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?