In his post, “The geriatrician shortage: The problem isn’t what you think,” I completely agree that the current gap in health care professionals’ skills to care well for our aging population is exceedingly complex, reaching well beyond lack of medical school training or funding. Funding for graduate medical education needs to be transformed to match the workforce needs of the nation, with special attention to filling workforce gaps in rural areas. Other health professions (nursing, pharmacy, social work, rehabilitation, and many others) need to enhance geriatric competencies in their schools and residencies so that health care teams have adequate expertise to care for older adults.
However, I would like to point out misperceptions on Dr. Young’s part. He wrote that most ailments among older adults “are the same ones middle-aged people have: hypertension, heart failure, diabetes, arthritis, etc. The elderly just have more of it.” This is simply untrue. Older adults have dementia (now the sixth leading cause of death in that population), falls (the number one injury-related death in people over 65), pressure ulcers, and many other illnesses seldom seen in middle-aged adults. Conversations with older adults and their families often include counseling to retire from driving, manage caregiver burnout, and assist families in finding a long-term care environment suitable to a frail elder’s needs. These syndromes often give rise to difficult conversations, which require knowledge and communications skills rarely learned or practiced during medical school and residency.
A second misperception, implied from the following quote by Dr. Young, is that primary care physicians provide the same quality of care that geriatricians do: “The vast majority of elderly Americans get their primary care from family physicians and internists who have no extra training in geriatrics beyond what they learned in their primary residencies. I’m not aware of any study that shows that their care is measurably different from fellowship-trained doctors.”
If primary care doctors were providing optimal care to older adults, polypharmacy would not be one of the leading killers in that population). Fifty percent of dementia would not be missed in primary care practices). Many patients with delirium would not be missed by physicians in our hospitals). Recent evidence about care provided by geriatrics teams shows that hospital length of stay is about one day shorter, costs less, and has fewer complications, including falls, pressure ulcers, and catheter-associated urinary tract infections.
I am continually impressed by the high quality of care provided by family physicians, and am in awe of all that my colleagues in rural areas accomplish. But gaps persist. I was a general internist for nine years before returning to complete a geriatrics fellowship. I loved my practice, which was full of older adults, and I thought I was doing a good job caring for my patients with dementia and other geriatric syndromes. I returned to training not because I felt my own knowledge base was inadequate, but because I wanted to do more geriatrics teaching and research. The fellowship opened my eyes. I had no idea what I didn’t know. I learned more during one year of fellowship than I had learned during any other year of medical training. And this was after nine full years of primary care practice.
There are no easy answers to solving the gaps in care of older adults in our current system. There are not, and will never be, enough geriatricians to care for all older adults, and not all older adults will need the expertise of a geriatrician. We need to increase the amount of geriatrics training that all health care professionals receive, because few health care teams (outside pediatrics) see no older adults. We need to train enough geriatricians (and right now we don’t know what “enough” is) so that older adults who do need the expertise of a geriatrician have access to one. And health care funding needs to adequately reimburse teams (rather than focusing reimbursement on the doctors) to incentivize excellent team care. Older adults deserve care that optimally supports their function, independence, cognition, and quality of life, and it is up to all of us in health care to work together to ensure this happens.
Elizabeth Eckstrom is a geriatrician.
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