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How Elders and Their Physicians Might Collaborate

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The U.S. geriatrician population has been hovering around 7,000 for several years without much change. At the same time, the elder population grows by about 10,000 a day. You see the problem.

One reason is that geriatrics is at the bottom of the pay scale for doctors and one reason for that is the time-consuming nature of the field wherein patients' needs are more complex than younger adults. As U.S. News reported in 2015:

”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...

“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.

“For example, older adults may have a hearing or visual deficit that impacts their physical health and quality of life. Something as simple as eye glasses or hearing aids can make a world of difference.

“'We look for little things that can improve quality of life and surprisingly enough you can often make things quite a bit better,' McCormick says.”

Because there are far too few geriatricians to go around, most elders, like me, wind up with a family physician or internist for their primary care. These men and women do their best to help but they are hindered by time constraints and by the less than adequate education they receive in medical school about old people's health issues:

”Despite the diverse range of knowledge and skills required to appropriately care for older adults, the median time devoted to geriatric education in medicine in 2005 was still only 9.5 hours,” according to a 2012 report published in The Gerontologist.

“A survey of medical schools in the United States revealed that less than half (41%) of responding schools have a structured geriatrics curriculum and less than a quarter (23%) require a geriatric clerkship.”

(As you can see in the quotation, these statistics are dated which is due, according to the report, to “an absence of more contemporary information” - common in healthcare related to elders – we are too often not included in studies or, as in this case, the studies are not conducted frequently enough.)

Eighteen years ago, Dr. Edward Ratner, a geriatrician and associate professor in the University of Minnesota’s Department of Medicine in Minneapolis started a senior mentoring program that had medical students spend a series of afternoons with older people as their mentors.

That worked well enough but students were reporting a lot of loneliness and isolation among the elders. So, according to an article at Next Avenue, he changed the program:

”Students moved into the Augustana Apartments in downtown Minneapolis, where their mentors lived — some of them very independently, some with a few support services. Augustana residents got new neighbors and companionship.

“The building, run by the senior housing and services nonprofit Augustana Care, filled several apartments that were standing empty. Augustana’s social services director got volunteer help from students with recreational activities and other needs that residents had.

“And the students gained more learning time with elders, a place to live near the university and a discount on rent in exchange for their volunteer work.”

Dr. Ratner goes on to explain the problem with the limited amount of geriatric study in medical schools – which is so bleeding obvious once someone says it:

”The trouble with traditional medical education isn’t just that it gives students only episodic glimpses of older adults or that it leaves out all the context of seeing them in their homes and communities. It’s also that every older adult the students see is sick, Ratner says.

“'That’s a terribly negative stereotype because most elderly aren’t sick most of the time,' he explains. 'If students think that elderly are always sick and disheveled and confused — because that’s how they look when they see them — they won’t appreciate that [older adults] can be a lot better after treatment and they’ll discount the value of even trying.'”

I've been thinking about elder medical care all week as an appointment with my primary care physician, not a geriatrician, was scheduled for this morning.

We are to check up on the “mystery malady” that is still with me, though less so than a few months ago, and I want to discuss with him why I am not taking his recommendation for a certain, well-known drug to treat osteoporosis or, in my case, osteopenia.

My physician is young – there are reasons this is good. But he also has little experience with the medical issues of old people yet so since I first met him late last year, I have made myself a mentor to him.

I haven't told him this and I probably won't. But I speak with him differently than physicians I had when I was younger and in the past decade of my elderhood because I believe we share responsibility for my wellbeing.

I know a lot more about my body than all the tests he schedules can reveal and because of what I do (this blog), I read a great deal more about the health and medical needs of old people than he has time for.

So gently, carefully and as it pertains to what is on our schedule on any given visit or phone call, I share my knowledge, my life experience as an old person and sometimes what I have learned from you, TGB readers, over the years.

It's not a lecture or a lesson; I make sure it is a conversation – short, to the point and not to get in the way of the expertise he has that I need to know.

This doctor is a good guy, I like him. But given the medical school deficiencies in geriatrics and, as we have discussed here many times over many years, no one really knows what it's like to be old until they get here.

So maybe my little project will help my physician not just with me but with future elder patients.

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Making a Good Life in Retirement

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An acquaintance, looking to discuss his recent unsought retirement, emailed to arrange lunch. His efforts to deal with retirement, he said, have been “futile” so far and he hopes my “advice will inspire” him.

Oy vey. Advice is not an item on my resume.

Two or three weeks ago I published a story here about how retirement is a good time to discover being in a world that prizes doing. It was a useful enough post but it doesn't cover the larger, existential shift from career to the next stage of life.

I'm probably not far off to say that about 99 percent of the 21 million results in a Google search, “planning for retirement,” is about finance and almost all of those are aimed at people who have both money to save or invest and many more years to do it.

But there are a lot more ways to arrive at retirement than planning for it. I'm one of them, one of the people who was age-discriminated (is that a verb?) out of the workforce long before I had intended.

And that was five years before 2008 when tens of millions of U.S. workers much younger than I were laid off 15, 20 or more years before their expected retirement date. Millions of them have never again worked in their fields nor for anywhere near the salary they had been making before the crash.

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So they were forced to retire only halfway through their expected career span living now on god knows what money or are eking out their years at minimum wage jobs until they are old enough for Social Security.

(An excellent piece of reporting on the latter circumstance can be found in a story titled “Too Poor to Retire and Too Young to Die” at the Los Angeles Times.)

But today, I'm concerned with the people in the middle, people like the friend I'm having lunch with next week and me and a lot of TGB readers: that is, people who may or may not have been surprised at finding themselves retired one day, who likely had to cut back expenditures but are not in dire monetary straits.

As I've related here more than once, I was lucky. I had begun this blog a year or so before I was laid off. It wasn't all smooth sailing – I flailed around working out money and living arrangements, and how to order my days without an outside schedule. But essentially I glided from a writing/editing web job with a four-hour, round-trip commute to a writing/editing web job with a two-minute commute, and it is still satisfying after 13 years at it.

In no way, when I started TimeGoesBy, did I have an inkling that it would become my main retirement interest - it was simple luck - and most people hit with unexpected retirement aren't even that well prepared.

Before settling into a new life, there are the practical realities, of course: money, location, healthcare. Once those are arranged, however, what comes next? What do I want to do with my time now? What will get me out of bed each morning? The questions are mostly short but hardly simple. Here are a few:

What gives me pleasure?
What do I most care about?
Can I use my career experience in new ways now?
What's been missing from my life?
What have I always dreamed about doing?
What gives me a sense of purpose?
What and who are most important to me?
What does an ideal day look like?

There are many others and the hard part is that no one can answer for you.

So for those of you who have already navigated to a satisfying life in retirement, how did you do that? And for those of you who haven't got there yet, how are you thinking about it? Or, maybe, what questions are you pondering?

Remember, this isn't about whether to move to a new city, state or country. Or whether to sell your home or what are the best investments for old people.

Instead, how did you or will you address these existential or life questions. How did you decide how to live these last years – maybe decades – in the most satisfying way for you?

This is important stuff for all older people and there may be hints in your thoughts for the rest of us.


The Republican Plan to Nuke the Internet

[I copied that headline from vanityfair.com because I'm lousy at headlines and “net neutrality” - which is what this is about - sounds boring. But it's important and depending on what happens, it could ruin your internet experience while also costing you more money for access.]

* * *

Here is a clear and concise, two-minute explanation of net neutrality from Armand Valdez at Mashable:

That was 2014. It is now three years later and this next video is an interview that was broadcast last week on the PBS Newshour with the new chairman of the Federal Communications Commission (FCC), Ajit Pai, about his plans to trash the net neutrality regulations that took effect in 2015.

Yes, it is seven-and-a-half minutes of two talking heads but it will save you 4,285 paragraphs written by me and give you some insight into this Trump-appointee:

Oh, man, this guy Pai is smooth. That alone should worry us all but don't forget, too, that like the rest of the Trump cabinet and agency heads, his first inclination is to trash the organization he now leads.

Since his appointment in January, Commissioner Pai has, according to billmoyers.com, already

”... moved aggressively to roll back Obama-era consumer protections and other regulations. He has undermined a program that provided low-cost broadband service to poor customers; eased FCC limits on shared service agreements between TV stations in the same market; reversed a rule that limited the number of airwaves any one broadcaster can own throughout the country; and removed caps on fees that ISPs could charge hospitals, small businesses and wireless carriers in markets where there is little competition.”

Further, in March, President Trump signed a bill that overturned a regulation requiring that internet service providers ask consumers' permission before collecting data from them about online activities. So that's gone now.

“'Recent weeks are prologue, and I am fearful that we are moving in a direction that will unravel and undo some incredible gains we’ve made for consumers,' Mignon Clyburn, the sole Democratic commissioner at the FCC, told The New York Times>.”

Since Mr. Pai's appointment in January, telecom and cable companies have flooded the FCC and members of Congress with requests to kill net neutrality. In addition, however,

”About 800 tech start-ups and investors, organized by the Silicon Valley incubator Y Combinator and the San Francisco policy advocacy group Engine,” reports The New York Times, protested the unwinding of net neutrality in a letter sent to Mr. Pai [last week].

“'Without net neutrality, the incumbents who provide access to the internet would be able to pick winners or losers in the market,” they wrote...”

Columbia University law professor, Tim Wu, is the man who coined the term “net neutrality.” Last Friday, he spoke out forcefully in The New York Times against Commissioner Pai's intention to make net neutrality voluntary (read: “eliminate”).

He notes that the change would raise prices on everyone and that net neutrality is wildly popular; a few years ago, four million people wrote the FCC to demand stronger controls of the cable industry “while those who took cable's side would have fit in the commission's lobby,” wrote Wu.

Here is some more of what he wrote:

”In analyzing the attack on net neutrality, one looks in vain for the problem that needs to be fixed...

“...it has sheltered bloggers, nonprofit organizatin like Wikipredia, smaller tech companies, TV and music streamers, and entrepreneurs from being throttled by providers like AT&T and Verizon that own the 'pipes'.”

Not to put too fine a point on this, it would mean that TimeGoesBy (and any of your blogs) could take so long to load onto your screen that readers would give up and never return.

More from Wu:

”Make no mistake: While killing net neutrality may be rolled out with specious promises of 'free video', there is nothing here for ordinary people. Lowering prices is just not something that cable or phone companies will do except under pressure.

“Instead, the repeal of net neutrality will simply create ways for cable and phone companies to tax the web and increase your broadband bill. Raise your hand if that sounds enticing.”

As vanityfair.com reports, the proposal will go up for a vote at the FCC's open meeting on 18 May. If it is approved (it will be), the public will have 60 days to file comments at the FCC website.

When that happens, I'll be reminding you of the need to make yourself heard and with this post today, you have the information we need to understand this crucial fight - and it is a fight, as Commissioner Pai himself made abundantly clear in a speech last week:

”Make no mistake about it,” he said. “This a fight that we intend to wage and it is a fight that we are going to win.”

Oh yeah?