarantee the safety of medical services? It turns out we come from a long tradition of such inadequacy: Patient safety has been the holy grail for everyone, long sought, never achieved.”
The book sounds fascinating. You can read more about it at The New York Times.
Recently, a friend mentioned in an email that his primary care physician told him that he should get a geriatrician.
”I said 'ok',” my friend told me, “but I knew it was about as close to possible as me getting on the next moon shot. The people on the 'inside' are clueless [about] what...patients go through just to get competent care. Live hard, die young, is a positive message!”
Are you lucky enough to have a geriatrician? Or, are you comfortable that your primary care physician is informed enough about elder medical issues?