The elder-care crunch

13 Jul 2008 Original Source By Tanika White, Sun reporter After four years of medical school and three years of internal medicine training, Jessica Colburn could have chosen just about any field of medicine to practice. Gastroenterology would have been lucrative, brain surgery exciting. At one point, pediatrics piqued her interest. But Colburn, 31, picked one of the least-popular areas of medicine to make her mark: geriatrics. “I’ve always loved old people,” said Colburn, chief resident at the Johns Hopkins Bayview Internal Medicine Residency program. “And I have been interested in the care of underserved people. I think it’s a need and a demand in medicine.” As baby boomers age, the demand for geriatricians – internal- or family-medicine doctors trained in the needs of elderly patients – will only grow. There is now only one geriatrician for about every 2,500 Americans over age 75, and experts in the health care industry expect the shortage to worsen. “Every place it’s a problem,” said Dr. Colleen Christmas, assistant professor of medicine in the division of geriatric medicine at the Johns Hopkins School of Medicine. “In Baltimore, it’s not as bad, but there are pockets of Maryland where you just can’t find a geriatrician. On the Eastern Shore, for instance, it’s very, very hard to find anyone with any extra training in the field.” Experts attribute the shortage in part to the required additional training, coupled with the lower pay relative to other physicians. Sen. Barbara Boxer, a California Democrat, has sponsored legislation to provide incentives for medical students and other health care workers to focus on geriatrics and gerontology, the study of aging. The legislation would provide $130 million in federal funding over five years to attract and retain trained health care professionals and direct-care workers such as nurses, by providing them with loan forgiveness and career advancement opportunities. “If there is not a sufficient number of providers trained to care for older adults, then older adults will be at risk for not getting the care they need,” AARP said in an April report to the Senate Special Aging Committee. “This in turn could lead to increased health care costs and poor patient outcomes.” The role of prescriptions One reason for the increased cost: prescription drugs. “The costs of drugs are tremendous in this age group,” Christmas said. “Most have two to three diseases at once.” Many older patients are prescribed too high a dose or too many drugs. Others mismanage their prescriptions at home because of confusion or poor eyesight. And some medications that are perfectly fine for someone in middle age are harmful to older organs and systems. “About 17 percent of prescriptions are inappropriate” for seniors, Christmas said. As a result, prescription drugs can create more illnesses for older patients or lead to more hospitalizations, an increased need for nursing home care and sometimes death. Geriatrics is relatively new to the medical landscape; many hospitals began offering fellowships in the field only in the late 1960s. Since then, geriatricians have been very much in demand. According to the Alliance for Aging Research, the United States will need about 36,000 geriatricians by the year 2030. But the Institute of Medicine estimates that there were about 7,120 certified geriatricians in 2007, a number that is expected to barely increase, or even decrease, by 2030. For geriatricians, seven years of basic medical training are capped with one to three years of a geriatric fellowship, during which they see patients ages 65 and older, many of whom have multiple chronic diseases such as high blood pressure or diabetes. Most geriatricians’ patients are older than 80. Unlike specialists, who focus on specific problems, geriatricians are trained to see the whole of a person whose body is slowing down and working differently than that of someone much younger. “We try to see the person as a person, not a sick organ or a tumor,” said Dr. Thomas Finucane, a geriatrician at the Johns Hopkins Bayview Medical Center for 23 years. Finucane has been seeing Emily Kropkowski, 87, for about five years, and her daughter, Fran Gustin of Perry Hall, can see the difference. Gustin said both her parents – her father is now deceased – had a generalist as a primary care physician. But she’s happy that her mother switched to Finucane, who has “just been wonderful.” “He’s sensitive to the elderly’s needs, very patient, especially with [Mom] asking questions five times,” Gustin said. “And he’s even patient with me. He gets back to me when I e-mail. He puts it in layman’s terms for me, so I can understand. It just amazes me.” Finucane has an easy way with his patients. When Kropkowski struggled to get up on the examining table during a recent visit, she apologized for her slowness. “Getting old,” she said. “Who? Me?” Finucane said, smiling and helping her to lift her up gently. Before long, Kropkowski was laughing, aches and pains all but forgotten. Seeing the whole patient In addition to their bedside manner, the geriatricians’ specialized training is helpful to patients who might be prescribed several different remedies by several different specialists, Finucane said. As an example, Finucane describes a patient who came to him with chest pains, heart disease, an irregular heartbeat and a spot on her lungs that looked like it could have been cancer. The patient, in her 90s, had been to see a thoracic surgeon, an oncologist, a radiation therapist, a cardiac surgeon and an electrophysiologist. Each recommended a different treatment. And each treatment would have been costly. “If you tried to fix everything that was wrong with her, she would be sick as heck, she’d be quite delirious, she’d suffer a good bit,” Finucane said. “And in the aggregate, it probably would not increase her [life span]. In fact, it might decrease it.” That’s where a good geriatrician comes in, Colburn said, to assess the best health care program for an aging body. “Instead of only being focused on treatment or cure, I’m interested in what is the quality of life for that patient and their own priorities and goals for their own health care and how we can make that possible.” But many medical schools have trouble finding students interested in geriatrics. In 2007, slightly more than half of 468 geriatric medicine first-year training slots across the country were filled. The biggest reason is financial. Saddled with huge loans after medical school, new physicians are presented with many lucrative options for careers. Geriatrics requires additional training, and ultimately it offers a lower salary than many other fields. “Geriatricians are making, on average, $12,000 less than other internal medicine doctors,” said Elizabeth Bragg of the Association of Directors of Geriatric Academic Programs. “And they have to go through at the very least another year of training. It’s like you’re going to school for another year to make less money.” Finucane again offers a real patient as an example. If an older man fell at home and broke a wrist but couldn’t explain why the fall happened, he would see two doctors afterward – someone to set the bones in his wrist and possibly a geriatrician, trained to understand falls among the elderly. “The 15 minutes to set the wrist would be far more richly compensated than the time it takes me to sit down and talk with that patient about what happened, why he fell, what is going on there,” Finucane said, “by about 4 to 1.” Contribution unrecognized There’s value in both, Finucane said. But the country’s medical reimbursement system doesn’t always recognize the geriatrician’s contribution. Many geriatrics patients rely on Medicare, which poorly compensates such “assessment” visits with doctors. The key, experts agree, is to draw more medical trainees into geriatrics. Colburn, for example, owes $150,000 in loans from her four years of medical school at the University of Pittsburgh. According to a Medical Group Management Association study of physicians’ compensation, she might make slightly more than that in one year as a practicing geriatrician. But if Colburn had chosen gastroenterology, as one example, she would earn more than double her debt load in one year. None of this matters to Colburn, who is applying for fellowships in geriatrics at Johns Hopkins. “It is kind of discouraging and disconcerting that we have this huge need and yet there’s not a huge value on the people who do it, but that is not a reason for me not to choose [geriatrics],” she said. “I don’t expect that choosing this field will mean I’ll get rich doing it. “Hopefully, our billing system will change over time. But in the meantime, I’ll be doing something that is meaningful to me.” Copyright © 2008, The Baltimore Sun © The Atlantic Philanthropie