[NPInfo] Seriously, why not US?????

[David Mittman]

As Population Grows Older, Geriatricians Grow Scarce
Officials, Schools Prod Doctors to Focus on Elderly Care
By Howard Kim
Special to The Washington Post
Tuesday, March 11, 2008; HE07



Mary Boland, 91, can consider herself fortunate. In 2006, the  
chronically ill former teacher from Cincinnati had a narrow brush  
with death when she came down with pneumonia. Within minutes,  
Boland's personal physician, Gregg Warshaw, was called.

"She was weak, confused and breathing abnormally," Warshaw recalls.  
"Her blood oxygen level was low, and she was suffering a low-grade  
fever."

In the elderly, pneumonia is often fatal. But instead of rushing  
Boland to the nearest hospital, as many family doctors might have  
done, Warshaw, a geriatrician, stabilized the condition and put his  
patient on antibiotics.

"Luckily, the pneumonia wasn't grave enough to warrant  
hospitalization," Warshaw says.

Geriatricians have provided specialized care to the elderly for  
decades, and until recently their numbers have been growing. But  
despite countless attempts to convince the medical profession and the  
public of their worth, the number of practicing geriatricians in the  
United States -- about 7,000 -- is falling seriously behind needed  
levels.

While the U.S. population age 55 and older is growing rapidly,  
according to a 2005 census report, the number of medical school grads  
going into geriatrics has been slow to keep up.

According to one estimate, the nation's teaching hospitals are  
producing one or two geriatricians for every nine cardiologists or  
orthopedic surgeons.

Low reimbursements and the allure of higher-paying specialties have  
been largely responsible. Then, too, the prospect of working long  
hours treating severely ill patients in their homes or at a hospital  
or nursing facility can be a turnoff, some physicians say.

"These are hard patients to treat because they're usually burdened  
with multiple complex disorders like Alzheimer's, dementia and  
congestive heart failure, and are often at the end of life," says  
Pittsburgh geriatrician Judith Black. Geriatrics isn't sexy, Black  
says, "but it can be extremely rewarding."

The rewards, geriatricians say, come from caring for a vulnerable,  
often misunderstood patient population and the strong relationships  
geriatricians develop with their families.

"Yes, they do die in the end; we all do," Black says. "But the effort  
is to bring dignity to those later stages of their lives."

That's not to say that primary care doctors aren't qualified to  
provide the same care. They are, says Kevin Grumbach, chief of the  
Department of Family and Community Medicine at San Francisco General  
Hospital. "What geriatricians are good at," Grumbach says, "is their  
coordinated team approach."

So it's all the more worrisome that the looming dearth of  
geriatricians is happening alongside another trend: a shortage of  
primary care doctors.

Most geriatricians are certified by either the American Board of  
Family Medicine or the American Board of Internal Medicine. To stave  
off the predicted deficit in the field's number of practitioners,  
geriatricians have pushed hard to encourage family doctors to get  
extra training in caring for the elderly.

But fewer physicians are going into primary care these days, and many  
are dropping out, tired of the hassles of low reimbursements and  
managed care.

Nevertheless, the American Geriatrics Society has lobbied  
aggressively for government support and more medical training:



¿ Last May, Sen. Blanche Lincoln (D-Ark.) introduced the Geriatric  
Assessment and Chronic Care Coordination Act of 2007, which codifies  
the coordinated team approach and requires that Medicare provide  
quality programs for older adults with multiple chronic illnesses.



¿ On March 4, Sen. Barbara Boxer (D-Calif.) introduced the Caring  
for an Aging America Act, which allows young physicians, nurses and  
other providers to work off all or part of their medical training  
debt by obtaining additional training in geriatrics or gerontology  
(the study of the aging process) and by working full time with the  
elderly for at least two years.



¿ In 2007, South Carolina established a loan-forgiveness program  
that offers physicians a free pass on their medical training if they  
go into geriatrics for five years. Five other states are looking at  
the plan.

Meanwhile:



¿ More than 50 medical schools have added elder care to their  
medical programs. The David Geffen School of Medicine at the  
University of California at Los Angeles recently revamped its  
curriculum to include geriatrics, and the University of Oklahoma  
College of Medicine in Oklahoma City requires a third-year rotation  
in geriatrics.



¿ Since 2001, the Donald W. Reynolds Foundation in Las Vegas has  
given $150 million to fund geriatrics training at 30 medical schools.  
The John A. Hartford Foundation in New York has doled out $40 million  
to 27 schools.

"There's still a ways to go," says AGS President Todd Semla.

At the same time, though, critics such as retired bioethicist Daniel  
Callahan wonder whether the investment in geriatrics is worth the  
social cost. "Are we going to continue funding programs for the  
elderly at a time when so many people have no health coverage?"  
Callahan asks. ¿

Howard Kim is a Los Angeles-based freelance reporter who covers the  
health-care field. Comments:health at washpost.com.





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