Recognizing a need for more elderly care

Health: The field of geriatric medicine is growing in popularity, but there are still too few practitioners to meet demands.

Life After 50

November 07, 1999|By Marsha King | Marsha King,Knight Ridder/Tribune

The field of geriatrics never used to exist in medical-school curriculum, had no leaders and offered little opportunity to students.

But in the past few years, student interest in learning to treat and care for older adults has increased significantly at medical schools across the country.

University of Washington medical student Karin Harp chose this four-week rotation "because I've always been interested in geriatrics and wanted to see if it was something I wanted to do for the rest of my life."

That's the hopeful news. But the less-hopeful reality, many say, is still that there may never be enough geriatricians trained to care for aging baby boomers, who are expected to survive into their 80s and 90s in record numbers.

"The sad fact is that not enough is going on. There is a tremendous national shortage of people who are qualified in the area of geriatrics," said Joseph Cerquone, spokesman for the Alliance for Aging Research in Washington.

The Alliance predicts that there will be only 7,000 qualified geriatricians in the United States next year, when the country will need 22,000 or 23,000.

Still, the field of geriatrics today finds itself the object of increased attention, even a little bit popular.

And everyone agrees the field has seen tremendous change.

More students of better quality are applying for geriatrics fellowships and scholarships at medical schools such as University of Washington, UCLA and the University of Michigan.

Geriatrics is one of the fastest-growing disciplines in medicine, drawing 67 percent more fellows than it did three years ago, compared with applicant drops in fields such as cardiology, traditionally considered more glamorous, according to the American Board of Internal Medicine. However, the numbers in geriatrics remain tiny compared with those in other fields.

Philanthropic organizations, particularly the John A. Hartford Foundation in New York, are pouring money into research and clinical scholarships in geriatrics at selected medical schools.

Most of the country's 125 medical schools now teach geriatrics as part of a required course. They have broadened their electives in geriatrics and beefed up research. National boards that regulate the training of doctors have instituted requirements for geriatrics in primary care, family practice and internal medicine.

The strategy at top medical schools never has been to produce enough geriatricians to treat every person who reaches a certain age or acuity of illness. Instead, the idea has been to train a cadre of specialists whose main job is research, teaching and acting as cheerleaders for the rest of the medical profession.

But some say that approach is likely to be too little, too late.

Indeed, the number of doctors actually graduating with a specialty in geriatrics is still minuscule: a little more than 200 a year among the 15,000 to 16,000 who graduate annually from medical schools.

That means the bulk of the care for older people still will be provided by generalists, many of whom don't understand the unique medical needs of older adults, said Dr. David Reuben, chief of the geriatrics division at UCLA.

"If these doctors don't know how to care for old people, then we're in deep trouble," he said.

Inadequate Medicare reimbursements likely will continue to play a huge negative role, according to several physicians.

"The big reason more doctors don't practice geriatrics is that basically you get paid 30 percent less per hour under Medicare fees than any other insurance," said Dr. John Addison, who has practiced the specialty in Seattle for the past 16 years. On top of that, older patients take more time and have more complex medical issues, he says.

"There's a long way to go," says Dr. Wayne McCormick at UW.

But he also believes the message that older people may need special consideration and different treatment has reached medical students and residents.

Students and doctors who practice geriatrics see firsthand the potential rewards and challenges.

They learn that older adults are more sensitive to medication and to infection, that some drugs don't work or may even kill them. Older adults are susceptible to multiple, complex problems. They may have high blood pressure, osteoporosis, incontinence and arthritis all at once. Cognitive deficits and depression are common. They may not have family or social support.

"I like the patient population. I like to hear their stories, and I like the pace, which is often a little slower than with younger patients," said UW geriatric fellow Dr. Evan Seevak. "A lot of the patients we see have complex medical problems, and the symptoms are subtler."

Talking with older patients requires unusual sensitivity and even detective skills.

"You have to allow more time. You have to give people time to pause," said fourth-year student Harp. "If you wait, you get a lot more information."

And the whole philosophy of geriatrics is different. The goal isn't necessarily to cure disease, but to return people to as high a level of functioning as possible with as little treatment as possible.

"It just gives you a good feeling," Harp said, "to help somebody get back to where they came from."

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