Monday, February 29, 2016

Doctors and the Aging Population

The general decline in birth rates coupled with improvements in longevity have led to populations in developed countries where the fractions of elderly are increasing.  This chart from the OECD illustrates this trend.

One consequence of this demographic shift is that healthcare industries must deal with a larger number of aged patients and their associated health issues.  The medical discipline focused on the health of seniors is geriatrics.  One might assume that societies would be preparing for this mission by training greater numbers of geriatricians, but one would be disappointed.  The Association of American Medical Colleges provides this perspective.

“The statistics tell the story: By 2025, the number of Americans over the age of 65 will nearly double, making them the fastest-growing age group in the country. Providing quality medical care for these seniors will require a certified geriatrician population of 25,000 according to The American Geriatrics Society, but as of 2014, there were fewer than 7,500 geriatricians in the United States. Only eight of the country’s 145 academic medical centers have full geriatrics departments, and only 44 percent of the nation’s 353 geriatric fellowship positions are filled.”

We will have far fewer doctors than needed trained to deal with the problems of the elderly.  That means most will be treated by physicians who have little or no training in addressing their special needs.  Since much of the burden of healthcare costs arise from end-of-life medical treatments, this appears to be a rather absurd failure in public policy.

“Older adults soon will surpass pediatric patients in the percentage of practice time devoted to them, and they bring a set of needs that are both specific and highly complex. Currently, however, geriatrics rotations are still elective in most internal medicine, family medicine, and psychiatry programs.”

Atul Gawande, a surgeon, has written eloquently of the special needs and circumstances of the elderly and others whose health has left them in a fragile state in his book Being Mortal: Medicine and What Matters in the End.  He provides this insight.

“Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010.  Applications to training programs in adult primary care medicine have plummeted, while fields like plastic surgery and radiology receive applications in record numbers.”

This is a classic example of market failure.  Doctors expect to make money so they tend to go where the money is.  Dealing with old people is not particularly rewarding financially, nor is it an easy task.

“….incomes in geriatrics and adult primary care are among the lowest in medicine.  And partly, whether we admit it or not, a lot of doctors don’t like taking care of the elderly.”

Gawande quotes the geriatrician Felix Silverstone.

“Mainstream doctors are turned off by geriatrics, and that is because they do not have the faculties to cope with the Old Crock…..The Old Crock is deaf.  The Old Crock has poor vision.  The Old Crock’s memory might be somewhat impaired.  With the Old Crock, you have to slow down, because he asks you to repeat what you are saying or asking.  And the Old Crock doesn’t just have a chief complaint—the Old Crock has fifteen chief complaints.  How in the world are you going to cope with all of them?  You’re overwhelmed.  Besides, he’s had a number of these things for fifty years or so.  You’re not going to cure something he’s had for fifty years.  He has high blood pressure.  He has diabetes.  He has arthritis.  There’s nothing glamorous about taking care of any of those things.”

Most doctors are trained to fix things.  A patient is someone with a problem, and her job is to fix that particular problem.  For a patient aging and approaching end of life, the problems accumulate and interact and the notion that they can be treated individually can lead to disastrous outcomes.  The appropriate skill provided by geriatric doctors is to know how to manage a collection of ailments while still taking into account the continuing quality of life of the patient.

Gawande observed several geriatricians in practice and learned that there is a necessary level of skill required in dealing with the elderly who are in fragile health.  One was named Juergen Bludau who provided valuable insight.

“The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease and the retention of enough function for active engagement in the world.  Most doctors treat disease and figure the rest will take care of itself.  And if it doesn’t—if a patient is becoming infirm and heading toward a nursing home—well, that isn’t really a medical problem, is it?”

“To a geriatrician, though, it is a medical problem.  People can’t stop the aging of their bodies and minds, but there are ways to make it more manageable and to avert at least some of the worst effects.”

Most doctors are trained to take a different approach, as Gawande admits.

“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 high blood pressure, arthritic knees, and various other ailments besides—an elderly woman at risk of losing the life she enjoys—and we hardly know what to do and often make matters worse.”

Treating each ailment individually rather than as a collection of issues often means utilizing different doctors for each problem, making it difficult for each physician to know of, or to care about, other medications or treatments the patient is receiving.  Also, this approach relieves each doctor of any responsibility for addressing any social or personal issues the patient might be having that could interfere with her treatment.

Gawande tells us of a study performed by researchers at the University of Minnesota on 568 patients who were over age seventy and suffering from health problems sufficiently severe that they were at risk of becoming disabled.

“With their permission, researchers randomly assigned half of them to see a team of geriatric nurses and doctors—a team dedicated to the art and science of managing old age.  The others were asked to see their usual physician who was notified of their high risk status.  Within eighteen months, 10 percent of the patients in both groups had died.  But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression.  They were 40 percent less likely to require home health services.”

The team leader, Chad Boult, and the other geriatric specialists at the University of Minnesota were rewarded for this good work by losing their jobs as the university closed down the division of geriatrics.  The issue was cost.  If these specialists had been making heroic interventions with expensive drugs, devices, and procedures, there would have been no financial problem.  Unfortunately for the geriatricians, but fortunately for their patients, they were doing little of that.

“Instead, it was just geriatrics.  The geriatric teams weren’t doing lung biopsies or back surgeries or insertion of….[devices].  What they did was to simplify medications.  They saw that arthritis was controlled.  They made sure toenails were trimmed and meals were square.  They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.”

The Minnesota geriatric team had actually saved the nation money with their efforts, but because of the way Medicare is required to finance healthcare, they received no credit for it.  Medicines, devices, and procedures are reimbursed.  However, cutting back on those types of things and spending more personal time assisting the patients is not.  So although Medicare was being saved money, the university housing the study was losing money.

“Scores of medical centers across the country have shrunk or closed their geriatric units.  Many of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients.  ‘Economically, it has become too difficult,’ Boult said.”

“I asked Chad Boult, the geriatrics professor, what could be done to ensure that there are enough geriatricians for the surging elderly population.  ‘Nothing,’ he said.  ‘It’s too late.’  Creating geriatric specialists takes time, and we already have far too few.  In a year, fewer than three hundred doctors will complete geriatric training in the United States, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade.  Geriatric psychiatrists, nurses, and social workers are equally needed, and in no better supply.  The situation in countries outside the United States appears to be little different.  In many, it is worse.”

Boult and others believe that the only possible strategy is to make geriatric instruction an integral part of the training of primary care physicians and nurses.

“Even this is a tall order—97 percent of medical students take no course in geriatrics, and the strategy requires that the nation pay geriatric specialists to teach rather than to provide patient care.  But if the will is there, Boult estimates that it would be possible to establish courses in every medical school, nursing school, school of social work, and internal-medicine training program within a decade.”

Gawande warns us that the medical system is designed to support and finance extreme procedures that might make sense for a person who could have decades of life remaining if successful, but it is not designed to assist people who have few years left and might prefer to spend the remainder of their time as comfortable and active as possible.

Most doctors would prefer to encourage the sick to pursue all known options to attack their disease.  They are uncomfortable with the notion of the heart-to-heart talk with the elderly where they ask if they prefer to spend a few of their remaining years in pain, discomfort, and isolation in order to perhaps have a few more if treatment is successful.  The option of foregoing extreme treatments in order to spend whatever time is remaining with family and friends often never gets discussed.  Palliative care is often the best option for patients—if they are given the opportunity to consider it.

“When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept that we are not.”

Gawande offers his feelings about how medical professionals should approach treatment of the elderly.

“Sometimes we can offer a cure, sometimes only a salve, sometimes not even that.  But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.  When we forget that, the suffering we inflict can be barbaric.  When we remember it the good we do can be breathtaking.”

The specific needs of a growing population of the elderly seem to have been lost in our focus on market-based solutions.  There is much yet to be done in terms of medical training and policy making if we are to be properly prepared for inevitable demographic changes.

Gawande’s book suggested earlier posts that the interested reader might find informative.

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