The Deadly World We Live in Now
Recovery Time in Old Age

Not Enough Geriatricians

When I moved to Oregon in 2010, and needed a new physician, I used the internet to track down the geriatricians in my area. About half the listings included a note that the doctor was not taking new patients.

When I telephoned the remaining names on my list, each one told me they were not taking new patients.

So much for finding healthcare that actually relates to my stage of life and needs.

FACT: In 2014, there were 46.2 million people 65 and older in the U.S.

FACT: In 2030, there will be about 71.4 million people in the U.S. 65 and older

FACT: Currently, there are about 7,000 geriatricians in the U.S. - about one for every 6600 people.

As The New York Times reported in January,

”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.”

In case you are misinformed – many people are - the Times article also includes a good, short explanation of what a geriatrician is:

”...a physician already certified in internal or family medicine who has completed additional training in the care of older adults. In addition to providing clinical care, geriatricians are skilled in navigating the labyrinth of psychological and social problems that often arise in the aging population.”

Some people, even some physicians, believe that primary care doctors can delivery the same-quality care to elders as geriatricians. Elizabeth Eckstrom, a geriatrician who happens to practice right near me in Portland, Oregon, refutes that:

”If primary care doctors were providing optimal care to older adults, polypharmacy would not be one of the leading killers in that population. Fifty percent of dementia would not be missed in primary care practices. Many patients with delirium would not be missed by physicians in our hospitals.

“Recent evidence about care provided by geriatrics teams shows that hospital length of stay is about one day shorter, costs less, and has fewer complications, including falls, pressure ulcers, and catheter-associated urinary tract infections.”

Dr. Eckstrom also says not every elder needs a geriatrician but has called for additional training of all types of health care providers (except pediatricians).

Many residencies in geriatrics go empty. The biggest reason is that geriatricians are paid much less than other specialists. They can expect an annual income of about half that of other specialties - $200,000 versus $400,000. Their insurance reimbursement is usually less that other physicians because elder care just takes more time than other specialists require.

”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, reports U.S. News and World Report.

“...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.

American surgeon, Atul Gawande, wrote the best, most eloquent explanation of the complexities of geriatric care I've ever read. It is a long story in the 30 April 2007 issue of The New Yorker magazine titled “The Way We Age Now.”

For the story, Dr. Gawande shadowed a geriatrician through his day seeing patients and recounts in detail the entire examination and the many questions the geriatrician asks one 85-year-old woman who lives on her own. Then -

”In the story of Jean Gavrilles and her geriatrician, there’s a lesson about frailty. Decline remains our fate; death will come. But, until that last backup system inside each of us fails, decline can occur in two ways.

“One is early and precipitately, with an old age of enfeeblement and dependence, sustained primarily by nursing homes and hospitals. The other way is more gradual, preserving, for as long as possible, your ability to control your own life.

“Good medical care can influence which direction a person’s old age will take.

“Most of us in medicine, however, don’t know how to think about decline. We’re good at addressing specific, individual problems: colon cancer, high blood pressure, arthritic knees. Give us a disease, and we can do something about it.

“But give us an elderly woman with colon cancer, high blood pressure, arthritic knees, and various other ailments besides—an elderly woman at risk of losing the life she enjoys—and we are not sure what to do.”

This is what geriatricians are for – to “think about decline” and to preserve, “for as long as possible, your ability to control your own life.”

And bless every one of them for doing so.

Unfortunately, most of us will not have that kind of care and will need to educate ourselves in our own care to work with the kind of physicians we have.

From an article last week in Kaiser Health News:

”[Dr. Todd] Goldberg also teaches at the Charleston division of West Virginia University and runs one of the state’s four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.

“For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.

“'This is not just our local program, or in West Virginia,' said Goldberg. 'This is a national problem.'

“The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled.”

One more problem in our world for which there seems to be no solution.

Comments

You are so right, Ronni. When my husband was diagnosed with Alzheimer's in 2002, our then-PCP had no clue what to recommend, and when I asked if he knew of any clinical trials underway for Alzheimer's medications, he said, "Why would you want your husband to be a guinea pig?" His only suggestion? "Live each day to the fullest."

I found a new doc immediately, one who was not a geriatrician per se but was known for his caring treatment of elderly patients -- and, it turned out, of their caregivers. He was of enormous help to me when my husband eventually got cancer and I had to decide whether to put him through chemo. With the doc's compassionate support, I decided not to, and my husband died shortly thereafter. I will never forget that doctor. If only there were more like him.

Troubling. The huge demographic change alone, regardless of whether we think adequate resources may be in place, is overwhelming, The projection of a doubling of the number of those 65 and older in the U.S. in a 16 year period (now just over 13 years) is mind-boggling enough, but we seem to be moving further and further away from meeting the various needs that come with this. Here in Illinois, whose budget stalemate went for more than a year, many social services have gone far too long without the public funds that typically keep them afloat. Although a six month "stop-gap" budget was recently adopted, most of our struggling social service agencies, including those providing senior services, still have seen no payments from the state, and some have gone without their federal funds because the governor says no "pass-through" funds can be distributed without a budget. Many people may not understand how bleak the big picture here is, but it is very harsh indeed.

I fear we may be rapidly entering the dark age of which Jane Jacobs wrote a little more than a decade ago, but a prophet is not without honor save in his or her own land. You don't need a weatherman to know which way the wind blows.

I would recommend considering a nurse practitioner (NP) for your healthcare, especially a nurse practitioner with bedside nursing experience. Nurses understand the physical and psychological issues related to aging and the downside of aggressive, unnecessary treatments. A nurse with 5 – 6 years of bedside experience before going into an advanced practice program has the 10,000 hours of caring for patients that Malcolm Gladwell says is needed for mastery in a field. Nurses are also trained to identify and report changes that may require a physician’s intervention.
Nurse practitioners are less likely to have crushing student loan debt or the sky high malpractice premiums of physicians. Because of decreased financial pressures, they may be able to spend more time with you. Obviously, there are good and bad actors in every field but in light of the reality of a geriatrician shortage, consider a NP.
Full disclosure, I am a nurse and my primary care provider is a NP.

I agree Mia. My NP is my go to person. She is part of my primary doctors practice. She is more available either in person or by telephone. I have enjoyed good health, I'm 73 and my NP provides everything I need with the connection to my primary if needed. My NP is highly skilled with advance degrees . Health care has greatly changed and I am very satisfied with this relationship. Gratefully I'm pharmacy free...do not need any meds at all, but know my NP has the knowledge if something may be necessary.

No, there aren't nearly enough. I just checked Google for those in the Denver metro and found 20-25.

I did note, with some relief, that there is a Dept. of Geriatrics at the Univ. of Colorado. UC has been my primary base for medical care for the last year and that relationship is destined to continue for at least another 4 or 5 years.

My bigger concern has always been being hospitalized and suddenly thrown into the care of a hospitalist who has never seen me before and must rely on whatever records do or don't come in with me. The one time it happened last year, it worked out fine. But I'm leary of any system where the doctor who knows me best won't be seeing me when I'm hospitalized. Seems to me that's when I'll need him or her the most.

While I would never advocate entering an assisted living facility over home based care , one of the "perks" of such a situation is access to doctors who specialize in treating the elderly.
I am fortunate to have such a physician who, not only has an understanding of the health needs of the elderly, but of my particular wants as well.
On our first meeting a couple of years ago, I expressed my desire to keep the medications to a minimum fearing that I would become one of those people who take 12 to 14 or more pills a day.
He promised to do his best.
So far, he had kept his promise.
Finding the right physician is a crapshoot.
Finding the right geriatrician is like shooting craps with phony dice.

If you look at the course of study for geriatrics or gerontology, it is not an easy road. So not surprising to me that there are few going into the field.
The future looks bleak for the aging and ailing population. All the more reason keep active and take good care of yourself so you can be self sufficient well into your later years.

To be clear: geriatricians and gerontologists are not interchangeable words; they are not the same thing. A geriatrician is a medical doctor with full medical training and extra study requirements in the treatment of old people.

A gerontologist is a personal with a degree in the study of social, psychological, cognitive, and biological aspects of aging. It is not a medical degree in any sense.

I just need to chime in again here, and say that while it would seem that a perk of assisted living would be access to physicians more experienced in treating the elderly, that alone should not be taken as an endorsement of their qualifications. When my in-laws moved into what appeared to be a very nice assisted living facility (and certainly was expensive) in the same town we live in, they chose the physician connected with that facility, rather than make the 35 mile trip back to the town they had lived in for most of their lives and continue to see the doctor there who had been providing their care for more than ten years, and was, in fact, a credentialed geriatrician with an excellent NP. After my father-in-law's death in that facility, and a rapid decline of my MIL within three months of being moved to the "memory care" floor after his death, we moved her back to her home where I took care of her for the next 18 months for several reasons. The first thing her doctor back home did was diagnose her with scabies. It took him about two minutes to determine this, pulling out his magnifying glass to show me the defining pattern of this condition. It turned out that a topical medication she had been prescribed by her doctor at the AL was, in fact, for scabies., We had been lied to, and I believe that she had been improperly treated for the condition, as it took me 30 days of consistent application to clear it up entirely. It turned out that she had been prescribed the cream at the AL three months earlier. The real horror that was revealed after moving her back home, is that the AL physician was charged with sexual abuse of a number of female patients. He worked with several AL's in northern IL and apparently this had been going on for a while. Just within the past year he was convicted of the charges and sentenced. You can never be too vigilant nor should you simply accept someone, based on their credentials, especially when putting the life of someone fragile and vulnerable in that person's care.

After working in nursing homes doing risk management for eight years after retiring as a staff mortician and picking up people from nursing homes in many locales in my state I would have to say that the neglected state of some of the clients that I had the pleasure of doing business for leaves me feeling like the entire field is at the level of (in Steve Martin's words) "Theodoric of York". I would also like to state that we can in no way judge long term care by the appearance of the facility. Some of the county and state facilities cared for patients much better than some of the high-end facilities that were self-pay. Also, long term care facilities are now being purchased by investment groups and the staffing goes down right along with the care. The entire scenario has left me with the feeling that we are just warehousing the elderly to support our health care system with no regard to quality of care, ethics or morality.

I would love to have a doctor who remembers who I am without looking at my chart. I have come to the conclusion that I have to be my own geriatrician. When you are shuffled between several doctors who do not communicate you can end up taking a medication that worsens a different problem.

I tried to get a geriatrician years ago and discovered that there is only one in my HMO and, of course, she is taking no new patients.

While some areas (California seems to be a pioneer in this) are using the Internet to have all of your doctors connected to each other working as a team. They discuss your condition and come to an agreement on what treatment would be best.

Those of us who have primary care physicians who see you once or twice a year and write out referrals to other doctors when something goes wrong don't have a clue as to your mental health or, seemingly, don't have a any information as to what the other doctor is prescribing.

So I listen to my body and decide when I need to see the doctor, try to avoid taking unnecessary medication and, to the best of my ability, take care of myself.

What Mia said.

A Canadian snowbird friend went to a Florida clinic last winter.

After explaining her symptoms, snowbird was seen by a fantastic caring nurse practitioner.

There was no waiting.

Snowbird asked to call her Canadian health plan office from the US clinic. She was immediately handed a phone. The call was a 1-800 free number.

Canadian office said "let me talk to the US clinic nurse practitioner." Canadian clinic gave the go ahead to US clinic.

All covered by snowbird's Canadian health plan.

NP's are trained to treat certain health issues, and they do it well.

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