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Here’s why geriatrics really shouldn’t be a medical specialty

Here’s why geriatrics really shouldn’t be a medical specialty

Picture of Monya De
[Photo by Emilio Labrador via Flickr.]

In medical training, there were very few students or residents who intended to go into geriatrics, a subspecialty of medicine involving the care of older patients and an extra one-year fellowship after an internal medicine or family medicine residency. Future geriatricians got significant side-eye from their peers and superiors. “Bleeding heart,” people would think. “Oh, that’s so cute. She’s frumpy — it’s kind of a frumpy field.” Or: “What’s the point of medical school to end up working harder for less money?” Cardiology or gastroenterology, with their video-game procedures, one-percenter salaries and prestige, were sexy specialties. Taking care of old people? Not so much, and not really better paid than foregoing the extra year of training at $55,000 per year and going straight into private practice as a primary care doctor.

Except by 2050, one in five people will be elderly, and that growth is happening now (between 2010 and 2030) as baby boomers are aging over 65. And today’s graduating doctors have an education that emphasizes the care of patients up to the age of 55. The elderly have the same diseases as young and middle-aged adults, but with more of them. They face higher risks when it comes to drug interactions and surgical complications, and more complex critical care wishes (for example, a 95-year-old may ask not to be put on chemotherapy or resuscitated).

Our medical education, particularly in books and written tests, was lopsided toward single-answer cases (Who always needs a chest X-ray for TB screening? Immigrants who had a TB vaccine as a kid) and inherently interesting factoids about rare conditions (a red eye with nausea and vomiting means acute glaucoma). Of course, all this information is useful and relevant. But we graduated medical school lacking confidence about how to manage pain in a 90-year-old cancer patient. Drug interactions and dosing adjustments for the elderly get short shrift. Family practice doctors often know more about rare pediatric genetic diseases than they do about clearing an elderly female for surgery. How do you balance depression, epilepsy, and pain treatment in a 75-year-old? We were not challenged to answer these questions often enough, and the advice to “be slow and careful” was not enough.

We graduated medical school lacking confidence about how to manage pain in a 90-year-old cancer patient. Drug interactions and dosing adjustments for the elderly get short shrift. Family practice doctors often know more about rare pediatric genetic diseases than they do about clearing an elderly female for surgery.

Much has been written about the fallacy of the 15-minute appointment. Doctors who see older patients have an even harder time with this restriction, given the delays in check-in from a patient who might be slowly trudging with his walker from the parking garage, struggling with confusing instructions, or dealing with disagreements between family members in the exam room. But given our demographic future, this type of appointment will increasingly dominate future physicians’ offices. These patients are not just a temporary inconvenience until the “easy” 20-year-olds come in for their birth control refills.

The idea that older patients will disappear conveniently into geriatricians’ offices once they turn 65 or 70 is just that, an idea. The Wall Street Journal has reported on a shortage of geriatricians. As of 2014, the fellowship positions for geriatrics were the least likely to be applied for or accepted, leaving hospitals with geriatrics funding and no doctors to train. As of 2017, this continues to be the case. Several medical centers in the U.S. have been looking for a geriatrics fellow for nearly a year. Many hospitals do not even have a geriatrician on call to consult on tricky medical decisions or prescribing plans.

The solution is to give every doctor who is not a pediatrician — urologists, primary care doctors, cardiologists —the needed training so they can care for older patients. Geriatric patients should be better represented in test questions and medical books, and training programs with relatively young patient populations should make efforts to ensure that their students know the guidelines for elderly patients and have more of these patient encounters under their belts by the time they finish residency.

Rheumatoid arthritis and myelofibrosis are conditions that require switching to a specialist. Being old should not be.

[Photo by Emilio Labrador via Flickr.]

Comments

Picture of <span class="username">Guest (not verified)</span>

About 46% of seniors already live in 2621 lowest physician concentration counties with 42% of Americans. Soon this will be over half of seniors as more seniors are driven out of higher concentration counties by worsening housing deficits. Only 13% of geriatricians are found in the lowest concentration counties. The lack of geriatric care and the maldistribution is entirely about the financial design - payments too low for care most complex and costly. Geriatric workforce has to cluster around in-kind contributions from academic, geriatric rehab, or long term care settings.

It is the same financial design that defeats generalists and general specialty services that are 90% of local services in lowest concentration counties. Family practice positions filled by MD DO NP and PA are by far the most important local contributor.

Family practice is the only specialty with population based distribution. About 36% of family practice positions match up to this 42% of the nation. Other specialties concentrate with higher concentrations of physicians, social determinants, and better paying insurance plans. Providers in lowest concentration counties care for the most complex patients despite receiving lowest payments and being forced to address crippling increases in cost of delivery. They are paid less and penalized more because they serve where needed. They must perform geriatric, pediatric, mental health, public health, and other services as there is often no one else to do so - adding more to complexity but again without the support for the team members that already do too much for too little.

Workforce deficits are predominantly about the financial design. This design is so powerful that no training intervention is capable of addressing care where needed.

Picture of <span class="username">Guest (not verified)</span>

That headline is a problem. The issue is not whether geriatrics should be a specialty; it's whether you should need to see a geriatrician to get good care when you are older, and whether everyone should keep expecting geriatricians to take care of all those challenging older people. The answer -- as the author says -- is no, and no.

Geriatrics, like pediatrics, is the art and science of modifying healthcare so that it's a better fit for people at a certain stage of life.

In fact, the author never states geriatrics shouldn't be a specialty, so the headline is perhaps an unfortunate editorial decision. It certain distracts from the author's comments, which are mostly spot-on.

All clinicians -- other than those specialized in peds and OB -- should be trained in geriatrics. Currently all medical students and family practice residents must rotate on peds; why not for geriatrics?

Just as PCPs are expected to manage basic cardiology problems -- and they rotate on cardiology during residency, to prepare them for this -- they should be able to manage basic geriatric syndromes. (So they should have rotations during residency, required.) Specialists should be reserved for teaching, and for the hands-on care of more complex situations.

I applaud the author's ideas. But we should be careful about headlines that further devalue a specialty that is already underappreciated.

Picture of <span class="username">Guest (not verified)</span>

Older people can be very helpful in the world and need to be kept in the best health as possible!

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