Geriatric Physicians: Worth Their Weight in Gold

As a geriatric care manager I spend quite a bit of time in doctor’s offices, much of it waiting for the doctor to come in!  A recent visit with a client to see a geriatric physician is typical of many of my clients and demonstrates the value of someone trained in geriatrics especially for frail elderly, but even for relatively healthy elders as well. Mary is a relatively fit 88 year old woman who has a history of heart arrhythmia, severe scoliosis, insomnia, decreased energy, recent unexplained pain in her right leg, and problems breathing when walking up hill.
Mary’s physician, Dr. S., started out by asking about how things were going in her life- was she getting out to socialize, eating habits, hydration, and exercise habits. How were things going with her family? Dr. S. asked Mary if she thought she was depressed, and Mary said yes this was possible at which point the doctor suggested a low dose anti-depressant explaining that sleep and energy problems can be associated with depression. She also recommended a physical therapist for Mary’s leg problem, suggesting that the scoliosis could be the culprit causing a pinched nerve that was affecting not only the leg, but the breathing problems as well. Doctor S. asked Mary if she would like to have an echocardiogram to rule out any additional heart problems, but Mary declined. Mary and Doctor S. agreed to meet again in three months to see how things were going, but in the meantime, if Mary has any questions she is welcome to email Dr. S. The visit took over an hour.
This visit demonstrates the best characteristics of geriatric medicine:
• A “holistic” view of the patient, meaning taking the time to ask about Mary’s life circumstances which may reveal stressors or frustrations.
• Focusing on the basics. Asking about nutrition, hydration, exercise and socialization. Trouble in any of these areas can lead to greater physical, emotional and cognitive problems.
• Empowering the patient to make decisions in a partnership with the physician. In other words, not “telling” Mary what to do, but making suggestions that are ultimately Mary’s decision.
• Being accessible. When was the last time, if ever, that a physician gave you their email contact information?
Many cities are fortunate to have teaching hospitals, VA medical centers, and several geriatric practices from which to choose a geriatric specialist. Other areas of the country are not so fortunate. There are enormous challenges enticing medical students into an area of practice that is already in great demand and growing exponentially. Many people do not realize that geriatric physicians are on the bottom of the pay scale for doctors while having to deal with enormously complex and challenging medical problems. At the same time, they have significant medical school debt which is a disincentive to choosing geriatrics over more lucrative areas of medicine. “Geriatrics is one of the few medical specialties in the United States that is contracting even as the need increases, ranking at the bottom of the list of specialties that internal medicine residents choose to pursue.” (New York Times, January 25, 2016. Katie Hafner).
As the example of Mary above demonstrates, much of geriatric medicine involves developing a plan of care, assessing lifestyle habits, and inquiring about home environment and family and social relationships. All of this takes time and Medicare does not pay for these services. Medicare pays for procedures and treatment. The New York Times article reports that changes to this type of reimbursement are being discussed. This will go a long way towards the recruitment of geriatric physicians.
Not every geriatric physician is a good doctor and I suggest a vetting process if possible. Ask friends or acquaintances if they have had a good experience with a particular physician. Look on line to see reviews. Call your area agency on aging to see if they have any recommendations.
If you live in a community where there are no physicians trained in geriatrics I recommend doing the following:
• Make a detailed list of questions before the appointment.
• Be your own advocate or better yet, bring someone with you who knows your wishes and concerns.
• Always ask for explanations and alternatives to suggested treatments or medication changes.
• If you don’t like your physician, change.
As the aging population swells, having physicians trained in geriatrics will go a long way
towards enhancing and improving the quality of life for our elders.