The case for geriatricians

If ever there was a case to be made for the importance of gerontology as a medical specialty, it can be found at the GeriPal geriatrics and palliative care blog, where several recent entries focused on the special needs and dynamics surrounding health care for older adults.

One entry explored what’s known as “hospital disability syndrome,” or the downward spiral that can occur among older adults for whom a hospital stay might result in higher risk of falls, delirium, poor nutrition and functional decline.

Another entry raised important issues about the growing use of standard, one-size-fits-all indicators to measure quality of care. While rigorous control of blood pressure and blood sugar is beneficial for the majority of adults, it can result in more medication, a higher risk of side effects and a higher risk of harm for older patients, blogger Ken Covinsky wrote. “A key issue is that quality indicators almost always promote more medical intervention and more medical is not always better. This is especially the case for frail older persons, where the risk of treatments often exceeds the benefits.”

Finally, an entry titled “Too Much of a Good Thing” analyzed a recent study in the New England Journal of Medicine about emergency hospitalizations among older adults due to adverse drug events, and drew two conclusions: First, many of the older patients in the study got into trouble because they were receiving too much of a prescription medication – for instance, too much insulin. Second, many of the less obvious adverse drug events among the elderly, such as drug-induced delirium, can be difficult to recognize in the emergency room and indeed might not be identified at all.

Geriatrics is defined as “the branch of medicine concerned with the diagnosis, treatment and prevention of disease in older people and the problems specific to aging.”

It’s not a specialty that carries much allure. Doctors who specialize in geriatrics tend to earn some of the lowest salaries in medicine. Moreover, in America’s youth-obsessed culture, caring for aging patients with multiple health issues often holds little appeal.

It’s not surprising, then, that the U.S. health care system is woefully short of geriatricians, even as the number of older adults has been rising dramatically. According to the Geriatrics Workforce Policy Studies Center of the American
Geriatrics Society, only 86 students who graduated from medical schools in the U.S. in 2009 chose geriatrics as a specialty. That’s fewer than 1 percent of family medicine and internal medicine grads. And it’s not for lack of training slots, because about half of the fellowships available in gerontology were left unfilled.

The Geriatrics Workforce Policy Studies Center estimates there’s currently one geriatrician for every 2,620 Americans over the age of 75. By 2030, this ratio is projected to fall to one geriatrician per 3,798 older adults.

You could argue that we don’t really need specialists in geriatrics. Why can’t the care of aging adults be managed just as well by internists or family medicine physicians? There’s in fact a fair amount of debate on this point, helped along by confusion on the part of many patients and families about what, exactly, a geriatrician does.

To be sure, many internists and family medicine doctors are skilled and knowledgeable in caring for the elderly. And not everyone who’s old necessarily needs to have a geriatrician, particularly if they’re relatively healthy.

But let’s not underestimate what geriatricians bring to the table. In “The Way We Age Now,” a lengthy article that appeared in 2007 in The New Yorker, Dr. Atul Gawande takes readers into the world of aging, what it means in the medical sense to age, and what it takes to help older adults remain healthy and functional.

Gawande makes many important observations about care of the elderly, one of them being this: “Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline.”

And this: “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.”

Although primary care doctors can certainly fulfill this role, it’s perhaps unrealistic to think they’ll be able to keep up with the new research being added almost daily to what we know about aging. Moreover, it takes both expertise and experience to understand the nuances surrounding geriatric health – to recognize, for instance, that when we talk about rigorous cut-off points for blood sugar levels, it can be harmful to older adults whose bodies don’t function the same way as younger adults and who have much more to lose from side effects such as dizziness leading to falls.

If we can’t buy into geriatrics from the standpoint of enhancing the quality of life for older adults, maybe we’ll be swayed by the economics of what it’s likely to cost if we don’t become better at meeting the health needs that come with aging.

Photo: Wikimedia Commons

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