As the population of the United States grows older and lives longer, the shortage of doctors trained to treat the problems of the elderly has become acute.
Most doctors, even those who have a lot of elderly patients, have had little, if any, systematic training in geriatrics, and medical schools are only now introducing such training.
According to Dr. Louis J. Kettel, a former medical school dean who is now a vice president at the Association of American Medical Colleges, doctors and medical educators nationwide are finding that their patient population has aged dramatically -- but that much basic knowledge about older patients is still lacking.
"We don't know the normal lung volume or hemoglobin of someone who's 90, because the charts and research didn't go out that far," he said. "There's now a lot going on to try to catch up on that. We need geriatricians to teach and do the research, but they can't possibly treat all the elderly. Every internist, every surgeon, every anesthesiologist, every gynecologist needs to know more about treating older people."
In recent years, a new body of knowledge has developed on some common medical problems affecting the elderly, including incontinence, depression, dementia and falling. Such chronic problems, one on top of the other, often snowball to the point where the frail elderly can no longer manage an independent life, especially when doctors unaware of the latest research simply dismiss their problems as an untreatable fact of aging.
"I had a 79-year-old lady, sharp as a tack, who was wheelchair-bound and incontinent when I met her," said Dr. Walter Ettinger, a geriatrician at the Bowman Gray School of Medicine in Winston-Salem, N.C.
"She had pains in her knees and early Parkinson's, which made it hard to walk, and was taking diuretics for her high blood pressure, which made her wet herself because she couldn't get to the bathroom, and without exercise, she had put on weight, making it even harder to get around."
Dr. Ettinger found that the knee pain was treatable bursitis. Along with treatment for the Parkinson's and weight training for strength and fitness, the woman was ultimately able to walk and use the bathroom.
"Like most of our patients, it wasn't that she had had terrible treatment," Dr. Ettinger said. "But no one else had the time to think about her problems overall or the resources to try to restore her function."
The 32 million Americans who are 65 years old or older make up 13 percent of the population but account for 44 percent of all days spent in the hospital, 40 percent of all visits to internists and a third of the nation's health care expenditures.
But while medical students see many older patients during their training, most do not have any formal instruction in geriatrics. Only 13 of the 126 American medical schools require either a course or a clinical rotation in geriatrics.
And although most medical schools offer elective courses in geriatrics, only 3 1/2 percent of the students take them, according to the Association of American Medical Colleges.
"If you ask medical students graduating from most of these schools that don't have required courses what they know about geriatrics, I can guarantee you, you'll get a blank look," said Dr. William Hazzard, chairman of the internal medicine department at Bowman Gray, which requires a geriatrics course.
While no one suggests that the internists and family practitioners who provide most general care of older people should be replaced by geriatricians, many health experts say it is crucial to develop a cadre of geriatricians to consult on difficult cases, do research on the aging and teach young doctors how to treat the elderly.
"No one thinks that all the care of older people should be by geriatricians," said Dr. T. Franklin Williams, director of the National Institute on Aging. "What we're saying is that all physicians need to learn more about aging, because most patients, except in pediatrics or obstetrics, are going to be older people. Until recently, we didn't have many people who were very old. But with the population aging, every community and every nursing home should have at least one qualified geriatrician available to consult."
Geriatricians are especially useful for people over 85, a segment of the population that increased to 3.3 million in 1990 from 1.4 million in 1970, and will likely top 6 million by 2010.
"You really need to know how diseases interact when you have a patient who's 85, has diabetes and osteoarthritis, doesn't see anymore and has cognitive deficits," said L. Gregory Pawlson, a geriatrician at the George Washington University School of Medicine, and past president of the American Geriatrics Society. "You need to consider how all those things affect his life."
Some experts say there are simply not enough academic geriatricians to teach such skills.