amily octor - Louisiana Academy of Family Physicians

G U E S T A R T I C L E
Missing M.D.s
Wanted: more geriatricians to treat the aging
By ANDREW GOLDSTEIN
Stephen Bzdok began experiencing seizures
at age 65, and doctor after doctor was unable
to discover the cause. A Las Vegas lounge
singer for more than 20 years, Bzdok nearly
became homebound. The internists and neurologists
he saw never took the time — and
didn’t have the expertise — to figure out what
was wrong. Then an especially fierce seizure
put Bzdok in a coma for four months. His
family, assuming the worst, sold most of his
possessions. One day, miraculously, Bzdok
woke up. This time he consulted a geriatrician
— a doctor with special training in care
for the elderly — who soon discovered the
problem: a heart murmur. Bzdok had a pacemaker
implanted, and has been seizure free
ever since. The fun-loving sexagenarian says
he feels as if he were 50 again. He lives on
his own, walks half a mile a day and spends
weekends on a speedboat.
If only the rest of the nation’s seniors were as
lucky. When politicians and journalists talk
about problems in elder care, they usually
point to horrific abuse in nursing homes or to
retirees who are forced to skip meals to pay
for prescription drugs. But the most serious
crisis in elder care has been largely ignored:
not enough doctors who know how
to diagnose and treat aging’s special ailments.
Out of 650,000 physicians in the U.S.
today, just 9,000 are certified in geriatric
medicine. And that number is shrinking, as
many quit the poorly paid field or retire. Only
3 out of 144 U.S. medical schools have a
full department in geriatrics (all have a
department in pediatrics), and fewer than 3%
of medical students take even one course in
geriatrics, according to the International Longevity
Center. During the next 30 years,
more than 70 million baby boomers will
reach age 65. Who will care for them
Medicine for the elderly is a different science
from medicine for the young or the middleaged.
Seniors face a range of age-related
ailments — dementia, Alzheimer's, arthritis —
and typically swallow more than four medications
a day. A doctor’s attention to how drugs
interact can mean the difference between
saving a life and taking one. Many geriatricians
say they devote much of their efforts to
sorting out the complications caused by their
patients' previous doctors. Each year 17% of
elderly Americans are hospitalized after experiencing
a dangerous drug interaction or
taking incorrect dosages. The American
Medical Association says nearly 7 million
seniors a year are routinely prescribed drugs
that are too risky for them.
Mary Richert, 79, of Jennings, La., had been
living on her own, taking trips as far away as
Alaska, until she began suffering from memory
and balance problems. She stopped driving
and traveling and became depressed. At
the urging of her children, she spent 18
months trying to find a doctor who could help
her. But the message from the series of internists,
urologists, neuropsychologists and
neurologists she saw was always the same:
“Mama's problems are because Mama’s getting
older.”
That wasn’t the reason. Two years ago,
Richert went to see Charles Cefalu, one of
the top geriatric specialists in the U.S. “He
was different from any doctor I had been to,”
says Richert. “He took his time.” Cefalu’s
thorough examination helped him figure out
the cause of Richert’s seeming dementia: her
brain — like that of a child born with “water
on the brain”--had stopped draining cerebral
fluid. Cefalu sent Richert to a neurosurgeon,
who placed a shunt inside her brain to act as
a drain. Her health improved dramatically.
Today she gardens, travels and — to the
consternation of her children — is driving
again.
It’s an inspirational tale, yet what saved
Richert is what keeps doctors away from
geriatrics: it takes time to diagnose elders’
problems. A physician is reimbursed by insurers
for a typical office visit of 15 or 20 minutes.
But a geriatrician needs on average at
least an hour for an initial assessment. While
a general internist can see 2,000 to 3,000
patients a year, a geriatrician sees fewer than
500 patients, making for a smaller income.
Says Joseph Ouslander, head of Emory University’s
geriatric-medicine program: “I can
go into my clinic and spend an hour with a
very complicated 90-year-old patient, identify
her 10 medical problems, sort out her dozen
medications, talk to her children. And I get
the same reimbursement as the dermatologist
who spends 30 seconds shaving off a
mole.”
A geriatrician’s income is almost entirely dependent
on the amount that Medicare pays
for each patient, in effect leaving the doctor’s
salary up to the Federal Government. And
this year Congress has cut Medicare reimbursements
5.4%. Louisiana Senator John
Breaux, who chairs the Senate Aging Committee,
is one of the few members of Congress
to call attention to the shortages in
elder care, most recently at a hearing last
February. Yet Breaux, a fiscal conservative,
told TIME he won’t consider raising Medicare
reimbursement rates. “That’s not in the cards
right now,” he says. Instead, he proposes
forgiving student loans to doctors who go into
geriatric medicine.
A handful of medical schools have begun to
boost their geriatric programs, despite the
lack of student demand. (One medical resident
said he never took a class in geriatrics
because “old people are gross.”) Cefalu
started an expansive program at Louisiana
State University that he hopes will act
as a model for other schools. But when
Greg Sachs, chief of geriatrics at the University
of Chicago, launched a geriatrics fellowship
in 1986, only a few young doctors entered
the two-year program, in fits and starts,
and interest dried up altogether in the mid-
’90s. This year Sachs has just a single fellow.
When the legions of baby boomers begin to
retire, many will need the kind of geriatricians
who have the skills to save people like Bzdok
and Richert. Jennifer Moore, 30, hopes to be
such a doctor. Inspired to go into geriatrics by
watching her grandmother take care of her
grandfather after he suffered several strokes,
Moore followed med school with a two-year
fellowship in geriatrics. But now she’s having
trouble finding a satisfying job. “How can I
provide good care in the manner in which I
was trained,” she asks, “when all I get is 10
minutes with each patient” Unwilling to compromise
her standards, Moore is looking to
teach geriatric medicine instead. Now the
question is whether she can find some students.
— With reporting by Alice Jackson Baughn/
Louisiana, Paul Cuadros/Durham, Deborah
Fowler/Houston, Kathie Klarreich/Miami, Greg
Land/Atlanta, Jeanne McDowell/Los Angeles and
Maggie Sieger/Chicago
From the Nov. 11, 2002 issue of TIME magazine.
http://www.time.com/time/magazine/
article/0,9171,1101021111-386949-2,00.html
25