Vital Signs » Winter 2018
It’s well known that the population of the United States is aging. But instead of catching up with the coming gray wave as many would think, it appears health care is lagging behind in strategies that could help. A clear example of this is a worsening shortage of geriatricians, physicians who specialize in caring for older adults.
It’s a complex issue, brought on, in part, by the structure of the health care system, lower pay in geriatric medicine compared to other specialties, and American culture itself. But the results are easy to see. Older adult patients don’t consistently get the attention their life station should receive.
“It’s disappointing that we compromise, that we don’t prioritize the special needs of our elders the same way we do our children. Nobody says anything when a nurse spends more time playing cards with a child who’s sick and going through chemo,” said Karen Kirkham, M.D., ’89, associate professor emerita of internal medicine and geriatrics at the Wright State University Boonshoft School of Medicine. “But the same time isn’t afforded in our system for someone to spend time with a 90-year-old who just had surgery and is quite confused.”
Kirkham worked as a geriatrician with Wright State Physicians Geriatrics, where she got to spend much more time each day to really address the needs of her older, adult patients. In comparison, she saw two to three times as many patients as a general internist in the same time. She completed a mid-career fellowship in 2016 before transitioning to the department. Kirkham now works at Grant Medical Center in Columbus, Ohio.
“My patients get more of me and I get more of them. So for me, that’s ideal because I’m a relationship-based person in my work. Other specialties do the detailed technical interventions, but that is not something I have found fulfilling,” Kirkham said. “There’s time for me to say thank you. There’s time for them to ask for what they need and time for me to try to access resources and provide reassurance.”
The health care system can afford the extra time because doctors working in geriatrics make, on average, less than other medical specialties. Their income is on par with pediatricians, who are one of the lower-paid groups. Ironically, the job satisfaction of both of these specialties is near the top in national surveys. Kirkham suspects it has a lot to do with the recharge associated with relationship-based care.
“There’s roughly 7,500 of us in the entire country right now. And every day we lose two to three to retirement. Not many young physicians are doing the fellowships and few primary care doctors are willing to spend a large part of their practice on the specific health and wellness needs of older adults,” Kirkham said.
By comparison, there are about 50,000 emergency medicine doctors. “It’s not super sexy to go to a dinner party and talk about the older, adult lady you did a falls assessment on when your buddy, the cardiologist, is talking about that slick new procedure he does to unclog arteries,” she said. “Americans are fascinated with technology and that is definitely reflected in the hierarchy and values in health care.”
In addition to prestige and pay, the structure of the American health care system helps to feed the discrepancy. It’s not set up to prioritize qualitative measures, or to keep older adults out of nursing homes. Often, more financial profit can be gained through fixing what’s broken than preventing it in the first place. Kirkham is hopeful a shift is underway in the system to promote health, function, and quality of life, which is more highly valued and common in other nations around the world. Achieving such changes will take decades, as the structure of the current system is hard to change, evidenced by national conversations. But there is hope, as system leaders and legislators are actively exploring patient-focused care initiatives that better encompass wellness and functional outcomes.
There are also cultural impediments for shifts that could benefit older adults. As Americans, we can be geographically or emotionally alienated from our elders, something that is far less common in other societies. It is hard for organizations to advocate for older and frail individuals as well as for their caring families, so overall outcomes and their sense of well-being can suffer.
Other opportunities exist for systems to better support the care of elderly patients, but would require well-known geriatric knowledge and skills to be much better taught to medical students and resident physicians. Take, for example, hospitalized people who can’t sleep. The standard order is to give them Benadryl because it’s not addictive and is typically effective in younger adults. But in older, adult patients, going that standard route will often cause harm. For a patient with an enlarged prostate, it could mean a difficult trip to the restroom. For others, especially those with dementia, the treatment commonly causes a state of delirium, as well as falls.
For delirium in older patients, the fix could be as simple as changing the standard order to exempt those over 65 from medications identified as high-risk.
“As our knowledge of geriatrics has grown, hospital and other health care leadership has taken some time to incorporate the information. Incredible opportunities to improve delirium outcomes exist, often through prevention,” Kirkham said. “Negotiating these things in a system takes time. Exciting initiatives, such at the Hospital Elder Life Program spearheaded locally by Dr. Steve Swedlund is helping to confirm delirium is not inevitable, but rather preventable.”
Elderly patients also sometimes need extra explanations about medical bills, as they grew up paying cash for health care. They don’t know their way around insurance procedures and can get overwhelmed. The result can often be less care and poor patient outcomes.
Kirkham is hoping to positively contribute what she can by working inside the system with committed team members and alongside her learners. “Sometimes you have to do things that are a bit counterculture in order to promote patient-friendly care,” she said. “What geriatrics has highlighted for me over the past couple of years is a variety of opportunities to better systematize support for the needs of that population. I’m very focused on infusing into the culture that there’s a better way of doing things. We partner with hospitalists and primary care doctors, alongside our resident physicians and medical students, in very rewarding collaborations.”
Instead of taking on the primary care of older patients and treating them, another school of thought on geriatrics is to support other specialists who provide care. The hope is that the next time something clinically similar presents, the non-geriatrician physician will recall and use more appropriate treatments. There simply will never be enough geriatricians to provide all the care needed by senior citizens. As a recent internist educated in geriatrics, Kirkham would like to make the incorporation of geriatric care standards as seamless as possible for her former peers.
She has found the work incredibly fulfilling, and believes that most geriatricians are pretty proud of and happy with what they do with their lives. “The relationship-based things make you happier because you’re simultaneously getting recharged,” Kirkham said.
No two patients are the same and all have stories to tell, as her former internal medicine department chair, Glen Solomon, M.D., always emphasized. It keeps things interesting, and Kirkham feels like she gains wisdom from each interaction. “They have 90 years of uniqueness built into them,” Kirkham said. “It challenges me. It keeps me on my game.”
One person or organization alone can’t address the geriatrician shortage or provide all the care needed for the aging population. Teamwork will continue to be important as the health care system adjusts to care for our elders.
“For the aged, understanding how to navigate the health care system is really overwhelming. So part of what I’ve learned as a geriatrician is that I need team members from many other health care professions to consistently contribute their unique skills if I want to really maximize the outcome for my patients,” Kirkham said. “Sometimes when we’re being made into doctors, we’re told it’s all on you, you have to be really good, and you can’t make mistakes. That’s not a very realistic message anymore.”
— Daniel Kelly