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