August 24, 2007
Few doctors to serve aged as population grows older
Milwaukee Journal Sentinel
JEFFREY PHELPS / MILWAUKEE JOURNAL SENTINEL
LaVonne "Bonnie" McAdams' first visit with a geriatric specialist lasted an hour. It was time well spent.
Her doctor changed several prescriptions McAdams should not have been taking with her other medications. She discovered McAdams was anemic, immediately ordering two blood transfusions and starting her on an iron supplement.
She put McAdams on a different drug to deal with fluid retention and got her new patient into therapy to improve her balance.
Not surprisingly, McAdams, 75, is sold on geriatricians.
"They just seem to know what to look for," she said.
McAdams' doctor, Reny Varghese, is among four geriatricians hired by Wheaton Franciscan Healthcare in Glendale, Wis., in the past 18 months. And the health-care system, which sees a growing need and potential market for geriatric services, has plans to hire more.
The challenge will be finding them.
Geriatricians – doctors who have additional training in caring for the elderly – are in short supply, and the shortage will only get worse as the population ages.
There are more than 7,000 geriatricians in the United States. That works out to about one for every 2,500 people age 75 and older. By 2030, the ratio is projected to be one geriatrician for every 4,200 adults in that age group.
"We need an army of geriatricians to make up for the void we have even now, and it just is not going to happen," said Paul Hankwitz, an internist and medical director for the Olsen Medical Clinic, which has clinics at two retirement communities in Milwaukee.
Few medical students are interested in the field. In 2003, fewer than 300 doctors nationwide entered geriatric fellowships – a year of additional training after a three-year residency in family or internal medicine.
Roughly one-third of the available geriatric fellowships in the United States went unfilled in the 2004-05 academic year.
The lack of interest stems partly from the nature of geriatric medicine. The goal is often to manage patients' inevitable decline, helping them to maintain their independence and to age as well as possible.
That brings its own rewards. But many future doctors view geriatrics as a disheartening and difficult specialty, with little glamour or prestige.
Economics also is a factor. In a health-care system that pays top dollar for tests and procedures, geriatricians make a fraction of what other specialists make.
Nationally, geriatricians make about $162,500 a year, less than half of what specialists such as radiologists, gastroenterologists and cardiologists make, according to the 2006 compensation survey by the American Medical Group Association.
For an office visit with a moderately complex patient, Medicare will pay a geriatrician $87. The visit typically will take a half-hour.
In roughly the same amount of time, a cardiologist can do a single-vessel angioplasty. Medicare will pay the doctor $570 for the procedure, according to Wheaton Franciscan. A commercial health plan will pay even more – about $1,230.
The same pay disparity exists for other primary-care physicians. But geriatrics brings its own set of economic challenges. Medicare pays less than commercial health plans. And elderly patients require more time.
Many health-care economists contend the money to be made on tests and procedures partly explains the U.S. system's emphasis on specialty care and why its costs are the highest in the world.
In contrast, the best treatment in geriatrics is often the simplest. Instead of reaching for a prescription pad, for instance, a geriatrician may recommend a patient change diet or drink more fluids.
"We have high-tech, but we also have high touch," said Hankwitz, a clinical professor with the Medical College of Wisconsin.
The field is among the most challenging in medicine. Nearly half of all Medicare beneficiaries have three or more chronic conditions, such as high blood pressure, diabetes and arthritis.
Further, an older patient's symptoms can differ from someone who is younger.
"I usually tell students and residents that all bets are off with older people," said Ellen Danto-Nocton, a geriatrician with the Wheaton Franciscan Medical Group.
The textbook diagnosis – the one doctors are trained to make – may not be the right diagnosis for someone elderly.
Diagnosing underlying causes also can be tricky. For example, confusion can stem from something as simple as a urinary-tract infection. For this reason, misdiagnosis is common among the elderly.
Family-practice physicians and internists do well in treating chronic conditions in older people, said Edmund H. Duthie, a professor at the Medical College of Wisconsin and chief of geriatrics at Zablocki Veterans Affairs Medical Center and Froedtert Hospital.
But they are less familiar with geriatric syndromes such as dementia, incontinence, falls and depression.
Duthie agrees with a study that found only 31 percent of the elderly population receives recommended care. That contrasts with 55 percent of the total population.
Focusing on more than just the patient's health also sets geriatrics apart.
Age also brings psychological and social changes. Where patients live, how they spend their days and what they eat can be more important than their blood pressure or cholesterol level.
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