But if we value it, we actually would transform what it’s like to age

Why is the number of medical specialist geriatricians in the USA declining so sharply at a time when the population is aging so rapidly?((And is the same thing happening here in Australia, and elsewhere in the affluent West?~tigtog)) Below is an excerpt from a fascinating lecture by Atul Gawande, Harvard Professor of Surgery, about “What makes a good doctor, and how do the best hospitals work?”, broadcast on Radio National’s Background Briefing (this is from near the end of the transcript).

Kirsten Garrett: A member of the audience asked about a recent article written by Professor Gawande in The New Yorker magazine, in which he had discussed among other things, the decline in specialists in geriatrics in America. And the need for patients themselves to ask for good care in old age.

Atul Gawande: One of the reasons why I went into such excruciating detail about how your teeth start to age, and what happens is your hair roots start to lose their cells, is that I wanted people to grasp the difference between recognising that we are ultimately going to die and having the fantasy we all have that well maybe we can somehow live forever. And what it comes down to is the idea of the geriatrician.

Does anybody clamour for geriatricians? We’ve had a drop from 1998 to 2004 in the number of geriatricians in our country, by one-third. At a time when the number of elderly are increasing enormously. In just a decade we’re going to be a 20% of the population being over the age of 65.

Now part of the reason people don’t clamour for the geriatrician is what the geriatrician does. What the geriatrician does is they don’t make your life longer, they help figure out how to be attentive to your nutrition, and whether your toenails are clipped and whether you have good balance and whether your strength is there, and whether you’re exercising, and whether your eyes are doing well. All the things that you need in order to stay independent, to have control over your life.

And so there was a randomised trial in Minnesota that showed that the likelihood that under geriatricians’ care, as opposed to the usual primary physician for these elderly patients, the likelihood that they would have a disability dropped by 25%. The likelihood they developed depression dropped by 50%. But they didn’t live any longer. And so what we’ve had is the gradual disappearance of geriatrics as a profession and almost no outcry about that.

And so my answer to what do we do about it? Well the reasons why geriatricians are disappearing is in part because we don’t pay them very well, it’s one of the lowest-paid professions compared to becoming a radiologist, becoming a surgeon like I am. Another reason is because it’s not glamorous work, taking care of older people with lots of different problems, arthritic knees, a tumour they might have developed, bad back pain, diabetes, high blood pressure, and them somehow helping them live and stay at home as long as possible.

But if we value it, we actually would transform what it’s like to age.

When I was working as a physiotherapist, my major work area was in geriatric therapy and rehabilitation, which I found very satisfying because of the ability to extend my patient’s capacity for independence. Many of my colleagues found my enthusiasm for it rather baffling, because they were interested in the more “glamorous” and far better remunerated areas such as sports medicine, or manipulative therapy working with young adults’ acute injuries, rather than the maintenance therapy needed to manage chronic conditions of the elderly with the goal of simply maintaining their independent living capacity.

Geriatrics tends to attract a disproportionate number of women practitioners, largely because of all the usual gender socialisation about how being there for the needy is meant to give meaning to work for women whereas chasing the recognition and reward of the more competitive professional arenas is meant to give meaning to work for men. As usual for fields dominated by women, the pay is lower than fields dominated by men. Which makes the field of geriatric rehabilitation and gerontological physiotherapy less and less attractive to new graduates, driving up the workload of those in the field, and thus driving down the quality of care. The same goes for all the other disciplines in the area of gerontology.

FSM willing and the seas don’t rise, most of us reading blogs can expect to live until at least our mid-70s, and many of us can expect to reach our mid-80s (the same of course goes for most of our friends and neighbours who don’t read blogs, it is our technological society which has extended life expectancy). The difference between a contented old age and a miserable old age is, in my experience, almost totally down to the level of independence we can maintain: the sense of continuing to control our own lives until as close to the end as possible.

So why on earth are we not, as a society, recognising the social infrastructure investment that needs to be made in services to maintain the independent elderly? Does it come down to what Gawande describes as the fantasy that we will live forever, or at least the fantasy that if we’re going to live until our 80s that will automatically include being healthy and independent in our 80s? How can the reality be made more manifest, so that the deterioration of gerontological services can finally generate an outcry?

Categories: gender & feminism, health, medicine

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8 replies

  1. I suspect it is not only the fantasy that we will automatically be healthy and independent in our 80s, but the idea that we will automatically be so because of some moral aspect of our person, and those who need support just aren’t trying hard enough.
    It actually reminds me a bit of the fatphobic stuff, of the “well I’m thin because I do XYZ and if you’re not you’re just not trying hard enough”. So I wonder, and it’s not really a well developed thought at this stage, but it’s there, whether the same sorts of people kind of carry this idea that all the people who will need that support as they get older can be picked out now, when they’re young, as, y’know, the lazy fat ones, or the smokers or [insert stigmatised aspect/behaviour here].
    arielladrake’s last blog post..Reasons My Comics Store is Awesome #512

  2. There’s also the boomer hatred thing. Sometimes reading the internet, I really get the feeling some people would like us ageing people to just fuck off and die.
    Helen’s last blog post..But it?s OK – they?re white!

  3. The was a recent article talking about how many people are expecting to live into their 80s as fit and as healthy as they were in their 30s – and criticising doctors for not preventing the problems and illnesses that ccome with old age – the article also reported that doctors have been physically attacked by patients relatives after their loved ones die – the article quoted one doctor: “they don’t seem to understand that we all have to die sometime.

  4. I found that Atul Gawenda article fascinating. It really opened my eyes to the little things about ageing. I might be drawing an overly long bow here, but the lack of recognition and funding for geriatric care also seems a little that society likes the big heroic life saving technology solutions.
    Geriatric care is about the little things – making sure people have their toenails cut, that they have a small enough set of medications that they can manage them themselves, rather than the big dramatic surgical intervention like replacing their hip.
    It’s a little bit like the contrast between midwives and obstetricians.
    Jennifer (Penguin)’s last blog post..Party party party

  5. I can’t comment from my own experience, but from watching my step-father, and in-laws all of whom are facing 70 in the next few years, my guess is that they can’t imagine not being as well and as able to get around as they are now. Although at an age that was in the past considered elderly they are still very active and get around like they are still 55. I suspect that it may be a sudden illness or fall which suddenly renders them ‘elderly’ or a rapid decline in the next ten years. I think like many of us, most people think it could never happen to them. I don’t think many people, certainly not me, ever think about needing help to cut toenails either (except during pregnancy).
    Mindy’s last blog post..Underpants Retirement Ceremony

  6. Cutting toenails, getting to the loo, checking meds, helping patients and their relatives to adjust, and making sure there were rails/ramps in appropriate places were the major jobs of my former workmates. They made sure their patients could get to church, the supermarket, or the pub according to their preference. They got people out of hospital, and taking care of themselves, as quickly as possible. They also made money for the hospital, because a home based service is in some circumstances more efficient than a hospital based one. For their trouble, the department was re-structured, professionals lost their autonomy, and I (the admin assistant) ended up working mostly in other departments. So my former workmates were compelled to waste a whole lot of time doing their own data entry, photocopying, records management and so forth. It’s made them miserable. It’s made them want to leave.
    My Mum worked as a social worker in rehab, mostly in aged care, for 30 years. She retired at 56, completely burnt out, not by the patients, but by hospital managers. In her final year of work she and a colleague had taken to keeping score – whoever had seen (or been seen by) their manager the fewest times in the day was the winner. One of her managers described aged care as the ‘arse end of social work’. This isn’t an area attracting a lot of graduates. For social workers, it’s just one step up from the horrors of working in child protection. Based on her good health, and the longevity of her parents, my Mum can probably expect to be retired for 30 years. Her father was retired for 28 years, most of that in good health, he gave up golf at 79. None of our social systems were designed to deal with people who lived much past 65.
    As for the boomer hatred Helen, I doubt that’s got much to do with the social policies in question – most of these problems were created by governments full of baby boomers and war babies, not least Jeff Kennett. They’re not the result of decisions made now, but of ten and twenty years ago. Shortsightedness, stingyness, and a total disregard for those who aren’t self-funded retirees – definitely – but not necessarily blind intergenerational hatred. Perhaps the boomers who became decision-makers thought they’d never get old or have a stroke. All we can hope for is that Jeff needs a public hospital eventually, and he gets left on a trolley for a few days to think it all over.

  7. I wonder whether the difficulty securing good, affordable non-medical aged care, both residential and at-home (showering assistance, home help and so on), plays a part in why people aren’t keen to do the job? I remember the immense frustrations trying to arrange home care and placements for elderly people with higher needs, and that was back in the 1980s and 1990s, before things got as stretched as they are now.

  8. Yeah, the Atul Gawende article is great — well-worth going to the New Yorker archives to read.

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