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More Doctors for Older Americans?

At the age of 87, Lloyd Brisk of Homewood, Ill., feels like a lucky man. True, he has battled an aneurism, carotid artery problems and prostate cancer. But he has lived through it all, he says, thanks to the help of a geriatrician—a primary care doctor trained in the special needs of older men and women. Brisk’s doctor, William Dale, M.D., tracks the subtle and not-so-subtle changes that happen to an aging body. “I wish everybody could have the quality of care I receive,” says Brisk, who visits Dale at least four times a year. Unfortunately, not nearly everyone can.

The Institute of Medicine of the National Academies warns that the nation’s health care workforce is too small—and unprepared—to handle the exploding number of older people. Today, of the more than 750,000 medical doctors in the United States, fewer than 7,200 are licensed geriatricians. By 2030, when the number of Americans age 65 and older will have nearly doubled to 77 million, experts estimate there could be just one geriatrician for every 10,866 of them if nothing is done to encourage more doctors to enter the field.

New incentives proposed

Luckily, many of the nation’s legislators are boomers themselves, and they’re diligently drafting a number of bills to address the shortage. “With our country aging at a rapid rate, and Americans living longer than ever before, we have got to provide more training in geriatrics to medical professionals and to direct-care workers on the frontlines,” says Sen. Herb Kohl, D-Wis., chairman of the Senate Special Committee on Aging, who has championed this issue for years.

Sens. Barbara Boxer, D-Calif., and Susan Collins, R-Maine, are sponsoring a bill that would allocate $130 million over five years to fund training and educational loan repayments for health care professionals who commit to caring for older Americans. Sen. Edward Kennedy, D-Mass., chair of the Senate Health, Education, Labor and Pensions Committee, recently endorsed Boxer’s bill as a nod to the issue’s importance, and his blockbuster health care reform bill includes scholarships and fellowships to bolster the geriatrics workforce.

Kennedy’s bill doesn’t include loan repayments, however, which Boxer believes are crucial to encouraging doctors, psychiatrists and pharmacists to take up geriatrics. A spokesman for Boxer said they hope to work such a provision into the health care reform bill when it hits the Senate floor, which may happen before the August break.

In the meantime, the Obama administration has proposed reducing some of the fees Medicare pays to high-priced specialists and pass the savings on to primary care physicians starting in January. The plan calls for boosting payments to geriatricians, internists, family doctors and general practitioners by 6 to 8 percent, according to the Centers for Medicare & Medicaid Services.

Geriatricians—who do for older patients what pediatricians do for children—fall near the bottom of the physician pay scale. They earn on average $171,000 a year versus $191,000 for general internists and, at the top end, $638,000 for neurosurgeons.

Shortchanged in medical schools

Making matters worse, only 11 of the nation’s 145 medical schools run full-fledged geriatric departments, says Robert Butler, M.D., president of the International Longevity Center-USA in New York. (Another 30 or so offer a geriatrics program.) This limitation makes it difficult to train a new generation of geriatricians, not to mention educate all medical students in aging. And without training, doctors may not know, for example, that heart attack patients over age 65 may experience confusion instead of chest pain.

Studies have shown that geriatric care increases patient and family satisfaction, shortens hospital stays, improves social functioning and decreases rates of depression.

What a geriatrician does best

Geriatricians receive at least one extra year of training in aging-related health issues. They learn to manage chronic conditions such as heart disease and arthritis, to coordinate care and prescriptions from specialists, and to focus on signs of everything from dementia and depression to faltering balance and incontinence. They counsel their patients on how to remain as healthy and independent as possible, and help them weigh the risks and benefits of surgery.

“Every elective operation, every new prescription, is of potential great benefit but also has potential adverse effects,” says Stephanie Studenski, a professor of geriatric medicine at the University of Pittsburgh. “A geriatrician is a knowledgeable advocate who helps you find your way across a complicated part of life when there are meaningful risks.”

Special knowledge helps identify problems

Yet doctors such as Dale, who is chairman of the geriatrics department at the University of Chicago Medical Center, worry that as the U.S. health care system pushes more high-tech care and ever more expensive and aggressive surgeries, it misses the big picture in the process. He recalls meeting a patient with worsening dementia whose ill-advised surgery for low-grade prostate cancer left him incontinent. This side effect created a need for more surgery, which only caused further disruptive complications.

“His dementia should have been recognized from the beginning, and they never should have started this sequence of expensive, unnecessary care, which lowered his quality of life,” Dale contends. “That’s something any reasonably trained geriatrician would have noticed.”

Medical conductors keep patients on track

Unlike some specialists, geriatricians take an interdisciplinary approach to medicine, working with teams of nurses, psychiatrists, surgeons, social workers and therapists. Geriatricians tend to be “more low-tech,” says Butler. They refer to themselves as quarterbacks or conductors, as they juggle conversations with various specialists and prescriptions from various other doctors, maintaining a focus on quality of life.

Without a geriatrician, a patient can get sent to a slew of specialists, each with a myopic interest in treating his or her area (the brain, the heart). That can lead to expensive, invasive treatments that drive up health care costs and, ironically, may undermine the overall health of the patient. A geriatrician can improve quality of life and save money by preventing falls, spotting early dementia and coordinating medications and care, notes Cheryl Phillips, M.D., president of the American Geriatrics Society.

Finding a geriatrician

In the absence of a referral, the best place to find a geriatrician is through the American Geriatrics Society. Its Foundation for Health in Aging includes a physician referral service and many links and consumer tools.

But the fact is, “we’ll never have enough geriatricians,” says David Reuben, chief of geriatric medicine at UCLA. The alternative for many patients will be to find family physicians or internists with some geriatric training and simply an interest in older patients.

Real rewards

Geriatricians say that interest can be profoundly rewarding.

“The corny part is that I was just the happiest after I had an interaction with an older patient,” says Studenski, who was a doctor of internal medicine before going on to specialize in rheumatology and then geriatrics. “Many, many people of advanced age have a wonderful perspective on life. They’re very wise, they’re often very funny. I get a lot from my patients.”

Karen Springen is a former Newsweek correspondent who lives in Chicago.

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