September 27, 2015

Right diagnosis, wrong treatment

This past week, frailty came out of the closet. The NY Times ran an op-ed about people who aren’t dying and who aren’t thriving. They’re old, they typically have multiple medical problems, and they need help with some of the basics we must deal with to get by every day. They are the people I write about all the time in this blog. Marcy Houle bravely brought this neglected population to public attention, telling a story about her orthopedic surgeon-father-with-Alzheimer’s disease who broke his hip. 

Kudos to Houle, a writer, wildlife biologist, and adult daughter, and to the Times for breaking a taboo and talking about frail elders. But while the diagnosis is correct, the treatment is not. The article asserts that what we need is more geriatricians. Houle's father saw a geriatric specialist who prescribed pain medication for him after he had a hip fracture, and suddenly he perked up, he was more alert and more himself. His daughter writes that he was able to “escape the land of the pink bibs,” her picturesque way of referring to the dining room table where he sat with others in his nursing home, staring into space. (In my father's nursing home, they have banned bibs, on the grounds that they are demeaning. Instead, the residents doze at the dining room table for hours, their shirts encrusted with the remains of their last meal, until it's time for the next meal.) In fact, Houle's father still had Alzheimer’s disease. He was still frail. His quality of life was better than it had been, which is terrific, but he was still in that zone between robust aging and dying, even if he had improved enough that he didn’t need to wear a pink bib. He benefited from the advice of a skilled physician with geriatric training, but for him to receive optimal treatment on an on-going basis, he will likely need more than a one-time geriatric consultation. And the kind of care that he, along with the millions of others like him, will need involves something other than just a good doctor.

We’re not going to transform the care of frail elders by increasing the number of geriatricians. As Houle rightly points out, there are fewer than 8000 geriatricians in the US and the number is decreasing, not increasing, even though by 2050, there will be an estimated 90 million Americans over age 65, of whom 19 million will be over 85. Geriatrics has been a specialty in the US since 1988—at least, that’s when the first certifying exam was offered, though that examination does not actually confer full specialty status. Passing the exam means receiving a Certificate of Added Qualifications in Geriatric Medicine, which doesn’t have quite the ring or the reputation of subspecialty status. It is analogous to subspecialties such as Nephrology or Cardiology (or for that matter, Palliative Care) without the cachet. 

The number of physicians taking the exam each year it is offered has been decreasing, reflecting the reality that fewer young doctors are seeking the extra year of fellowship training now required to sit for the test. Slots in geriatrics fellowship programs regularly go unfilled. It's just not a very attractive field to many doctors emerging from medical school and residency addicted to curing people and with a mountain of debt. Not only does Geriatrics pay poorly—internists who spend an extra year doing a geriatrics fellowship find their salary is, on average, lower than that of general internists who don’t do a fellowship in anything—but most of the healthcare systems in which geriatricians practice medicine are not conducive to providing high quality care. They should be interdisciplinary, they should have geriatric-friendly offices and examining tables, they should facilitate integration of care across multiple sites (office, hospital, rehab), and they should offer home visits. A few innovative programs do just that, including GRACE (Geriatric Resources for Assessment and Care of Elders), designed at the University of Indiana, and Guided Care, pioneered at Johns Hopkins; most practices do not.

We know how to remedy the situation. The Institute of Medicine got it right in 2008 when it issued its report, Retooling for an Aging America: Building the Health CareWorkforce. The IOM advocated a 3-prong strategy: enhancing the geriatric competence of the entire workforce (which includes lawyers, architects, and urban planners along with personal care attendants); recruitment and retention of geriatric specialists (which includes informal caregivers along with doctors and nurses); and improving the way care is delivered (redesigning the system to provide coordinated, multidisciplinary care). That's what we need to do. Some institutions are beginning the process:  the Faculty Program to Advance Geriatric Education, a novel curriculum in use at a number of medical schools, focuses on geriatricizing internists rather than on producing more specialists. 

Simply minting more geriatricians, even if we knew how to attract more physicians to the field, will not be sufficient. We all need to retool to face the coming demographic reality.

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