December 9, 2020

It’s five AM and I’m not going to be able to go back to sleep after sitting bolt upright at four so I might as well do some writing. I was having one of those narrative dreams. I was watching a film (and was also somehow within its world at the same time). It was a generic rom com about a twenty something couple who kept meeting cute and awkward but who were destined for each other. Then, suddenly, there was a hostage situation and a grenade blast and one of them ended up dead and kept trying to reach through and correct things to what might have been. That’s what woke me up. This overwhelming feeling of loss. I think that’s me processing what’s going on in the world in metaphorical terms. At this point, Oliver, one of my two cats heard me stirring and came over and curled up next to me demanding attention. It’s very odd. Oliver has been part of the household since 2008. For the first 12 years he despised any human contact. He would only appear at feeding time and heaven help you if you approached him. Since moving to the condo, he’s a different cat. He wants affection and likes to be in the same room with me. He’ll even share space with his sister, Anastasia which he never used to do. He still vanishes if anyone else enters the condo so he’s not a completely changed feline.

So where are we in terms of the Accidental Plague Diaries? The news isn’t good. The results of Thanksgiving gatherings are beginning to make themselves known. UAB hospital is now running about 170 Covid inpatients. Back in the spring, it was more in the 40-50 range and it peaked out in the summer surge around 100 inpatients on the daily census. And these people are sick. You aren’t being admitted these days unless you’re in danger. Those without significant oxygenation problems or other complications are sent home to recover on their own. We’re at a bit over 15 million cases in the US which means we’re adding nearly a million and a half cases a week. The daily death toll in the country is hovering between 2500 and 3000 which is between a Pearl Harbor and a 9/11 occurring on a daily basis. I expect in the next couple of weeks, with more holidays coming, it will surpass 3000 a day and we’re likely to see 100,000 deaths a month in January and February.

Each one of those people was someone who was alive and looking forward to the holiday season a year ago. They were parents, children, siblings, spouses, friends. They had no idea that 2019 was going to be their last chance to celebrate with those they loved. 286,000 to date – roughly the population of Orlando, Florida. Most of them would still be living if we had a federal government capable of functioning and meeting challenges head on. Perhaps we will have that again, perhaps not. We’ll find out shortly. I’ve lost a number of patients. The story is usually the same. Younger family members who have not been as careful as they could be come to visit and bring an unwanted house guest and an elder pays the ultimate price. As a society, we tend to heave a collective sigh of ‘so what, they were old’. But I can tell you from thirty years of experience in geriatrics that most of our elders have a lot to give and teach us all about the human condition and who we are as people.

It wasn’t so long ago that a well respected senior physician from a surgical specialty was talking to me at a social event and said to me ‘You’re so bright. Why did you waste your career by choosing geriatrics?’ I’ve had a lot of successful academic physicians say things like this to me over the years. Usually it’s not quite so blunt and couched in more politically palatable terms but the end message is the same and unmistakable – taking care of the elderly is somehow for losers. I obviously don’t think so or I wouldn’t have chosen the field. Actually, I think it’s more that the field chose me. Most who go into geriatrics do it based on some life experience with an elder – a grandparent or great grandparent. It didn’t happen that way for me at all. Like most things in my life, there was a great deal of accident and serendipity.

I chose internal medicine as my specialty coming out of medical school because I didn’t know what I wanted to be when I grew up. Internal Medicine seemed to be the best way to delay that choice. I knew I wanted some sort of rigorous academic training. Having grown up in an academic family, I understood innately how that world works and felt comfortable with it. Off I went to my residency in Sacramento at UC Davis with only a vague understanding of what I was getting myself into. I did my residency in the late 1980s – a different world than today. It was before national legislation regarding work hours went into effect and you were expected to work until your job was done, which was generally an 80-90 hour week. You were on call in the hospital every third or fourth night with no guarantee of sleep. Six months into my first year, the dreaded internship, I was sleep deprived, lonely, miserable, and wondering if I’d made a huge mistake. (Pretty common feelings among all of us). Then things started to get better: I met Steve. I came out and began to live a more authentic life. I finished the intern year and schedules got easier. (To this day, most of that intern year has been erased from my memory – not enough sleep…) I got the hang of how to do my job in residency and do it well.

Half way through my third year, my program director had her quarterly meeting with me and looked at me and reminded me that there was no fourth year on the program and I had better figure out what I wanted to do with myself. That pulled me up a bit short until she told me ‘Go home and figure out who you are, and then you will know what you should do’. So I went home and talked to Steve about things and realized that I enjoyed ambulatory care, liked talking to patients, believed more in health than in disease and liked working collaboratively in teams. That made it obvious, I needed to receive my advanced training in academic general internal medicine and off I went to talk to the head of that division who welcomed me and offered my a fellowship with them to train to become clinical faculty. On my way out the door, he mentioned the geriatrics fellowship they also offered and which no one ever wanted to do.

Here I am, seven years into medical training and I have never met a geriatrician but I am quite capable of reading demographic charts so I thought it might be a good idea to see what was happening in the area. It didn’t take me long to figure out that this was a group of people who thought about medicine in the same ways I did so I signed for geriatrics training, not out of a specific wish to treat the elderly, but out of a specific philosophy of how I could create and mold systems of care that would be good for all people, just using an elder population in which to do it. I have always believed that what I do as a doctor is what is good for human beings in general. I just happen to do it for the elderly as the system will begrudgingly allow me to take the time necessary and utilize complementary resources such as nursing, therapies, and social work rather than insist on my getting a patient in and out the door every fifteen minutes.

The health system, in general, understands that geriatric care is important as most of their client base is aging and Medicare is often their largest payor source. However, it has a very tough time understanding the role of geriatrics. Our system is built on specialization, a breaking down of a human being into organ systems or even further into basic biochemical and physiologic components. You achieve success in the system by becoming a subspecialist. You achieve great success in the academic world (even as a geriatrician) by becoming a leading expert in a very narrow area. As the system hums along and creates new doctors, there is an implicit bias against general thinking in favor of specialty thinking. Bright candidates are steered toward narrow subspecialties, especially if they involve procedures (highly compensated) versus what are known as evaluation and management (E and M) services which involve thinking and listening and chart research to achieve a diagnosis. If I had a nickel for every time I’ve heard an attending physician tell a promising medical student a variation on ‘you’re too good for primary care’, I’d be a very rich man. There’s an interesting tangent as to why this attitude exists. Procedures are easy to quantify. You can describe them in exact terms. You can distinguish one from another easily. It’s not too difficult to understand what level of expertise, what sorts of ancillary services, and what equipment are needed for each one. E and M services, on the other hand, are very vague. If I am seeing an older person with memory problems trying to distinguish dementia from normal aging change, I do no biopsies, I rely on my experience, intuition, interviewing skills, and simple paper and pencil tests. I will do some lab work and a brain MRI if I am concerned about an interfering undiagnosed medical condition. All of that can take me well over an hour. We are reimbursed by Medicare (and most other insurances) by submitting bills coded through a system known as the CPT. There are thousands and thousands of codes for procedures but only a handful for E and M services. These codes are proprietary (put out by the AMA) and the committees that create the coding systems consist almost entirely of subspecialists eager to show their worth but who have grave difficulty with the expansive thinking of someone like me who thinks backward from their coning down process. Consequently, those of us in cognitive specialties tend to be paid at much lower rates.

This has, over the decades, led to a bit of a crisis in geriatric care. The number of board certified geriatricians in the country topped out at around 9,000 in the 1990s. Most of these took the test without formal training through a grandfathering process. Many of those chose not to recertify or were older and have since retired so the number of geriatricians currently is closer to 6,000. (It’s been estimated that we need about 30,000 to care for the aging baby boom, who start turning 75 next month). There used to be about 800 training slots for geriatrics in the country. Due to lack of interest from medical students and residents, many of them have closed. There are now about 400. Only 200 individuals applied for the training programs this past year. UAB, a major university with an excellent training program and track record has now been unable to attract any trainees in geriatrics for three years running. Those who come up through our medical programs, like most young people, head for brighter lights and bigger cities.

There’s been a surge in applications to medical school this last year (up 18%) – which some have dubbed the Fauci effect. I think that’s wonderful but those applying this year will not graduate Medical school until 2025 and residency until 2028. So even if some of them choose geriatrics, and I expect we’re going to see a huge surge of infectious disease specialists before that, they’re not going to be ready until about 2030, the year the very last boomers pass 65 with the leading edge bumping against 85- less functional and with chronic disease burden, but not yet into their die off, in other words, peak age. Every demographer has been pointing out this phenomenon since the 1970s but no one has been listening. My planned retirement date is somewhat before this. It’s going to be someone else’s problem.

The cynical piece of me can’t help but wonder if there’s someone sitting in the offices of the Center for Medicare and Medicaid Services running spreadsheets of data and calculating what percentage of the boom needs to die of Covid over the next few years to reduce tax dollars flowing to the health care sector over the 2020s and 2030s. I hate to think of it but I put nothing past the current administration. Don’t be a statistic they can use: wash your hands, wear your mask, social distance. You know the drill.