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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