The Atlanta Journal-Constitution
A DOCTOR SHORTAGE
Older population rises, but specialized care lacking. Some experts question need for geriatricians.
Even as the number of senior citizens rises like a tidal wave across metro Atlanta and the nation, the number of doctors who specialize in their care is dwindling to where some consider them an endangered species.
These physicians, called geriatricians, have found it difficult to find a foothold practicing medicine. Many older people are uncomfortable switching from their trusted doctor to a stranger. And many primary care physicians resist handing off their patients, believing they can provide needed care.
Advocates contend the shortage of geriatricians can lead to substandard care for the elderly. They say problems can occur such as incorrect diagnoses, overmedication or procedures that do more harm than good.
Children are treated by pediatricians, they argue. Why shouldn’t seniors have specialists of their own?
The numbers alone are startling. Georgia has just 135 doctors who are board-certified geriatricians to care for a senior citizen population of 1.3 million. The American Geriatrics Society calculates the state needs roughly four times that many geriatric doctors.
And the senior population is growing. Fast.
Here in metro Atlanta, a place generally known for young people and families, the older adult population of people above the age of 60 doubled between 1970 to 2000. It doubled again between 2000-2015, according to the Atlanta Regional Commission.
That makes it among the nation’s fastest growing populations of seniors in the country. Add to that the fact that people are living longer in general.
‘We’re losing ground’
The future of the geriatric profession hardly looks bright, as few medical students pursue the specialty. Emory has only three geriatric medicine fellows becoming board-certified geriatricians this year. That’s about average. The only other school in Georgia that offers a geriatric fellowship program is the Medical Center of Central Georgia/Mercer University School of Medicine. It had no fellows this year.
Some experts worry about sustaining the training should the number of students fall much further.
“There’s definitely a crisis,” said Dr. Ted Johnson, chief of geriatrics at Emory University School of Medicine. Few people are even entering the field. “We’re losing ground. We’re not even at a replacement rate.”
What does it matter? Well it matters to people like Doreatha Champion, 78, of Decatur, who swears by her geriatric specialist. During a recent doctor’s visit, Champion rattled off her latest ailments: muscle spasms in her legs, swelling in her knees and something in her chest she says was “just indigestion.”
“Did it hurt?” asked her physician, Dr. Ugochi Ohuabunwa. Champion raised her hand to her black sweater and clutched it, just to show her. At that, Dr. “O,” as everyone calls her, ordered up an EKG of the woman’s heart and a range of blood tests.
But not everyone agrees that geriatricians — who receive an extra year or two of schooling — provide superior care.
Among the skeptics is Dr. Thomas Bat, a family medicine physician and president of the Medical Association of Atlanta.
“We all train extensively on elderly care,” Bat said. “I don’t see any difference in their abilities versus the internists and family physicians who work here.”
Little action on shortage
Dr. Mark Supiano, a board member of the American Geriatric Society, said the dearth of these specialists means some older people receive a lesser quality of care. At worst, he said, peoples lives are shortened, lives that could have been lived longer and in better health.
What’s being done to address the shortage?
The short answer is not a lot. The limited number of federal and private grants have failed to attract many more students. Medical schools offer scant incentives. A few states provide student loan breaks, but Georgia is not among them. No action is planned by the Georgia General Assembly.
Even the Georgia Gerontology Society, the trade group that advocates for older adults, acknowledged it has no plans to press the issue.
“We haven’t picked this as a flagship issue,” said executive director Amanda James. Part of the problem is that there are too few of these specialists in the group. “There’s not enough geriatricians at the table.”
Some say it’s depressing work
With his smart white coat and stethoscope slung around his neck, Justin Kappel makes the rounds with the geriatric team at Grady Memorial Hospital.
The fourth-year medical student, who grew up in Buckhead, is considering making geriatrics his specialty. That makes him a rarity among young people going into medicine, who tend to view the field as one that offers little prestige and few of the rewards that come with curing someone.
“There is a general impression that this is kind of depressing,” Kappel said.
Geriatrics is among the lowest paying physician specialties, in part because most older people pay for their treatment through Medicare, the government insurance program that reimburses physicians at lower rates than private insurance.
The training takes longer, as well. After medical school, the doctors must obtain specialty training in family practice or internal medicine, followed by a year or two to complete a geriatrics fellowship.
In the age of the 10-minute doctor appointment, geriatric work takes longer. Older patients have more complicated health problems. Doctors don’t just focus on just the ailment of the day, but explore the person’s full picture of health. How are they managing at home? How mobile are they? Are they having trouble picking up prescription refills?
Older folks tend to take a little more time to explain things, mixing in their experiences and recollections. That reduces patient volume and profits.
A passion for the work
Dr. O spent a good 40 minutes with Doreatha Champion. She went through each of her medications to make sure they were on point and not conflicting with other pills. The doctor advised her to stop taking a cholesterol pill for at least a month, thinking it might be causing the muscle spasms in her legs.
Champion told the doctor she’s feeling down lately because she’s recalling that her home burned down this time last year. The two women talked that through like old friends.
(Days later, Champion learned that her heart tests all came back clean. The Decatur woman’s symptoms might have been stress from her emotional upset about her home or, indeed, indigestion, the doctor said.)
Dr. Johnson believes strongly that there is a place in medicine for geriatricians. Many medical students receives little in the way of specific training on the care of the elderly, he said.
Many who choose this field have a passion for it, often spurred by an emotional connection to some older relative. For Johnson, it was an older neighbor when he was a kid, a man who drove an old Cadillac that looked like the Batmobile and who helped the boy build little Pinewood Derby cars.
For Kappel, the medical student, it was his grandmother, Margarite. He was a senior at Westminster High School when a series of strokes and heart trouble sent her health spiraling. He watched her lose a lot of her personality and vitality before she died.
When he began medical school, Kappel viewed geriatrics as “a hopeless brand of medicine.” But over time, Kappel came to see his grandmother’s story in a new light.
“I see it as a cautionary tale of how things could have been done better,” he said.
‘How doctors should treat everybody’
For now, Kappel is still making up his mind. He’s spending a month with the Grady geriatric team, walking from room to room in the 11th floor geriatric unit at Grady hospital.
At the same time, he is a little wary of a future in which he would only treat elderly patients.
Geriatrics, Kappel said, is not about performing some mind-blowing procedure that completely cures a person. It’s about “meeting the person where they are” in their health.
The geriatric team at Grady — more than a dozen professionals including a dietitian, nurse, pharmacist, physical therapist and Dr. Ohuabunwa, who runs the unit — focuses on more than just the pills a person needs. They employ a holistic, wraparound approach to help a person manage day to day.
“That’s how doctors should treat everybody,” Kappel said.
Looking ahead
By 2030 about one in five people in the Atlanta area will be over the age of 60, according to the Atlanta Regional Commission’s latest forecast.
The numbers may be the strongest argument in favor of geriatricians. The 80-plus set is among the fastest growing populations in the country.
Geriatricians say they are a better fit for these people, better at treating a combination of age-related physical and cognitive problems, such as stroke, cardiovascular disease, chronic pain, arthritis, osteoporosis, incontinence, vision and hearing problems.
Here again, Bat, the primary care doctor, believes such statements smack of overstatement. Most primary care physicians are well aware of the dangers of mixing drugs, he said.
Dr. Johnson, the Emory geriatrics chief who also practices at the Atlanta VA, said the medical community needs to change its often derogatory view of the field. He recalled back when he was a medical student deciding on a specialty.
“What do you want to do?” his training supervisor had asked him.
“I like gerontology,” Johnson answered.
“Well,” said his supervisor, “you don’t have to decide now.”
Medical students need more “early, positive educational experiences” with older people, he said. Some students tell him they don’t even know anyone over the age of 65.
Beyond that, the public needs to better understand the benefits of seeing a geriatric specialist, several geriatricians said. Sometimes it’s the little things that matter. Dr. Ohuabunwa said she may not control the blood pressure of an older person as tightly as that of a younger person. That’s because some medications make an older person dizzy and heighten the chance of a fall.
Some good news
For all the concern, some bright spots exist.
Last year, Grady Memorial Hospital, which serves many lower-income people, opened its first inpatient geriatric unit. The hospital has had a geriatric outpatient clinic for years.
Atlanta is home to the VA’s only geriatric outpatient clinic for veterans in the state, serving 1,700 of them, said clinic head Dr. Thomas Price. Doctors there say older veterans come in with more complicated health issues: combat injuries that haven’t aged well, long-term effects of Agent Orange and even radiation illness from being present during the atomic tests of the Fifties.
For now, the geriatricians are focusing on those who need them most, the oldest, the sickest, those with the most complicated chronic conditions, said Dr. Supiano.
Looking ahead, he’d like to see health care systems and insurance providers place more emphasis on geriatric work.
The last place an insurance company wants to see a person is in a hospital, because of the high costs of care there, he said. He sees these systems managing older people’s health care so they spend less time in hospitals, or at least have shorter stays.
That, he said, means more geriatricians.