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Posted: December 08, 2004

Professional Caregiving

Where Are All the Geriatricians?

Seems that our older clients, as well as you and I, dear colleague, had better stay healthy because there is a significant drop in the number of physicians trained in geriatrics. What do I mean by significant? How does a 30% drop grab you?

This drop is precipitous, not only because the legions of elders is growing and will keep growing for the next three decades, but also if you look at the training options, barely 25% of non-pediatric and fellowship training programs have specific geriatric curriculum requirements. That means that not only are there 30% fewer physicians with advanced training in geriatric conditions, but 75% of physicians complete their schooling and enter their practice with minimal if any geriatric specific training at all, to say nothing of a specialization!

Aren?t hospitals primarily filled with older adults? Aren?t nursing homes filled with older adults? Aren?t there many middle aged folks who, like Bill Clinton and his peers, look healthy one day and are undergoing bypass surgery the next?

Conditions that affect us with more prevalence as the years go on are treated by fewer and fewer physicians who actually have been trained to deal with them. Other than in pediatrics, isn?t the bulk of any one general internal physician?s patient load older, not younger? Strokes, dementia, hypertension, sensory loss, and neurological impairments, occur more often than not in those over age 65, and the medical community is losing those specially trained to care for them.

Uh, Oh! This does not bode well. We have to ask ourselves what could explain this distinct void in training for a condition all of us, if we are lucky, will experience -- aging!

Can you imagine the absurdity of completing an eight-year course in medicine whose curriculum was guilty of forgetting (or denying, or ignoring) care conditions faced by children? That would never be considered a complete curriculum. So why is there such a dearth of specialized course preparation for those conditions faced by the elderly?

I decided to call upon a colleague, Dr. Chuck Crecelius, who is the medical director of two large nursing homes and has a successful private practice in which he has been specializing in geriatric medicine for 17 years (you?d never know to look at him!).

I asked him what his biggest concerns were related to geriatrics, and he said, ?Societal lack of interest in geriatrics. There aren?t enough specialists, or care staff, in aging services as it is a very high touch, low tech field.? People come to him when they are in crisis, when they need direction, often of a psycho-social nature, in addition to the medical problems they face. He acknowledged that at this rate there won?t be enough geriatricians to go around in as little as 10 years.

Why? Says Crecelius: ?Litigation is one reason. Geriatricians and nursing homes face litigation at a greater rate than obstetrics and 90% of the cases settle. Death is considered a bad outcome in the U.S.

He continues: ?My question to patients and families is not whether death will occur, but more importantly, it?s how we pass through this phase that is the most important consideration. The quality, the life and death issues each patient feels is most important. How is that dealt with?? The fact that pharmaceutical companies stop testing medications on those 75 and older, points to the lack of research and studied outcomes for a knowledge base on the doses and effects of certain medications on the old-old patient.

When asked about the most significant medication breakthrough he has seen, his response was immediate. ?Alzheimer?s meds have changed the public?s thinking related to this disease. Because it reduces symptoms for a while, but does not cure the disease, we are beginning to hear people talk less about saving lives with medications, and more about saving quality of life with these pharmaceuticals. That?s what geriatric medicine is all about. Stretching the quality as far as possible, acknowledging that there will be an inevitable ending point.?

Trends that he sees are that more are using the growing store of knowledge in geriatrics, explaining that the American Geriatric Society Journal only 10 years ago was new and now it is highly respected and quoted. The advice he would have liked early on, and now is central and shapes his practice, is that ?Communication is King.? It?s all about communicating with your patients. Geratricians need to sit down, take the time to get to the core end of life concerns and goals for each patient. Patient satisfaction, a ?good death? the way one?s loved one wanted it, is what gives his work meaning.

What about your own aging, Dr. Crecelius? What?s in store for you? ?By the time I reach 85, there will be much more knowledge about what works and how we get the biggest bang for the buck. People will more consistently have prepared their living wills, even though at present it is a source of discomfort in many families.?

Sitting on the End of Life Coalition, Dr. Crecelius strongly urges families to have these discussions, ethical wills, living wills, advanced directives as tools to ease the psychological stressors related to aging, disability and one?s sense of control. His greatest challenge is still helping patients see that setting goals for living out one?s life with the greatest quality is a far better plan that trying to outsmart death. Is it living to your grandson?s wedding? OK, let?s try for that. He tries to coach his patients away from the mindset of living longer, despite diminished capacity and comfort. Embracing the inevitable with realistic goals is central to his work with patients.

My last question was a selfish one: Are you accepting new patients?


Sylvia Nissenboim is a licensed clinical social worker and who has been working in the field of adult day services in the St. Louis area. She is the director of four adult care and enrichment centers for the American Red Cross and also operates a personal and professional coaching firm, LifeWork Transitions, specializing in caregiving concerns, adult day care management and other aging services, such as virtual coaching and family care giving support groups. She co-authored The Positive Interactions Program, is a national speaker, and has served as president of the Missouri Adult Day Care Association and as a member of the Missouri Governor's Advisory Council on Aging..

© 2004 Pederson Publishing, Inc. All Rights Reserved.
Commercial use, redistribution or other forms of reuse of this information is strictly prohibited without the prior written permission of Pederson Publishing.

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