Rx for Elder Health Care: Geriatricians

Having more of these specialized physicians is the best way to ensure the future health of all older adults.

By JEANETTE LEARDI

According to the U.S. Census Bureau, in January the world’s population surpassed 8 billion. Because of improvements in public health and advanced treatments for chronic disease, there are more people everywhere and they are living longer. In this century—and for the first time in human history—our planet is inhabited by more people over the age of 60 than under the age of five.

And while this trend is good news for us older adults, it also poses some challenges, mainly because our bodies change as we get older. Our cells gradually lose some of their ability to ward off infection or other potential environmental damage and aren’t as efficient in repairing or reproducing themselves when the need arises.

While aging itself isn’t a disease but is instead a natural process, it does make us more prone to develop certain chronic diseases such as arthritis, cancer, hypertension, heart and pulmonary disease, and dementia. The National Council on Aging reports that about 95 percent of Americans ages 60 and older cope with one chronic condition and about 80 percent deal with two or more.

But biology isn’t the only way in which we elders differ from middle-agers. Our emotional and social needs change over time, and often our goals change as we envision a different life purpose. We can also find ourselves affected by negative cultural attitudes and public practices that often marginalize us and present us with greater challenges in maintaining our quality of life.

Fortunately, specially trained doctors called geriatricians can help us navigate the landscape of our later years. What do they do and when should we consider consulting one for our care?

A Person-Centered Approach

“When I tell people that I am a geriatrician,” says Suvi Neukam, DO, assistant professor of internal medicine and geriatrics at Oregon Health & Science University in Portland, Ore., “it is not uncommon for them to assume that I only ‘help people die.’ Sure, death is a part of geriatrics, but goodness, there is so much more to the field of aging.”

In addition to advising patients about hospice and palliative care, Neukam is responsible for helping them with the maintenance of their physical function and cognitive health, reduction of medications, care planning, and addressing their concerns regarding falls, bone health, urinary incontinence, and delirium.

“A 70-, 80-, 90-, or even 100-year-old is quite different from a 20-, 30-, 40-, or even 50-year-old,” she explains. “They are in a different chapter of life with different medical considerations, a different social context, and different existential questions and values.”

Wayne C. McCormick, MD, MPH, professor in the Department of Medicine at the University of Washington and head of the Division of Gerontology and Geriatric Medicine at Harborview Medical Center in Seattle, would agree. “As we reach advanced age,” he says, “there are natural changes in kidney, heart, and liver function that change the way medicines are metabolized and cleared. Some medicines may last twice as long in the body when you are 90 versus 55.”

He nevertheless clarifies that “a solid majority of U.S. citizens over age 75 are completely healthy and independent. Most do not need a geriatrician. When an older person in their 80s or 90s has multiple medical issues, cognitive and/or functional debilities, and trouble with falls or sensory impairments, it’s time to consider a geriatrics evaluation.”

For her part, Neukam believes that geriatricians don’t invariably “do less” for their patients. Instead they “do differently” by considering how each patient’s personal values and goals interface with the medical condition at hand. And that often means doing more, not less, in terms of personal care.

Says McCormick, “We focus on patients with multiple problems and seek practical objectives, embracing the patient’s goals verbatim. If they want fewer meds, you aggressively work on that. If they want a house call versus a clinic visit, you do a house call. If they do not want life-saving measures if seriously ill, you adhere to that wish.”

Providing such person-centered care involves a different way of practicing medicine. Geriatric office visits are usually more involved and last longer than the average 15 to 20 minutes that most general primary care physicians spend with younger adult patients.

Unfortunately, this difference comes at a cost to doctors who choose to be geriatricians. Because their patients are on Medicare, which has lower reimbursement rates than those of commercial insurance, a board-certified geriatrician makes about $20,000 less than internists who see a wider age range of patients. This inequity can be a factor in discouraging many medical students with large student loan debts from specializing in geriatrics.

And this has resulted in a huge problem in elder health care.

Wanted: More Geriatricians

Currently, the U.S. has a serious shortage of geriatricians. In March 2023, a total of 7,300 physicians—fewer than 1 percent of all doctors—were board-certified in geriatrics. Some public health experts estimate that our healthcare system should have more than 25,000 geriatricians to keep pace with the growing older population, and by 2030, we’ll need at least 5,000 more. Yet, according to the American Geriatrics Society, of our 183 medical schools surveyed in that same period last year, only 11 of them had full departments of geriatrics.

Low wages may not be the entire reason for this dearth of specialized training. Medical school students tend to encounter patients of advanced age primarily in hospital settings under highly stressful, acute circumstances, and may assume that there is little upside in treating people who don’t have much longer to live and therefore it’s futile to try.

Neukam reflects on the possibility that ageism might be at work. “Geriatrics is not prestigious. Is this a reflection of a lack of intergenerational respect in our society? Or perhaps an anti-aging mindset? Or a belief that medicine is only about ‘fixing’ and ‘curing’? I’m not sure.”

What can be done to grow the field of geriatrics to meet the needs of an ever-larger elder population?

Neukam suggests establishing new medical school loan forgiveness programs as well as increasing Medicare reimbursement and expanding its coverage to include “in-home care, caregiver support, long-term and memory care, nonpharmacologic treatment options, geropsychology, and hearing aids.”

McCormick offers an equally wide-ranging solution: “When all medical students receive comprehensive geriatrics training as part of medical school, we’ll be in better shape.”

There is an irony in the many negative perceptions of the field. According to the American Geriatrics Association, “geriatrics ranks among the most satisfying health professions …[and]geriatricians ha[ve]the highest job satisfaction of physicians practicing in any subspecialty. Geriatrics health care professionals cite their encounters with inspirational older adults, the deep and meaningful relationships they develop, and the typically steady work hours as significant factors adding to their job satisfaction.”

“People of very advanced age bring tremendous wisdom to every encounter,” says McCormick, “if we’d only take advantage of it. It is profoundly satisfying to follow these patients on their final journeys, and to let them know you’re going to stick with them, no matter what.”

“We truly like spending time with elders, and in my experience, this sincere enjoyment is mutually felt during inpatient visits,” says Neukam. “Many of us would say ‘The patients chose us.’”

Whether or not each of us seeks out the expertise of a geriatrician for our care, one thing is certain: Geriatricians can have a promising future…only if society chooses to care for them as well as they care for us.

Jeanette Leardi is a Portland-based social gerontologist, writer, editor, and community educator who has a passion for older adult empowerment. She gives popular presentations and workshops in journaling, memoir writing, ethical will creation, brain fitness, creativity, ageism, intergenerational communication, and caregiver support to people of all ages. Learn more about her work at jeanetteleardi.com.