Help Wanted: Geriatric Docs

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Elderly patients are demanding an increasing amount of health care. So why isn’t the system keeping up?

AS YOU AGE, THE MOST IMPOR- tant relationships in your life become the ones you have with your spouse, your kids and your doctor—and not necessarily in that order. The older you get, the more medical care you need and the more frequently you need it; in fact, a majority of seniors suffer from at least one chronic illness. It’s crucial to your financial and overall health to have a physician you trust.

Unfortunately, your doctor may not know best when it comes to caring for you as you age— even if he or she has been treating you for years. Most medical schools in thelJ.S. don’t require any training in geriatric medicine, and few residents spend any time treating patients in settings dedicated to seniors, such as nursing homes or assisted-living facilities. As a result, while there are pediatricians and orthopedists in just about every city and town across the United States, there arc only about 7,000 geriatric specialists in the entire country. More disturbing, many general practitioners don’t fully understand the particular symptoms that elderly patients exhibit or the specific treatments they require.

As a 2008 report by the Institute of Medicine put it: “The health care workforce receives very little geriatric training and is not prepared to deliver the best possible care to older patients.”

In patients over 80, for example, heart disease often manifests itself as shortness of breath rather than chest pain or pressure, which is more common in 50-year-olds. Pneumonia can lead to fatigue and sleepiness instead of heavy coughing. Confusion can be a sign of various physical ailments—even a bladder infection—not just cognitive impairment. Dr. Rosanne Leipzig, professor of geriatrics at Mount Sinai School of Medicine in New York, says it’s not unusual for doctors to be unaware of such differences. “Good doctors will develop a sense of them over time through trial and error,” she says. “ But most were never taught geriatrics in medical school, in part because it’s not required, and in part because we’ve just developed this knowledge in recent years.”

Seniors account for 28 percent of the average primary-care physician’s workload and 48 percent of the days patients spend in hospitals, according to the Department of Health and Human Services, and those numbers are sure to grow larger over the next few years. So at a time when other sendee businesses as varied as fast-food restaurants, hotels and telecommunications providers are rapidly reconfiguring to deal with an aging population, how can medicine be so far behind? The answers lie in the way that Medicare, which covers most medical expenses for nearly all seniors, is structured.

For one thing, Medicare generally reimburses doctors and hospitals 15 to 25 percent less than they can charge patients or insurance companies in the private sector. It makes sense for the federal government to use its market power to save money, but this tilts health care providers away from spending time with older patients.

Further, Medicare reimburses physicians only for time they actually spend with patients—for services provided or procedures performed directly— as opposed to working to coordinate patient care. Suppose you fall and injure your leg. Medicare will pay your doctor to run tests, diagnose your problem and prescribe anti-inflammatory medication. But it will not pay her to help you find crutches, check with your pharmacist to make sure it’s okay to mix your new drug with prescriptions you’re already taking or call you a week later to check that your leg is getting better. These arc the kinds of steps needed by seniors in particular, and doctors take them when they can. But again, financial incentives push them in the opposite direction.

Medicare’s policy of reimbursing physicians only for “face time” is actually well intentioned; it’s one of several regulations from an era when older Americans weren’t getting much medical care at all, and it was important to get them to visit doctors’ offices. But today seniors often sec multiple physicians and take many medications, and Medicare’s fee-for-ser- vices system has grown hugely wasteful while leaving too many patients—and doctors—without the information they need. That’s why it might make sense for Medicare to “bundle” payments to the entire group of health care providers that treat a patient, from office visits to hospital stays to post-acute care. Reformers believe that encouraging doctors to work as teams could save billions a year while improving care, and Medicare officials say they’re studying the idea.

Finally, Medicare spends nearly $9 billion a year to help train medical residents, but it doesn’t require residents to spend time in nursing homes or even show competence in geriatric care. This is one area where it would actually be helpful if the government threw its weight around more forcefully.

The good news is, there’s a growing awareness that doctors need a better understanding of seniors’ needs. The Institute of Medicine says all health care professionals should have to demonstrate an understanding of how to care for older adults to get a license. And earlier this year a group of doctors and medical educators led by Leipzig published a consensus list of 26 “minimum geriatric competencies” that all medical school students should have, such as identifying medications that should be used with caution in older adults.

But you need to make sure now that you’ve got a doctor who will meet your future needs. So talk with your physician about his experiences with aging patients—ask what he has seen and learned about how symptoms and treatments change as you grow older. Bring a complete list of your medications, and have him explain any potential problems that may come from using them as you age. And be sure your doctor is comfortable assessing aspects of your health that you may not be worried about now but that wiil eventually become very important, such as your cognitive function and your gait. If at any point you feel like he isn’t taking you seriously, move on.

it’s a good idea as well to involve whomever wiil serve as your health care proxy in these discussions; it will help that person develop an understanding of the full range of your providers and prescriptions before any medical crisis happens to befall you. And if you need help finding a physician in your area who is sensitive to the needs of older patients, you can get a referral from the American Geriatrics Society’s Foundation for Health in Aging (www.hcalthinaging.org).

It’s not easy to find a knowledgeable doctor who will serve as your medical advocate. But if you don’t do it, nobody will. As Leipzig says, “Making sure your diagnoses are right and your medications arc tended to—our health care system puts those responsibilities in the hands of the patient.”

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