Caring For Older Patients Is Not American Medicine's Priority
There is a prominent paradox in American medicine: we have an ever increasing elderly population, both in numbers of patients and the age of patients, but our capacity to treat these patients is not increasing proportionately. In other words, we are falling short now and if the trend continues, we will be doing worse and worse as time goes on. This is a well known problem, and even if it does not seem to provoke much action, it does provoke words. That's hopeful, in a way, because words are often a prelude to action, although when we look at the problem of global warming, we realize that words are often less effective than the appearance of the crisis in full-blown form. Humans tend to react to crises rather than plan for them, unfortunately.
So that's where we stand, we are talking about this crisis of an increasing population of the elderly.
In August of last year, two articles on older patients appeared in the medical literature, one in JAMA and the other in the NEJM, that illustrate our impasse. What do you do when there is little progress? The JAMA article is one of frustration. The author asserts that the field of geriatrics is so intrinsically interesting and important, yet the number of geriatricians is dropping, and he can't imagine what more can be done to attract young medical professionals. The NEJM article doesn't even mention the crisis of manpower, but it sets out in extensive and thoughtful detail what the authors think ideal arrangements would be to provide medical care for elderly dementia patients.
Here's the JAMA article.
The Paradoxical Decline of Geriatric Medicine as a Profession
Jerry H. Gurwitz, MD
From The Journal of the American Medical Association (JAMA), August 4, 2023 (https://jamanetwork.com/journals/jama/fullarticle/2808221)
The author, an academic geriatrician, bemoans the chasm between the need for geriatricians for an aging population, and the deficient supply of these specialists, that is withering even further.
The situation mystifies him. After all, the work itself is so interesting! Old people can have so many diseases and conditions simultaneously, many of them cannot be cured, the surrounding families trying to help in care can be stretched and exhausted, and putting together interdisciplinary teams for care can be so energizing! Well, Jerry, you say it's “interesting,” I'll give you “challenging.”
Moreover, he says, the money for research in geriatrics is increasing rather than decreasing, even some foundations are pitching in to support the teaching of geriatrics.
Yes, he agrees, the money is not great, and in fact, if you take the time to become a geriatrics specialist after your internal medicine training, paradoxically, you will earn even less than you would if you just stayed an internist! But then, pediatrics pays poorly, too, and pediatrics remains a fairly popular specialty, he says. (He could have looked further and realized that adolescent medicine, which like the geriatrics situation, takes extra time to qualify for, then enables you to make less money than if you had simply started practicing pediatrics, and adolescent medicine also has trouble filling all its spots – he didn't look quite far enough for a correlative situation.)
It must be the culture, he says, where old people are looked on with some disgust, agreeing with Louise Aronson and her great book, Eldercare. And it must be the graduate education councils that don't require medical students and residents to be exposed to geriatrics. (Adolescent medicine wages this same fight, by the way.) And it must be the health care organizations that take the extra money that is paid for treating the elderly (if you code properly, which they do, because it means more money,) but they keep the money for their organizations and their goals and profit, and they don't plow the money back into the organization by hiring geriatricians and serving the elderly better.
Jerry has no answer, no path forward. He is reduced to saying, the problems with an aging population will only mount, and people – you'll be sorry you have been making these anti-geriatrician choices!
Well, he's right about the need, and he's right about societal prejudice (I have it myself – I chose to be a pediatrician, partly because I thought of the dear kids and hopeful families and the futures they had before them, which old people don't.) And tastes vary – some people love working with old people and some don't, and it will ever be so. Like for me – give me the kids, every time.
But the main problem that Gurwitz isn't dealing with is the difference between a profession and a job. There isn't a single reference in his short paper to what it's like to have the job of being a geriatrician. Is it a good job? Are geriatric practices well resourced? Does a geriatrician feel like the captain of a team who can call on A and B and C to deal with the problems of his or her patients? Can the geriatrician identify a problem of insufficient assistance in the home, and assign a member of the team to solve that problem expeditiously, and then to report back, problem solved? Or is it always a struggle, always slogging through sand, begging for this or that agency to come through, looking for financing, etc. Are home supports easily available, with all the durable medical equipment at the ready, all the aides? Are there institutions available that are excellent and welcoming and well-staffed and well supplied and happy, vibrant places, or are they dingy and sad and full of dysfunction and is it hard to find a good one?
How does the geriatrician experience the day to day? Is the office work easy and efficient, or is he or she always struggling to keep up with the documentation required by the electronic medical record that is designed to optimize billing rather than care? Is the geriatrician served by a scribe who does all the work of electronic charting, or does the geriatrician do it him or herself, acting as a data input clerk? Does the parent organization take pride in the geriatrics office, even though it is more an economic drain rather than a profit center?
Does the geriatrician skate through the day or slog through sand to the point of exhaustion?
And the pay, the pay and benefits and vacation time. All the non-procedural specialties need better pay, the current structure of pay is an out-of-control outrage. But the job can make up for lower pay, if it is really well-structured and fulfilling. Is the structure of the job, the agency available for exertion by the geriatrician, the resources at hand – do they lead to great job satisfaction? Do health care groups have a carved out gerontology slots, with attractive job descriptions and resources at hand? These are things that students will see as they make their specialty choices.
Is the substance of the job enough to offset the inferior pay? Is it good enough to make it attractive to make half as much as your colleagues to elect to become strutting orthopedists?
There will always be people who choose to follow their interests and their ideals into a chosen field, no matter the consequences for their job. They can accept the indignities because they are obeying a higher calling, and they are following their passion, their bliss. That's true of all walks of life. But it makes it a lot easier to do so, and many more will choose them, if the jobs are really well-structured, well-operated, and well-conceived.
So my advice is, Jerry, is go work on that. You can do it right there where you are. Construct an ideal operation. Show the world what you can do to make the life of a geriatrician a dream. You don't have to match the orthopedist's pay and lifestyle (but you should get close, say 80% close), but you do have to make the organizations you are working for pass your increased remuneration down to you and not just spread it around the group. Make that extra degree worth something. And make the job one where you skate through the day, not one where you are continually slogging, which takes resources and organization. Match the job to the attractiveness of the profession, and maybe then you will get to serve society with what it needs, more services for the aged provided by the proper provider with the proper organization.
What Gurwitz has missed, in sum, is the difference between a profession and a job. While the profession of geriatrician can be terrific, the job of being one often sucks.
Here's the NEJM article:
Toward Gerineuropalliative Care For Patients With Dementia
Krista L. Harrison, Ph.D., Nicole Boyd, M.D., and Christine S. Ritchie, M.D., M.S.P.H.
from the New England Journal of Medicine (NEJM), August 30, 2023
https://www.nejm.org/doi/full/10.1056/NEJMp2301347
And lo! Just a little later in the same month comes an article in NEJM, a more hopeful one, on a similar subject, caring for older patients with dementia. Where the JAMA article sees an intractable problem in caring for older people because specialists are not being produced, this article posits a model of care that, they say, could be adapted for generalists rather than geriatricians, perhaps because the geriatricians are just not available. (Again, the same dilemma arises in adolescent medicine, where specially trained personnel would render excellent service, but where numbers dictate that they be mostly researchers, teachers of pediatricians and a referral specialty.) This service model also highlights the need for non-fee-for-service payments – nothing new there – and in a hopeful sign, Medicare has started a model program where capitated care would be available. Beyond those small nods to practicality, however, the article is a rather typical academic approach to matching resources to need in an ideal world. The summary chart in their article is impressive. What a plan! I only it could be implemented!
I would think that this interesting chart would be helpful in actually shaping programs in the field, but that remains to be seen. The problem is, who would try it, and why? Yes, the ideal of helping people is always there. If a program were to be mounted in academia, the careers of the progenitors would be enhanced, and staff working on the project would find their jobs enriched. But when a field with obvious needs has shown so little progress over time, there's a reason. Here and there in the country, there would be enthusiasts to take up the model.
There are deeper questions that need to be approached to really understand this situation. Let's just mention them.
Is the country prejudiced against old people? Yes, our culture does not honor the old very much. Put them out on the ice, some urge, the gerontocracy takes up slots that should go to younger people (like the author of that screed, one surmises.) Or probably, the wealthy can often take care of their oldster problems privately, so programs that would serve everyone are not their concern.
Why does the profession of medicine allow this situation to persist, and not target their efforts toward the country's problems with primary care and chronic care? Well, the profession of medicine is not a whole, it is pieces, and the haves are the procedural specialists, and the have-nots are the chronic caregivers, the primary caregivers, the procedure-less specialties. And as always, the well off have more resources than the less well off, and they use those resources to reinforce their position of privilege.
Why do people wait until situations get out of hand to react, why don't they see the future and plan for it? Well, they're not as smart and as disciplined as you would wish. You can plan and act thoughtfully in small groups, but not the larger ones, where entrenched interests are self-protective, and not naturally inclined to sacrifice their short term interests for putative long term possibilities. Present perks are hard to fight.
But, whatever. In the field of geriatrics, if you want to do good, it's a good idea to focus on the job rather than the career. Make it a rewarding job, and they will come. An interesting profession, OK, yes, but that's speculation. The job that you can see and feel, that's what will attract new entries.
Budd Shenkin
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