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Where are the Geriatricians?

By Lewis A.Lipsitz, Globe Newspaper Company

October 13, 2003

Despite the enormous growth of the elderly population over the next few decades, medical care in the United States is ill prepared to meet its demands. According to the National Institute on Aging, by the year 2030, the number of individuals age 65 and older will reach 70 million, up from 35 million today. In addition, the "oldest of the old" -- those 85 and older -- will increase from 4.3 million in 2000 to 19.4 million in 2050. Unfortunately, few physicians have the skills or resources necessary to properly address the medical challenges presented by many elderly patients.

Geriatrics is a medical subspecialty that focuses on the diagnosis and treatment of conditions that affect people as they age. There are approximately 9,000 certified geriatricians in the United States , a figure that represents a striking one percent of all physicians. According the Journal of American Medical Association, we need 20,000 geriatricians now and 36,000 by the year 2030.

A geriatrician is a physician trained to handle the multiple, interacting conditions, drugs, social situations, and psychological problems an older person may face. Rather than trying to extend life at all cost, the geriatrician is focused on preserving or improving physical and mental function for whatever time remains. The quality, rather than quantity, of life becomes most important.

Unlike younger patients who are concerned with preventing illness or treating one disease, older patients may be grappling with falling, urinary incontinence, confusion and memory loss, depression, osteoporosis, and heart disease. The average 75-year-old has three chronic conditions and takes five prescription medications. The treatment of one condition may worsen another. Rather than looking at individual symptoms -- or dismissing a problem as "just part of getting old" -- a geriatrician considers the whole person, examining each individual's special characteristics, medical conditions, medications, values, and preferences in order to develop a treatment plan.

For the geriatrician, treating a patient is more than treating a disease: If a patient doesn't have transportation, keeping medical appointments is nearly impossible. If an individual can't pay the rent, then paying for expensive drugs is out of the question. If fingers are twisted by arthritis, then opening a pill bottle can be difficult.

Because of their unique needs, older people can fall between the cracks of conventional medicine. Most of the drug doses learned in medical school, for example, are based on studies done in younger people. Few medical schools and residency programs provide formal training in geriatric medicine. In addition, a specialist trained to focus on treating one condition may well miss another. The orthopedist, for example, who evaluates a patient's fall, looks for injury, just as the neurologist examines the brain and nervous system. Both doctors could miss an underlying cardiac condition that caused the fall. A geriatrician takes into consideration all the contributing factors.

We need more academic leaders in the field to teach medical students, residents, practicing physicians, and nurses how to provide better care of their elderly patients. Unfortunately, only 20 of 126 US medical schools require geriatric coursework.

Attracting doctors to geriatric medicine presents its own challenges. Few role models and mentors exist in teaching hospitals. The field lacks glamorous technology. Reimbursement rates are low, and patient care demands are high. In addition, hospitals and HMOs are reluctant to spend what it takes to provide excellent geriatric care. However, the potential cost savings to society are enormous. If proper geriatric care results in a modest 10 percent reduction in hospital, nursing home, and home care costs, the nation would save $50 billion in health care costs each year.

There are promising solutions to the shortage of physicians equipped to care for elderly patients. With funding for additional geriatric training programs, more doctors could gain the skills they need. Higher payments for geriatric care and loan forgiveness programs would do much to attract new physicians to the field. Greater research funding could help promising new investigators become leaders in the field of aging.

More geriatricians are needed to provide direct care to elderly people, consult on complex cases, improve the quality of care in nursing homes and other chronic care settings, and teach primary care and specialist physicians how to care for elderly patients. Not every older person needs a geriatrician; however, every physician needs some training in geriatrics. We urgently need to create incentives for more physicians to enter the field of geriatrics, before our parents -- or we -- are in need of a geriatrician, but can't find one.

Dr. Lewis A. Lipsitz is vice president of academic medicine and co-director of the Research and Training Institute at Hebrew Rehabilitation Center for Aged and chief of gerontology at Beth Israel Deaconess Medical Center .

Copyright 2002 Global Action on Aging
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