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America's 'Forgotten' Patients

By: Source: AARP Bulletin Today Date Posted: 2003-07-30 14:28:15

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The seizures came on suddenly, without warning, until one nearly killed him.

Stephen Bzdok's neighbors found him lying unconscious on the floor of his Las Vegas home four days after he suffered a seizure so violent that it plunged him into a deep coma.

Bzdok woke up in a hospital bed four and a half months later.

"When I went into the coma I weighed 220 pounds," Bzdok, 68, told the AARP Bulletin. "When I woke up from the coma, I weighed 123 pounds, and I did not have the use of my legs."

Bzdok's seizures, it turned out, were caused by an irregular heartbeat—a condition that his heart specialist and other doctors had missed. It was a geriatrician—a specialist in the care and treatment of older people—who made the connection.

Bzdok had a pacemaker implanted and hasn't had a seizure since.

"My health problems started to turn around immediately," Bzdok, a retired singer, says. "It's unbelievable." He believes that earlier intervention by a geriatrician would have prevented his life-threatening ordeal.

WHERE ARE THE SPECIALISTS?

Bzdok's experience may not be all that unusual. Experts say that millions of older Americans face greater risks of misdiagnosis, misuse of prescription drugs and other medical problems because only about 9,000 doctors—less than 2 percent of the 650,000 physicians nationwide—specialize in geriatric medicine.

At least 20,000 geriatricians are needed to care for the nation's 35 million older people, according to a recent report by the Alliance for Aging Research, a not-for-profit advocacy organization in Washington, D.C.

For some older patients, being cared for by doctors and others with little or no experience in the field of aging can have dangerous—even deadly—consequences.

In the realm of prescription medicines, for example, some doctors do not know that older people metabolize certain drugs differently from younger people and may face potentially hazardous interactions from drugs prescribed by different practitioners.

In other cases, doctors dismiss an older patient's symptoms as a "natural" part of aging when in fact they're caused by an illness or medical condition.

"Half of my patients come to me because they're not satisfied with the care they're getting," David Reuben, M.D., chief of geriatrics and professor of medicine at the University of California, Los Angeles, told the Bulletin.

FROM CREATION TO CRISIS

As medical specialties go, geriatrics is still relatively young.

In 1909 Ignatz Nascher, M.D., coined the word geriatrics in an article for the New York Medical Journal in which he suggested that the diseases of old age and their treatment needed "a separate place in medicine," just like pediatrics.

But for many decades geriatrics was "medicine's forgotten discipline," as one medical historian has written. It wasn't until the 1960s that some within the profession forcefully took up the needs of older patients.

Robert Butler, M.D., the founding director of the National Institute on Aging, was among them.

"The whole country is going gray, and we don't have enough geriatrically trained doctors to take care of everyone," says Butler, the founder and president of the International Longevity Center, a nonprofit research and education organization based in New York. In a recent report, his organization branded the shortage of geriatricians "a national crisis."

Reuben, Butler and other specialists in aging and geriatrics point to two central factors that are behind the shortage:

• Money. Medicare reimbursement rates don't take into account the extra time that doctors typically spend with older patients. Geriatricians argue that a routine office visit for an older patient may take up to twice as long as for a younger patient.
• Prestige. Geriatrics isn't viewed as glamorous or "glitzy," Reuben says. And because it's far less lucrative than other specialties—cardiology, for example—fewer medical students are attracted to the field.

William Hazzard, M.D., professor of medicine at the University of Washington, blames a "society-wide denial of aging" for the shortage of geriatricians. "There is a lack of respect and support for those who care for the elderly," Hazzard says.

Most doctors admit that older patients can at times be difficult to deal with. But without physicians or specialists educated in the field, the needs of older patients—particularly those with complicated or multiple conditions—may go unmet.

MOMENTUM FOR CHANGE?

On Capitol Hill, some lawmakers are trying to address the critical shortage of geriatricians, though progress seems to be at a snail's pace. Members of Congress have introduced legislation that would offer various financial incentives, such as loan forgiveness and continuing education funds, that are designed to encourage medical students to study and specialize in the field of aging.

Help is overdue. Just a few of the 144 medical schools in the United States promote the teaching of geriatrics, reports the International Longevity Center. Only three of the 144 have full departments in geriatrics. By contrast, nearly all medical schools in Great Britain and more than half of those in Japan have departments of geriatrics.

Moreover, only 12 medical schools in the United States require their students to take courses in geriatrics.

"We're not training enough people in geriatrics … and we haven't built it into our curriculum," says T. Franklin Williams, professor of medicine emeritus at the University of Rochester in New York and a former director of the National Institute on Aging. "What we see often is older patients get into trouble with some common problems because physicians haven't been well-enough prepared to address them.

"I've seen patients whose conditions have deteriorated because doctors weren't sensitive to the type of problems they had."

Marie Brown of Washington, D.C., knows this firsthand. The medical care her 96-year-old mother received after she broke her hip two years ago changed her life.

Brown says that her mother's doctors, who had no training in geriatrics, ordered three months of bed rest for her mother. But her mother's muscles became so weak after 90 days, she says, that "it crippled her." Now her mother is permanently bed-bound.

"If her doctors had been trained in geriatrics, they'd have been more sensitive to her," says Brown, 66. "As you get older, you still want the dignity of leading a good life."