By Brian Goslow
Like many of his fellow geriatricians, Dr. Gary Blanchard of St. Vincent’s Hospital in Worcester has been keeping a leery eye on Jan. 1, 2011. That’s when the “Silver Tsunami” of baby boomers first hits the United States’ Medicare/Medicaid system with over two and a half million Americans turning 65 in the following 12 months alone.
With only 100 or so students graduating nationwide with a geriatric degree from medical school each year, it’s easy to imagine the challenges ahead for both the medical profession and those who will need their services.
A 2008 study by the National Academy of Sciences, “Retooling for an Aging America: Rebuilding the Health Care Workforce,” warned, “Recruitment and retention of all types of health care workers is a significant problem, especially in long-term care settings. Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.”
Should you be worried?
“In a word, yes,” said C. Seth Landefeld, M.D. of the University of California, San Francisco. “They should be especially worried as they become sick or frail. Most people at 65 are still pretty robust. I’m more concerned about the ability (to access proper care) for folks as they slow down and become less able to do everything they were used to doing in their 50s and 60s. Generally, with people, when they reach their 70s, 80s and 90s, they begin to slow down. They may not be able to do the chores they used to do or they become forgetful.”
When that occurs, more than likely, it’s not a single health issue, but a combination of them affecting one’s health. “It’s a collection of diseases that make treatment complex,” Landefeld said.
“The health care system is set up for a kidney replacement, a PET (Positron emission tomography) Scan or to fix someone’s cataracts.
“But they’re not ready for when somebody falls or becomes a bit more forgetful than they used to be,” he continued. “Traditionally, treatment has been organ specific — something’s broken, we can fix it. That doesn’t work in these instances.”
While it may be easy to find a neurologist or a cardiologist, said Landefeld, it’s harder to find somebody to talk about such issues as what memory problems mean and whether an elderly person should be driving “Finding good care for those who become frail is really hard,” he said.
Blanchard, a Fifty Plus Advocate contributor, hopes to help alleviate the shortage of geriatricians by sharing his knowledge through a chief resident immersion program in geriatrics and geriatric principles for those in a position to influence the greatest number of students at the UMass Medical School in Worcester.
Of the 100 or so doctors who enter the field of geriatrics each year, Landefeld noted that not all of them remain in the United States. Those who do, he said, “have to take care of tens of millions of people.”
Almost everyone will eventually find this shortage affecting the care of loved ones. “The shortage of geriatricians comes home to roost when you’re 40 or 50 and you can’t find someone to care for your parents,” Landefeld said. “And if you do find someone, the treatment can cost six figures.”
Carol Grannick of Wilmette, Ill., is grateful for a friend’s referral that enabled her to find an area geriatrician to look after her mother during the final 15 years of her life. Annette Coven had begun to be confused about her medication in her early 70s and had moved closer to her daughters. “She didn’t have Alzheimer’s,” Grannick said. “It was just complicated.”
Grannick said her mother’s main complaint was seeing lots of specialists and doctors who weren’t sensitive to her needs. “They’d say, ‘That’s because you’re old,’” Grannick said. “That’s not the best way to do it. Older bodies don’t metabolize medicine and food the same way and if doctors aren’t sensitive to that, it’s a real issue.”
She couldn’t say whether Coven’s doctor’s sensitivity was due to his training as a geriatrician; what made him stand out was his ability to address each medical issue on its own merit. “His attitude was let’s take this person where she’s at in every way in the context of her life — not just how she was living that day, but where she wanted to live and how she took care of herself,” Grannick said. “He was always kind and caring and sweet to her. He was always patient with her, even when she was feisty, which she could be. But he didn’t let it bother him.”
That turned out to be a good thing because when it came to following a healthy diet, Coven wasn’t always on her best behavior. “She was a non-compliant diabetic; she didn’t want to be told how to eat,” Grannick said. “Her doctor adjusted her medication accordingly. If she ate sugar-containing ice cream, which she shouldn’t have done, he gave her medicine to offset that. He put her on a low-salt diet for a week. She tried it, but knew it wouldn’t work. So he adjusted her medicine.”
The doctor not only worked with his patient, but with Grannick and her sister, who had a hands-on partnership in looking after their mother. All three agreed the doctor had the final word on treatment. “They (the doctor and Coven) had a strong bond that helped him care for her and helped by being our lynchpin when she didn’t want to take her meds. We’d say, ‘Your doctor wants you to take them.’ She respected him enough that she’d take them. Only at the end of her life, the last month when she was in hospice at home, did he agree she could stop taking her medication (because it was so difficult for her).”
Coven passed away just short of her 91st birthday last fall.
When St. Vincent Hospital’s Blanchard graduated from Tufts University in 2004, he had only received two weeks of geriatric training, at most. That’s slowly changing for med school students. “I’m optimistic the interns of today have a better mindset (toward older patients than when I was a student),” he said. “When it comes to geriatric patients, interns now consider the (overall) effect of a medication, maybe giving a smaller dose.”
A huge barrier in attracting current doctors and medical school students to becoming geriatricians is the pay tends to be less then in a general practice. In most instances, Medicare and Medicaid, which many older Americans depend on for their medical coverage, reimburses at a much lower fee. That’s unappealing for a student looking at thousands of dollars of college loans to pay off. Six years after graduating, Blanchard still finds himself saddled with a quarter of a million dollars of student loan debt.
“Medical school students don’t want to go into geriatrics,” he said. “You have to get extra schooling to become board certified, but even with the extra schooling, geriatricians make less money.”
Blanchard said a financial incentive might help turn things around. “It’s not motivated by greed or design to do more procedures and make money,” he said.
Blanchard said most Americans are used to their annual checkup taking 15 to 30 minutes, followed by the suggestion they lose some weight and perhaps start taking a medication to alleviate high blood pressure. “It’s not that simple when you walk in with an array of health issues and a failing body,” he explained. “Primary care physicians don’t have the time (to address them all properly). They only have a half-hour to cover 12 medicines and six problems.”
Also, some physicians have an age bias and haven’t acknowledged the expanding lifespan, now 78.3 years for the average American, a good 10 plus years longer than when most doctors entered the medical profession. “It’s about a mindset,” Blanchard said. “I can see a hearty 91-year-old with the protoplasm of a 73-year-old.”
Geriatricians don’t need to be a person’s primary health care provider, Blanchard said. “They can set up the system of care and provide the expertise,” he noted, adding, the shortage in the field means there isn’t a huge pool of geriatricians available to share that knowledge.
That’s what University of California’s Landefeld is doing. He contributed to the compilation of “Care of the Aging Patient: From Evidence to Action,” an ongoing series of articles in JAMA, the journal of the American Medical Association, that began in January. It’s aimed at educating physicians on the differences between geriatric and primary care and how to go about learning how to care for those 60 and older.
“A lot of people (physicians) assume they can take care of older patients but it is a little different,” Blanchard said. “It’s up to physicians already in the medical field to educate themselves on and keep up with trends in the geriatric field.”
When might the public start clamoring for the shortage of geriatricians to be addressed? “They’ll feel it when they become frail and have to see eight different specialists,” Blanchard said. “Then the chorus will grow louder.”