I’m grumpy tonight. I know why. It’s due to the unending public health idiocies being foisted upon us by conservative Southern governors who, despite all scientific evidence to the contrary, are busy abolishing mask mandates and social distancing requirments. Alabama hasn’t joined the parade yet but our governor has a press conference set for tomorrow morning and I’m pretty sure I can predict the substance of it. It all pisses me off for couple reasons. One, while numbers are down and vaccine is rolling out, we are not out of the woods yet and the rapid spread of more infectious variants means that relaxing of public health members is likely to send us towards another surge. Everytime we surge and numbers go up unnecessarily, for every thousand postitive tests, three people receive a death sentance. It’s also a huge slap in the face for an exhausted health care work force. And the people they are going to have to take care of are going to be middle aged folk who have either been unable to obtain vaccine or who have been taught by their information sources that they don’t need it. The elderly, being in the early group to get vaccine, will be relatively protected – the rapid decline in cases and deaths recently has been due to that low hanging fruit having been plucked. Then there’s my purely selfish reasons. If we start surging again and it prevents me from being able to do my planned travel and get back on stage again, Imma gonna be mad!
I wrote this essay a couple of weeks ago for an elder care website. Rather than go stream of consciousness this evening, I’m going to publish it here so I can spend the evening with my can of hard pear cider and old episodes of Community. Enjoy.
Why Can’t I Find a Geriatrician For Mom?
Most human beings, as they age, realize that their bodies and physiology changes from what it was in their younger adulthood. Things that never bothered them in the past start to hurt. Their reaction times slow. They have less strength and muscle mass. Eyesight and hearing aren’t as keen. American medicine began to understand that the precepts of medical treatment that were being developed post World War II, full of a newfound scientific rigor, might not be one size fits all and such specialties as pediatrics for children and obstetrics and gynecology for women were given new status. Geriatrics, a specialty dealing with aging and the older adult, was first formalized in this country with the founding of the American Geriatrics Society in 1942 but there wasn’t a lot of interest from either the medical community or from society at large as the numbers of individuals living healthy lives into their 80s and 90s was very, very small, most people being carried off by acute illness somewhere in what we would now consider late middle age.
Things began to change in the mid 1960s. First, the financing of health care for older individuals was radically transformed with the introduction of Medicare in 1965. This federal program, which was available to a majority of seniors, was instantly popular as aging adults suddenly had a resource for paying physician and hospital bills that did not rely on their own pocketbook. The older population signed up in droves and by the early 1970s it was fully enshrined in our culture as an entitlement, becoming one of those third rails of American politics. Second, demographers recognized and began to publicize what had been going on in America in the years following the end of the war. The relative privation of the Depression and World War II years, fifteen long years of never enough, had given way to prosperity and a resulting dramatic rise in the birth rate from the mid 40s through the mid 60s, forever known to history as the Baby Boom.
The scale of the Boom was enormous and society, rebuilding itself after years of trauma, was determined that this generation should never know want or unhappiness. A new media culture was created to reflect an idealized society from Sally, Dick and Jane to Leave It To Beaver. Schools were built and enlarged. Public Universities were lavishly funded to allow for their education at low prices. Their sheer numbers forced society to bend to their needs as they entered each stage of life. The demographers, forever thinking of the future, projected forward and began to wonder about what this might mean when they started to enter their elder years early in the 20th century, especially when other world populations were exploding meaning more and more competition for resources. The baby boom itself, as it matured, tended to ignore these calls as they, to this day, consider themselves a young and vital generation. The first year of the boom, turning 75 this year, contains such luminaries as Dolly Parton, Sylvester Stallone, Susan Sarandon, Bill Clinton, Sally Field, Donald Trump, and Cher – not exactly what we would consider a decrepit and over the hill cohort.
The medical system did start to take notice of what was coming and, in the early 1980s, began to formalize geriatric medicine as a specialty, creating (with the assistance of Medicare) specialized training programs for those who had completed initial training in either Internal Medicine or Family Practice. These fellowship programs began to pop up in University training programs by the late 1980s, usually as subunits of other programs rather than as fully funded entities in and of themselves. Formal educational criteria were set and board exams were created to determine who had the necessary skills to be called a geriatrician. For the first ten years of the board exams (mid 80s through 90s), there were two paths to becoming certified. You could either complete fellowship training or, if you had clinical experience in the field, you could apply to take the test based on that experience. Most individuals working in the field did so and the number of board certified geriatricians in the country rapidly rose peaking at about 9,000 in the late 1990s. Board certification is not life long, you must retest every ten years. Many of these early people who grandfathered in retired or found that maintaining certification was not worth the time and expense and the number of geriatricians began to fall. It’s between 5,000 and 6,000 today.
Those who study medical systems and the impact of aging populations on medical systems understand the role of the geriatrician in healthcare. Not everyone needs a geriatrician starting on their 65th birthday. Geriatricians are most valuable taking care of that subset of older people who have developed chronic disease burden to the point where their physical and/or cognitive function is impaired and they can no longer live independently in the life they have designed for themselves. Most of these people do not live in nursing homes or other congregate facilities. They mainly live in the community, cared for by an army of family members and friends doing the best they can. A geriatrician’s special skills in understanding the interplay between social and physical determinants of disease, medication management, fall prevention, maintenance of continence, management of dementia behaviors, and other such issues can make all the difference between a happy home life and misery for all concerned. Medical demographers have concluded that by 2030, when this country will enter peak age (the entire baby boom over the age of 65 but not yet having begun to die off in significant numbers) it will take about 30,000 geriatricians to provide optimal care, about five times as many as are available.
We are still training new geriatricians. There are roughly four hundred training slots available nationally on an annual basis. Only about two hundred of them fill with applicants after the matching process is complete. Here at UAB, we have been unable to attract a single applicant for the last three years. Geriatric medicine is the second least popular specialty among US medical school graduates, bested only by geriatric psychiatry. The reasons for this are complex. Some are buried deep within the culture of the US medical education system that devalues person to person work for complex procedural work. Some are tied up in the financing of health care and the pivot by health systems away from unprofitable service lines. Some are due to the economics of physician compensation. Geriatrics remains one of the lower paid specialties due to its reliance on Medicare reimbursement which is notoriously low for cognitive services.
This all leads to a fundamental problem. We have a rising demand due to the pressures from an aging baby boom on the health system. We have a society that has moved away from investment in public health infrastructure which would allow a less profitable specialty to sustain itself and provide compensation packages that would attract more medical graduates into the specialty. We have a stagnant number of qualified geriatricians. The two hundred new graduates a year just offsets the number who leave the specialty through retirement or change of job focus. Those few of us who remain in the field and committed to clinical geriatrics are well aware of all of these trends and saddle up for work every day determined to do the best we can but we are only human. The end result of all of this is finding a geriatrician for mom is exceedingly difficult. They just don’t exist.
Can this problem be fixed in the short amount of time remaining before peak age? Of course it can. We know this from looking at recent medical history. Prior to the 1990s, there was really no such thing as a hospitalist. There are now more than 40,000 of them nationwide. Financial incentives, working conditions, and system structures were changed in that decade to make it a viable choice for new physicians and they came flocking to the job opportunities. Something similar could be done for geriatric medicine. All it requires is a health system willing to make those changes, either intrinsically which would require economic inducements, or extrinsically through legislative fiat. These are things I cannot accomplish on my own. It will require societal will. In the meantime, I’ll keep saving the world one patient at a time.