Alive! 55 Plus and Kickin' - Inspired and Inspiring
INTERESTING STUFF – 30 January 2016

The Scarcity of Geriatricians

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?

Comments

Finding a qualified physician, whether you are 8 or 80, is crap shoot. especially if you are looking for one that accepts Medicare. Hopefully, as the population grows greyer (10,000 baby boomers turning 65 every day) doctors will at least try to familiarize themselves with the needs of old people even if they don't actually specialize in geriatrics.
My primary care doc is not a Geriatrician, but since most of his practice consists of senior citizens, he is quite used to dealing with us.

I would think being a geriatric doctor would be extremely difficult. I don’t consider myself anywhere near being on my death bed but nevertheless, I have at least five health issues that my doctor has to deal with. And given the allotted examination time given in most doctor’s offices of some fifteen minutes, at best perhaps he can give one issue his undivided attention.

When I go to the doctor I have to pick and choose the issue foremost affecting me at the time. The others are abated whether they need looking over or not. On the other hand, although I regularly go to the doctor every 6 months, were I to go regularly to address all my issues I would basically have to go in every month until we had addressed them all and then begin the rotation all over again.

I would assume that the presumed 15 minute patient time is not any different in a geriatric doctor’s office than it is in the primary care physician’s office. So I’m not sure just how much I would be gaining, given the additional expertise in the field or not....

I is most difficult to find what does not exist, isn't it? I will be interested in others experience, mine is similar to yours, Ronni.

I'm not at the point of needing a geriatrician, but I tried to connect my mother with one a few years ago, and was met with a blank stare. They didn't seem to exist! My hope is that the situation has improved. I live in Canada, and sometimes we have better availability of doctors, and sometimes worse. Depends on the speciality. My experience with general practitioners in this city is that they know a fair bit about geriatrics, but they can't know as much as a specialist, for obvious reasons.

make that initial "I", and "it".

The situation here in the UK is different. The NHS - the National Health Service - founded here in 1948 and funded through central taxation, provides a comprehensive range of health services, the vast majority of which is free. Everyone is assigned to a GP - General Practitioner - at a practice within the area you live , made up of a group of doctors, nurse practitioners, dispensing chemists etc. You may have the same GP all your life or move house and take up a new one. Your medical card stays with you all your life. It means for instance that when my husband was in Intensive Care for 5 days in 2010, at a bed cost of £3000 per night, no money ever changed hands or ever had to be discussed, no insurance policy had to be filled in, it was free . Free. Prescriptions do cost but only till you reach 60. My husband is now on 5 tablets a day, for free. He has them delivered to our house. For free. Yes the NHS is creaking and vulnerable now we are all reaching old age but it is the one institution every citizen is unspeakably proud of.

Reading your column this morning reminded me of something I thought of while I was reading Atul Gawande's wonderful book, Being Mortal, which is that the kind of people attracted to medical school are not generally the same type as those who would be good as geriatricians. Geriatricians, it seems to me, need skills akin to those of a social worker. Their job is not so much to cure diseases as it is to manage chronic conditions--some of which go beyond the physical. I wonder if recruitment for the geriatrics field might start among those interested in social work and related fields.

I have one now and it was just dumb luck. My internist left our small rural town and my pulmonologist called and told me to call right away because her replacement was an internist and a American Board of Internal Medicine Geriatric Medicine certified. She's a wonderful person. What a difference. The coordinating she and her medical assistant do is really important. I have COPD on top of some usual aging issues. Anything with anesthesia is a big deal and I'm allergic to morphine. I self advocate too but it is such a relief to have someone watching your back. Needless to say her practice is full up.

I think Nancy Wick's comment is prescient and while the money in geriatrics maybe less, it is a heck of a lot more than social workers are paid.

I've not yet felt a need for a geriatrician, but I've certainly thought about it this year. I have a team of specialists (oncologist, radiologist, pulmonologist) that's been handling all aspects of my cancer care this year, but they are totally separate from my family practice doctor who has been handling my routine care and check-ups. And of course there's the ophthalmologist treating my glaucoma. I think there is very little if any communication between them other than information I relay back and forth. Each needs to be aware of what the other is doing because everything is interrelated: heart, thyroid, and adrenal function; bone density; cholesterol; intraocular pressure; etc. Luckily I've yet to deal with things like declining mental acuity, chronic physical disabilities, etc. (Knock wood!) Sure would be nice to have a geriatrician trained to understand and coordinate "the big picture." Unfortunately it looks like being a knowledgeable, informed patient is the only recourse -- and that's not something we can count on doing forever.

I've just read 2 books on the very real problem of elders being more easily dismissed by healthcare professionals and I'm about to read a third. The most cogent take away is that you need to go to your appointments with a list. Every time. No exceptions. Leave off the really minor stuff (dry skin, eyes, etc); take that up with a pharmacist or friend whose judgement you trust. Only ask about 3 problems and make sure the doctor knows which one bothers you the most. Anything you don't understand - ask again.

If you're having problems with hearing, comprehension or memory, either ask the doctor to write it down for you, or take along someone who is willing to be an extra set of ears. The upside of all that keyboard tapping is that you may get readable instructions. You would think they could do that after the visit without the distraction of us talking to them wouldn't ya? One book by a geriatrician said to find another doctor if yours spends most of the visit on the computer!

Most importantly if there is anything about your doctor that doesn't feel right to you....find another.

I'm fortunate to have a general physician that works with me and whom I consider a friend. We frequently exchange books and talk about music at my visits! I started with this doctor when he was a new associate in the medical group I went to. My old doctor moved to Arizona..she hated the rain and finally gave up and moved! Though I preferred a woman physician I have stayed with Dan because we sort of clicked right from the start..and I trust him.

Dan was a new physician, less that 20 years younger than I, when I agreed to move to his practice in the clinic..I was in my late 30s or early 40s at that time. He saw my children grow up and has done an excellent job keeping up on geriatric medicine.

He moved to an office with other independent doctors and I followed him, making sure to carry insurance coverage that his practice accepted, though there was a couple of years I had to pay and submit for reimbursement, eventually he accepted the insurance I was able to get. He's moved his office several times, in the same general area, and though it's not particularly convenient it's close enough that I can comfortably drive there...I've started busing more and more lately and wish I could bus to his office in a reasonable time but it's not practical..maybe some day.

Now, at 73, I am confident with his care. I have a few physical issues that would make getting a new doctor, even if I could find a geriatric specialist close by, difficult.

I also have a Pain Specialist, a Rheumatologist, a Cardiac specialist as well as a naturopath, acupuncturist, chiropractor and massage therapist (my daughter). Dan supports alternative health care practices and occasionally sends his patients in need of massage therapy to my daughter, who is my youngest child and who went to him thru high school.

He no longer takes children in his practice as most of his patients are aging and he wants to be able to focus on elder health care. I like that he volunteers at a women's resource center for the poor, lectures at OHSU and trains young doctors who spend a semester shadowing him in his office. I have a tricky heart murmur that he uses to challenge the not-quite-a-doctors to diagnose.

I also like that I can send him an email about a problem or to order new prescriptions so I don't have to make an office visit just to pick one up. And I like that I can call him Dan- and have for several decades.

Elle-your neighbor in Beaverton

After my primary care physician failed to return my call about my concern with very high blood pressure I decided it was time for a new doctor. I called my customer service for my Insurance plan to find out if there was a geriatrician in my plan and the girl didn't even know what specialty a geriatrician was. I told her a doctor specializing in elder patients.

She was unable to find out.

I am 68 and my husband is 69. We are both in good health and are happy with our primary care doctor right now. I've not considered a geriatrician before but I wonder if our Humana supplemental would even cover a geriatrician.
I am so envious of Anne Brew in the U.K. What a relief it would be to know that your medical needs would be met!

I'm 75 and my wife is 73. We have been very lucky! Our primary is a PA-C and we're in a medical group with about 8 physicians in it, plus they accept Medicare. Our PA is one of the most dedicated 'doctors' I've ever had. I'm having health problems now and he has increased my visits to once every 4 months from 6 months. He encourages me to email him when I need his advise. If I have a problem with a doctor that he has referred me to, he immediately refers me to another and thanks me for telling him. I asked him about a geriatrician and he said that he would refer me whenever I felt the need. "Would you like me to do it now?" he asked. I didn't but thanked him. I know that we are extremely lucky and we are so appreciative for the care we get as I hear horror stories from my friends all of the time.
I do know that you can get the best care possible if you choose a PA. I would never hesitate to choose another one if we ever have to

I'm luciy too. My doc is an Internist (Adult Medicine) who practices in a local clinic group. She always has time to talk, often asking about my personal life. She's available if needed. The group has an excellent online patient portal which I have ofteen used to ask quick questions or to report problems needing her referral to lab or other specialties. There is always a prompt response via her excellent nurse.

I also have cardiologists and a retinologist. The cardiologists also have excellent and available PAs who are women and, as such, seem to be more simpatico and willing to take time and to listen. I put up with the retinologist.

It occurs to me that the patient profile in both of these specialties would describe an older person mostly. I wish there were more training/sensitization to dealing with elders for these specialties. But, like most Dr.s they focus on the ailment and not on the person. So far they've kept me alive and kicking, but, as they probably know in their bones, as their patient, my horizon is limited and eventually....

Good topic, as usual, Ronni. Thanks. PS, I got a new mouse that doesn't doubble click all by itself. (Re: my double post Wed)

no wonder there are so few; how can anyone hope to survive on a mere 220K?

Goodness, yes, it must be tough to make it on $220K. To be fair, though, thanks to our current vulture capitalist system in which almost all the money goes to the 1% (of which very few or none are physicians), most young doctors graduate with HUGE student loan debt. If they ever hope to repay their loans--let alone get married, buy a home and start a family--they need to earn as much as they can. One solution might be forgive or reduce student loan debt for doctors who choose geriatrics as a specialty.

Fortunately, we belong to a good HMO and I have a very competent family practice doctor there. I've been his patient for the past 20 years, and I think he is well-informed on older adult issues.

I, too, am envious of Anne Brew of the UK. (My husband and i have joked about moving to Canada; we'd actually be closer to two of our children.) I just turned 59 and live in the upper peninsula of Mich. I've always had problems getting any kind of Dr. since we moved here five years ago. It appears we'll have to drive an hour in any direction to find someone. At present, my husband and i see a nurse practitioner. She lives across the street and four or five houses up. It makes me uncomfortable to be chummy with people who know all your health secrets. We have Dr.s, but they seem to come and go so quickly that i've had one for two years before he left. The last Dr. I saw left after i saw her once! (Why did she tell me she was taking new patients??) It's all so irritating!!

I have a young woman as my geriatrician. Her new husband is also a geriatrician. They will make house calls if it should come to that. I trust the practice she joined, which also houses my gynecologist and my dermatologist. I entered my information once; it's updated across all physician's records as needed/relevant.

Yes, I am fortunate. I live in Tucson, which is an elder care centric place to retire.
a/b

We live in Hillsboro, OR. My husband uses Dr. Natasa Petrac, who has a speciality in geriatrics. She is located in the Orenco Station Clinic. She uses Tuality Hospital in Hillsboro.

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